# Neuroprotection in Diabetes Retinal Disease: An Unmet Medical Need

## TL;DR

Diabetic retinopathy is increasingly seen as a neurovascular disease, with early neuronal damage playing a key role, requiring new diagnostic and therapeutic approaches focused on neuroprotection.

## Contribution

The paper emphasizes the shift from a purely vascular to a neurovascular understanding of diabetic retinopathy and highlights emerging neuroprotective strategies.

## Key findings

- Neurodegeneration in diabetic retinopathy can precede vascular abnormalities.
- Neurovascular interactions create a damaging feedback loop in disease progression.
- Emerging neuroprotective therapies use innovative delivery methods like nanocarriers.

## Abstract

Diabetic retinopathy (DR) has been classically considered a microvascular disease with all diagnostic and therapeutic resources focusing on its vascular components. However, during the past years, the obtained evidence highlighted the critical pathogenic role of early neuronal impairment redefining DR as a neurovascular complication. Retinal neurodegeneration is triggered by chronic hyperglycemia, which activates harmful biochemical pathways that lead to oxidative stress, metabolic overload, glutamate excitotoxicity, inflammation, and neurotrophic factor deficiency. These drivers of neurodegeneration can precede detectable vascular abnormalities. Simultaneously, endothelial injury, pericyte loss, and breakdown of the blood–retinal barrier compromise neurovascular unit integrity and establish a damaging cyclic loop in which neuronal and vascular dysfunctions reinforce each other. The interindividual variability of these processes highlights the need to properly redefine patient phenotyping by using advanced imaging and functional biomarkers. This would allow early detection of neurodegeneration and patient subtype classification. Nonetheless, translation of therapies based on neuroprotection has been limited by classical focus on vascular impairment. To meet this need, several strategies are emerging, with the most promising being those delivered through innovative ocular routes such as topical formulations, sustained-release implants, or nanocarriers. Future advances will depend on proper guidance of these therapies by integrating personalized medicine with multimodal biomarkers.