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To highlight retinal ischemia as an important component of diabetic retinopathy (DR) pathogenesis, a significant prognostic factor, and a driver of various DR complications, including neovascularization. We aim to describe the main features of ischemic areas that can be identified through fundoscopy, color fundus photography, optical coherence tomography (OCT), and OCT angiography and provide clinicians with a step-by-step approach to identifying prognostically unfavorable markers of DR and accurately staging DR to improve management and prevent severe proliferative DR.

Cases of DR with subtle but significant retinal findings that are not readily identifiable unless a systematic multimodal imaging approach is used. We emphasize the presence of retinal ischemia in each case and show how to identify retinal vascular nonperfusion and its complications.

Advanced stages of DR may lack prominent fundus findings and may be easily misdiagnosed as milder DR without a comprehensive multimodal imaging diagnostic approach.