REPORTS OF an unanticipated and rather perplexing worsening of diabetic retinopathy occurring within several months after the initiation of intensive insulin treatment in patients with inadequately controlled type 1 (insulin dependent) diabetes mellitus began to appear during the early 1980s, shortly after the widespread use of home blood glucose monitoring, glycosylated hemoglobin measurements, and continuous subcutaneous insulin infusion pumps or multiple daily insulin injections made it easier to assess and improve blood glucose control. Several of these reports were from small randomized trials comparing intensive and conventional insulin treatment of patients with very mild to moderate nonproliferative diabetic retinopathy (NPDR). Among these patients, worsening consisted mainly of the development of cotton-wool patches, which tended to disappear after several months, leading to the term transient worsening, which was believed to be benign. Worsening occurred more frequently when the initial glycosylated hemoglobin level was high and the decrease with intensive treatment was large. Several other reports were of small series of patients, most with severe NPDR, in whom worsening was not transient and led to proliferative retinopathy, vitreous hemorrhage, and/or macular edema. These early reports were summarized in 1992.1
Davis MD. Worsening of Diabetic Retinopathy After Improvement of Glycemic Control. Arch Ophthalmol. 1998;116(7):931–932. doi:https://doi.org/10.1001/archopht.116.7.931
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