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Casey Eye Institute at OHSU, Portland, Oregon

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Diabetic Retinopathy

Diabetes Can Affect Sight

If you have diabetes mellitus, your body does not use and store sugar properly. High blood sugar levels can damage blood vessels in the retina. The retina is the thin layer of light-sensing nerve cells lining the inside back of your eye. It converts light rays into signals, which are sent through the optic nerve to your brain where they are recognized as images. The retina requires the proper amount of sugar and oxygen to nourish it. When the retinal vessels are injured by chronically elevated blood sugars, the retina does not function properly. This is referred to as diabetic retinopathy.

Types of Diabetic Retinopathy

There are two types of diabetic retinopathy: non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR).

NPDR is an early stage of diabetic retinopathy. In this stage, tiny blood vessels (microaneurysms) within the retina leak blood or fluid. The leaking fluid causes the retina to swell or to form deposits called exudates

Many people with diabetes have mild NPDR, which usually does not affect their vision. When vision is affected it is the result of macular edema or macular ischemia, or both.

Macular edema is swelling or thickening of the macula, a small area in the center of the retina that allows us to see fine details clearly. The swelling is caused by fluid leaking from retinal blood vessels. It is the most common cause of visual loss in diabetes. Vision loss may be mild to severe, but even in the worst cases, peripheral vision continues to function.

Macular ischemia occurs when small blood vessels (capillaries) close. Vision blurs because the macula no longer receives sufficient blood supply to work properly.

PDR is present when abnormal new vessels (neovascularizaiton) begin growing on the surface of the retina or optic nerve. The main cause of PDR is widespread closure of retinal blood vessels, preventing adequate blood flow. The retina responds by growing new blood vessels in an attempt to supply blood to the area where the original vessels closed.

Unfortunately, the new abnormal blood vessels do not resupply the retina with normal blood flow. The new vessles are often accompanied by scar tissue that may cause wrinkling or detachment of the retina.

PDR may cause more severe vision loss than NPDR because it can affect both central and peripheral vision.

Proliferative diabetic retinopathy causes visual loss in the following ways:

Vitreous Hemorrhage 

The fragile new abnormal vessels may bleed into the vitreous, a clear, gel-like substance that fills the center of the eye. If the vitreous hemorrhage is small, a person might see only a few new, dark, floaters. A very large hemorrhage might block out all vision.

It may take days, months, or even years to reabsorb the blood completely, depending on the amount of blood present. If the eye does not clear the vitreous blood adequately within a reasonable time, vitrecomy surgery may be recommended.

Vitreous hemorrhage alone does not cause permanent vision loss. When the blood clears, vision may return to its former level unless the macula is damaged.

Traction retinal detachment 

When PDR is present, the scar tissue associated with neovascularization can shrink, wrinkling and pulling the retina from its normal position. Macular wrinkling can cause visual distortion. More severe vision loss can occur if pulling of the scar tissue at the macula or large areas of the retina causes traction retinal detachment. 

Neovascular glaucoma 

Occasionally, extensive retinal vessel closure will cause new, abnormal blood vessels to grow on this iris (colored part of the eye) and in the drainage channels in the front of the eye. This can block the normal flow of fluid out of the eye. Pressure in the eye builds up, resulting in neovascular glaucoma, a severe eye disease that causes damage to the optic nerve.

How is diabetic retinopathy diagnosed?

A medical eye examination is the best way to detect changes inside your eye. An ophthalmologist (Eye MD) can often diagnose and treat serious retinopathy before you are aware of any vision problems. The ophthalmologist dilates (enlarges) your pupil and looks inside the eye with special equipment and lenses.

If your ophthalmologist finds diabetic retinopathy, he or she may order color photographs or optical coherence tomography (OCT) of the retina or a special test called fluorescein angiography to find out if you need treatment. In fluorescein angiography, a yellow/orange dye is injected into your arm and photos of your eye are taken to study the integrity of the blood circulation of the retina.  The angiogram precisely detects areas fluid leakage or areas of poor blood supply (non-perfusion or ischemia)

How is diabetic retinopathy treated?

The best treatment is to prevent the development of retinopathy as much as possible. Strict control of your blood sugar will significantly reduce the long-term risk of vision loss from diabetic retinopathy with attention paid to keeping the Hemoglobin A1c level to the level advised by your primary care physician or endocrinologist. If high blood pressure and kidney problems are present, they need to be treated.

Medical treatment

In certain cases, your eye MD may choose to treat your macular edema with injections of medicine in your eye. These special shots of medicine, called intravitreal injections, may be steroids or anti-VEGF medications. They are designed to shrink the swelling of the macula.

Laser surgery 

Laser surgery is often recommended for people with macular edema, PDR, and neovascular glaucoma.

For macular edema the laser is focused on the damaged retina near the macula to decrease the fluid leakage. The main goal of treatment is to prevent further loss of vision. It is uncommon for people who have blurred vision from macular edema to recover normal vision, although some may experience partial improvement. A few people may see the laser spots near the center of their vision following treatment. The spots usually fade with time but may not disappear.

For PDR, the laser is focused on all parts of the retina except the macula. This panretinal photocoagulation (PRP) treatment causes abnormal new vessels to shrink and often prevents them from growing in the future. It also decreases the chance that vitreous bleeding or retinal distortion will occur.

Multiple laser treatments over time are sometimes necessary. Laser surgery does not cure diabetic retinopathy and does not always prevent further loss of vision.  If numerous PRP treatments are necessary, the peripheral and night vision might become reduced in order to save the central vision.

Vitrectomy 

In advanced PDR, your ophthalmologist may recommend a vitrectomy. During this microsurgical procedure, which is performed in the operating room, the blood-filled vitreous is removed and replaced with a clear solution. Your ophthalmologist may wait for several months to see if the blood clears on its own before performing a vitrectomy.

Vitrectomy often prevents further bleeding by removing the abnormal vessels that cause the bleeding. If the retina is detached, it can be repaired during the vitrectomy surgery. Surgery should usually be done early because macular distortion or traction retinal detachment will cause permanent visual loss. The longer the macula is distorted or out of place, the more serious the vision loss will be.

Vision loss is largely preventable

If you have diabetes, it is important to know that today, with improved methods of diagnosis and treatment, a smaller percentage of people who develop retinopathy have serious vision problems. Early detection of diabetic retinopathy is the best protection of diabetic retinopathy is the best protection against loss of vision.

You can significantly lower your risk of vision loss by maintaining strict control of your blood sugar and visiting your ophthalmologist regularly.

When to schedule an examination

People with Type 1 diabetes should schedule an examination within five years of being diagnosed and then yearly. People with Type 2 diabetes should have an exam at the time of diabetes diagnosis and then once a year.

Pregnant women with diabetes should schedule an appointment in the first trimester because retinopathy can progress quickly during pregnancy.

If you need to be examined for eyeglasses, it is important that your blood sugar be consistently under control for several days when you see your ophthalmologist. Eyeglasses that work well when blood sugar is out of control will not work well when blood sugar is stable.

Rapid changes in blood sugar can cause fluctuating vision in both eyes even if retinopathy is not present.

You should have your eyes checked promptly if you have visual changes that:

  • Affect either one of both eyes
  • Last more than a few days
  • Are not associated with a change in blood sugar

When you are first diagnosed with diabetes, you should have your eyes checked:

  • Within 5 years of diagnosis
  • if you are 29 years old or younger
  • Within a few months of diagnosis if you are 30 years or older

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