The increasing life span of the populations worldwide along with the severe rise in the prevalence of diabetes has promoted macular disease to now become the major cause of mild, moderate, and severe vision loss, not only in the elderly (glaucoma and macular degeneration) but also in the working age group (diabetic retinopathy). Currently there are severe limitations of current, clinically available methods to detect disease, monitor progression, and define treatment outcomes until the severe end stages with neuronal death and atrophy with severe functional loss that is not retrievable.

This article reviews the limitations of current retinal imaging techniques and vision measurements and identifies potential new methods that appear necessary to adopt in order to detect the neuronal and microvascular disease process during the stages when reversible, not just slowing the disease progression but potentially providing vision improvement. It is only when such systems are made available for routine screening and monitoring that such prevalent macular diseases can be detected and intervention methods and periods assigned to treat sufficiently early that excellent functional vision is maintained. However, for multiple reasons, patients may miss such potential evaluations and present at later stages, requiring that interventions though out the disease course must be adequately evaluated and rehabilitation methods, improved with a better understanding of the functional deficits, applied.

The increasing life span of the populations worldwide along with the severe rise in the prevalence of diabetes has promoted macular disease to now become the major cause of mild, moderate, and severe vision loss, not only in the elderly (glaucoma and macular degeneration) but also in the working age group (diabetic retinopathy). This has demanded significant change in the implementation of programs to screen for retinal disease as well as to monitor the progression that will determine when to intervene as well as the chronologic efficacy of the promoted interventions. 

Until just recently the methods used to define and monitor the progressive retinal disease process have been primarily via fundus examination through a dilated pupil (or via fundus color photography and more recently OCT sectional imaging through an un-dilated pupil) together with functional evaluation by chart acuity (or contrast sensitivity) [Dunbar, et al 2022] and Humphrey photopic, spot contrast perimetry, predominantly with the 20-2 in which few spots are obtained within the macula. However, it is now well recognized that these fail to detect the diseases early in the course or to adequately define progression until moderately late in the injury process when there is significant functional vision loss due to multiple level and wide-spread retinal neuronal apoptotic injury, death and atrophy.

It must be remembered that all three diseases are focal in their onset and progression, very often initially involving the parafoveal retinal structures, thereby creating para-fixation defects in the field of functional vision. Screening for structural abnormalities, usually performed by fundus examination or color fundus photography, detects the disease only when there is sufficient, color-defined atrophy or with the occurrence of secondary lesions (e.g. microaneurysms, hemorrhages, IRMA or NV) that are currently the focus of AI image evaluation and disease staging. In addition, images acquired over time are not registered for overlay to define progression of local abnormalities. Because of this, the interventions have been primarily oriented toward the later detected stages, and clinical trials, while demonstrating a slowing of the disease progression, demonstrate minimal improvement in function. For example in multiple studies of diabetic retinopathy, only 25– 34

The author reports no conflicts of interest in this work.