It has been said that there is no systemic disease which does not have a sign identifiable on ophthalmic examination. For many doctors, retinopathy—microaneurysms, haemorrhages, “hard” lipid exudates, microinfarcts of the retinal nerve fibre layer (cotton wool spots)—is synonymous with diabetes. A clinically distinct form of retinopathy is also recognised in hypertension, although traditionally, abnormalities of arteriovenous crossing architecture are the sine qua non feature of hypertensive retinopathy, with haemorrhagic and exudative changes only following later. However, population-based research has shown that retinopathy is a relatively common finding in older people without diabetes.1

In this edition of the journal, Liew and colleagues report increased coronary heart disease (CHD) mortality associated with retinopathy (see article on page 391).2 Retinopathy was present in 29% (57/199) of those with diabetes and 10% (268/2768) of those without diabetes. The presence of retinopathy in people without diabetes increased the risk of CHD death by the same magnitude as did a previous diagnosis of diabetes without retinopathy. Similarly, the presence of retinopathy in those with diabetes increased the rate of CHD mortality by an additional similar amount over and above that associated with diabetes itself. Adjustment for body mass index, fasting plasma glucose, oral hypoglycaemic drugs and serum creatinine level did not change the results appreciably. Associations were similar in men and women.

In view of previous publications, the findings of retinopathy in people without diabetes, and that retinopathy is a biomarker for vascular causes of mortality are not surprising. Glycated haemoglobin concentration has a …