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Endgames Picture Quiz

Atypical diabetic retinopathy

BMJ 2011; 342 doi: (Published 09 March 2011) Cite this as: BMJ 2011;342:d678
  1. Hon Shing Ong, specialist registrar,
  2. Areeb H Moosavi, specialist registrar,
  3. Susanne R Althauser, consultant ophthalmologist
  1. 1Department of Ophthalmology, Royal Free Hospital, Hampstead NHS Trust, London EN5 3DJ, UK
  1. Correspondence to: H S Ong honshing{at}

A 61 year old white man was referred urgently to the ophthalmology department from the English national diabetic screening programme for severe non-proliferative diabetic retinopathy.

He had been diagnosed with type 2 diabetes five years earlier, and his glycated haemoglobin a month before referral was 9.1%. He had no ophthalmic symptoms and denied any visual distortion, floaters, flashing lights, eye discomfort, or headaches.

He was on treatment for hypercholesterolaemia but had no other relevant medical history. He was otherwise well and had no systemic problems, such as fevers or rigors.

On examination, his right visual acuity was 6/12 and left visual acuity was 6/6. He had mildly pale conjunctiva. Slit lamp examination was normal with no signs of inflammation or infection. His conjunctivas were not injected and his corneas were clear. No cells were present in the anterior chamber or vitreous body. Fundus examination showed retinal haemorrhages in both eyes (fig 1).

Fig 1 Colour fundus photograph of the patient’s left eye


  • 1 What are the abnormalities seen on this fundus photograph?

  • 2 What are the differential diagnoses for this case?

  • 3 What features in the history and examination may help in the diagnosis?

  • 4 What further tests can be done to confirm the diagnosis?


1 What are the abnormalities seen on this fundus photograph?

Short answer

All layers of the retina contain widespread multiple haemorrhages. Some haemorrhages look round and have a white centre. These are indicative of Roth spots (fig 2). There are also some cotton wool spots but no features of retinal abscess or necrosis.

Fig 2 Colour fundus photograph of the patient’s left eye showing widespread haemorrhages in all layers of the retina and multiple Roth spots …

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