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As the veins and arteries become obstructed, retinal blood flow is reduced, resulting in the abnormal vasculature appearance typically seen in patients with diabetes. Cotton-wool spots appear clinically when capillaries are completely occluded. As the leukocytes bind to the endothelium, inflammatory mediators are released that increase vascular permeability, producing hard exudates and edema. As hyperglycemia damages more small vessels, hypoxemia develops within affected areas of the retina.

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