To determine whether a quantitative approach to assessment of the severity of diabetic retinopathy (DR) lesions on ultrawide field (UWF) images can provide new parameters to predict progression to proliferative diabetic retinopathy (PDR).
146 eyes from 73 participants with DR and 4 years of follow-up data were included in this post-hoc analysis which was based on a cohort of 100 diabetic patients enrolled in a previously published prospective, comparative study of UWF imaging at the Joslin Diabetes Center. Diabetic Retinopathy Severity Score (DRSS) level was determined at baseline and 4-year follow-up visits using mydriatic 7-standard field Early Treatment Diabetic Retinopathy Study (ETDRS) photographs. All individual DR lesions (hemorrhage (H), microaneurysm (ma), cotton wool spot (CWS), intraretinal microvascular abnormality (IRMA)) were manually segmented on stereographic projected UWF. For each lesion type, the frequency/number, surface area, and distances from the optic nerve head (ONH) were computed. These quantitative parameters were compared between eyes which progressed to PDR in 4 years and eyes which did not progress. Univariable and multivariable logistic regression analyses were performed to identify parameters which were associated with an increased risk for progression to PDR.
A total of 146 eyes of 73 subjects were included in the final analysis. The mean age of the study cohort was 53.1 years and 42 (56.8%) subjects were female. The number and surface area of H/ma’s and CWS’s were significantly (p ≤ 0.05) higher in eyes which progressed to PDR compared with eyes which did not progress by 4 years. Similarly, H/ma’s and CWS’s were located further away from the ONH (i.e. more peripheral) in eyes which progressed (p < 0.05). DR lesion parameters that conferred a statistically significant increased risk for proliferative diabetic retinopathy in the multivariate model included hemorrhage area (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.25-5.53), and greater distance of hemorrhages from the ONH (OR, 1.24; 95% CI, 0.97-1.59).
Quantitative analysis of DR lesions on UWF images identifies new risk parameters for progression to PDR including the surface are of hemorrhages and the distance of hemorrhages from the optic nerve head. Although these risk factors will need to be confirmed in larger, prospective studies, they highlight the potential for quantitative lesion analysis to inform the design of a more precise and complete staging system for diabetic retinopathy severity in the future.

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