Fundus Image Analysis Report

Ophthalmology — Color Fundus Photography, Diabetic Retinopathy Screening

Report ID: MAA-FUN-7B4E33
Generated: May 25, 2026
Analysis: AI-Powered Image Interpretation

Patient Profile

Sex / Age:
Male, 56 years
Indication:
Annual diabetic retinopathy screening
Visual symptoms:
None reported. Best-corrected visual acuity 20/25 OD, 20/20 OS (clinician-supplied).
Diabetes:
Type 2 DM × 12 years; recent HbA1c 8.2%; on metformin and basal insulin
Other:
Hypertension (well-controlled); no nephropathy; no neuropathy; non-smoker
Study:
45-degree color fundus photographs, both eyes; macula and disc-centered fields

Summary Overview

Bilateral fundus photographs show microaneurysms, dot-blot hemorrhages, and hard exudates in both eyes, more prominent in the right. No proliferative changes (no neovascularization, no vitreous hemorrhage). Findings are consistent with moderate non-proliferative diabetic retinopathy (NPDR). Possible center-involving diabetic macular edema (CI-DME) suspected on the right — OCT recommended.

Mod NPDR
DR Stage (OD)
Mild–Mod
DR Stage (OS)
?CI-DME
Macula (OD)

Diabetic Retinopathy Severity Scale (ICDR)

Mild NPDR:
Microaneurysms only
Moderate NPDR:
More than microaneurysms but less than severe
Severe NPDR:
4-2-1 rule (intraretinal hem in 4 quadrants, venous beading in 2, IRMA in 1)
Proliferative DR:
Neovascularization or vitreous/preretinal hemorrhage
Reference:
Wilkinson CP, Ophthalmology 2003 (ICDR scale)

Detailed Imaging Findings

Right Eye (OD)Moderate NPDR
Optic disc margins sharp; cup-to-disc 0.3, no neovascularization at disc. Multiple microaneurysms scattered throughout the posterior pole. Several dot-blot hemorrhages in the supero-temporal quadrant. Hard exudates within 500 µm of the foveal center, with focal retinal thickening on stereo viewing — suggestive of clinically significant macular edema. No cotton-wool spots. No venous beading or IRMA. No neovascularization elsewhere.
Left Eye (OS)Mild–Moderate NPDR
Optic disc unremarkable; cup-to-disc 0.3. Several microaneurysms and one dot hemorrhage temporal to the macula. Foveal reflex intact, no clear lipid exudates, no obvious thickening. No neovascularization.
Optic DiscsNormal
Symmetric C/D 0.3 bilaterally. Margins sharp. No pallor. No disc neovascularization (NVD).
MaculaOD: suspected CI-DME
Right macula shows lipid exudates near the fovea with possible retinal thickening — definitive characterization requires OCT.
Vasculature / Periphery (visible)No NV / No Hemorrhage
No neovascularization elsewhere (NVE). No vitreous or preretinal hemorrhage on these views. Note: peripheral retina partially imaged with 45° field; ultra-wide-field or specialist examination provides fuller assessment.

Diagnosis & Risk

  • Moderate non-proliferative diabetic retinopathy (OD)Confirmed
    Multiple microaneurysms, dot-blot hemorrhages, and hard exudates beyond a "mild" presentation, but without 4-2-1 features.
  • Mild–moderate NPDR (OS)Confirmed
    Few microaneurysms and isolated hemorrhage.
  • Center-involving diabetic macular edema (OD)Suspected — OCT needed
    Hard exudates near fovea with possible thickening on photograph. OCT is the gold standard for confirmation [Browning DJ, Ophthalmology 2008].

Analytical Summary & Recommendations

Imaging impression

Bilateral non-proliferative diabetic retinopathy, asymmetric (worse on the right), with possible center-involving macular edema on the right that requires OCT confirmation. No proliferative disease and no acute sight-threatening hemorrhage.

Recommended next steps

  • Refer to ophthalmology within 4 weeks for slit-lamp examination and OCT
  • OCT macula bilaterally to confirm/quantify diabetic macular edema
  • If center-involving DME confirmed: discussion of anti-VEGF intravitreal therapy (typical first-line) [Wells JA, NEJM 2015]
  • Glycemic optimization: HbA1c target individualized; current 8.2% is above typical target of < 7% for many patients
  • Blood pressure < 130/80 — important for retinopathy progression
  • Annual fundus screening minimum; sooner if disease progresses or new symptoms develop
⚠ Important
New floaters, sudden vision loss, dark curtain across vision, or distortion (straight lines appearing wavy) require same-day ophthalmology evaluation — these can signal vitreous hemorrhage, retinal detachment, or macular edema progression.

Key Questions for Your Physician

  • How urgent is the OCT and ophthalmology visit, and where will it be scheduled?
  • If macular edema is confirmed, what are the treatment options and what to expect?
  • What HbA1c and blood pressure targets are right for me, given my eye findings?
  • Are there warning signs that should make me come in immediately?
  • How often will I need fundus screening going forward?

What This Means for You

Your fundus photographs show diabetic retinopathy in both eyes — small blood-vessel changes in the back of the eye caused by diabetes — at a moderate stage on the right and milder on the left. There are also signs that suggest fluid may be building up in the central part of the retina (the macula) on the right, which is the most common cause of vision loss from diabetes.

Your vision is currently good, but these findings are important to act on now — early treatment is much more effective than late treatment. The next step is an OCT scan and ophthalmology examination within about a month. If macular edema is confirmed, modern treatments (intravitreal injections) are very effective at protecting and often improving vision.

Equally important is tightening blood-sugar and blood-pressure control, which directly slows progression of retinopathy. Your HbA1c of 8.2% is above target for most patients with diabetes — your physician can help you build a plan.

Same-day care is needed for any sudden vision change: new floaters, sudden loss of vision, a dark curtain, or distortion of straight lines.

Analysis Confidence 90%

High confidence in NPDR staging on standard photographs. Macular edema characterization on color photos alone is limited; OCT is required for confirmation and quantification.

References

  1. Wilkinson CP, Ferris FL 3rd, Klein RE, et al. Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales. Ophthalmology 2003;110(9):1677–82.
  2. Wells JA, Glassman AR, Ayala AR, et al. Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema. NEJM 2015;372(13):1193–203.
  3. Browning DJ, Glassman AR, Aiello LP, et al. Diabetic Retinopathy Clinical Research Network: Optical Coherence Tomography Measurements and Analysis Methods in Optical Coherence Tomography Studies. Ophthalmology 2008;115(8):1366–1372.
  4. American Academy of Ophthalmology Preferred Practice Pattern: Diabetic Retinopathy. AAO 2024.
  5. American Diabetes Association. Standards of Medical Care in Diabetes — 2025: Retinopathy. Diabetes Care 2025;48 (Suppl 1).