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Saai Eye Hospital

Retina: Diabetic Retinopathy

What is Diabetic Retinopathy?

Diabetic retinopathy is the most common form of diabetic eye disease. Diabetic retinopathy usually only affects people who have had diabetes (diagnosed or undiagnosed) for a significant number of years.

Retinopathy can affect all diabetics and becomes particularly dangerous, increasing the risk of blindness, if it is left untreated.

The risk of developing diabetic retinopathy is known to increase with age as well with less well-controlled blood sugar and blood pressure level.

All people with diabetes should have a dilated eye examination at least once every year to check for diabetic retinopathy.

Diabetic retinopathy occurs when changes in blood glucose levels cause changes in retinal blood vessels. In some cases, these vessels will swell up (macular oedema) and leak fluid into the rear of the eye.

In other cases, abnormal blood vessels will grow on the surface of the retina.
Unless treated, diabetic retinopathy can gradually become more serious and progress from ‘background retinopathy’ to seriously affecting vision and can lead to blindness.

Diabetic retinopathy includes three different types :

  • Background retinopathy
  • Diabetic maculopathy
  • Proliferative retinopathy


What are the symptoms of Diabetic Retinopathy?

Diabetic retinopathy typically presents no symptoms during the early stages.

The condition is often at an advanced stage when symptoms become noticeable. On occasion, the only detectable symptom is a sudden and complete loss of vision.

Signs and symptoms of diabetic retinopathy may include:

  • blurred vision
  • the impairment of colour vision
  • floaters, or transparent and colourless spots and dark strings that float in the patient’s field of vision
  • patches or streaks that block the person’s vision
  • poor night vision
  • sudden and total loss of vision

Diabetic Retinopathy usually affects both eyes. It is important to make sure that the risk of vision loss is minimized. The only way people with diabetes can prevent Diabetic Retinopathy is to attend every eye examination scheduled by their doctor.



What are the Causes and Risk Factors of Diabetic Retinopathy?

Anybody with diabetes is at risk of developing diabetic retinopathy. However, there is a greater risk if the person:

  • does not correctly control blood sugar levels
  • experiences high blood pressure
  • has high cholesterol
  • is pregnant
  • smokes regularly
  • has had diabetes for a long time

Damage to the network of blood vessels that nourish the retina is the key cause of diabetic retinopathy.

High glucose levels damage these vessels and restrict the flow of blood to the retina. The problems with the blood vessels can be as mild as tiny bulges in the vessel wall that occasionally leak blood without affecting vision.

However, in the advanced stages of the condition, these blood vessels may become completely blocked. The eye then produces new, less stable blood vessels. The new vessels break easily and leak into the vitreous gel of the eye. The bleeding causes blurred and patchy vision by further blocking the retina.

This bleeding, on occasion, forms scars that can separate the retina and the eye, leading to a detached retina. As symptoms develop, a person with DR becomes increasingly likely to experience complete vision loss.



How can Diabetic Retinopathy be treated?

Laser surgery is often used in the treatment of diabetic eye disease, but each stage of diabetic retinopathy can be treated in a different way.

Background retinopathy has no treatment but patients will need regular eye examinations.
Maculopathy is usually treated with laser treatment (tiny burns that help to prevent new blood vessel growth and improve the nutrient and oxygen supply to the retina).

This is usually painless and has no side effects, but can influence night driving and peripheral vision.

This type of laser treatment for diabetic retinopathy will not improve vision, but it can prevent deterioration. Proliferative retinopathy is also treated with lasers, with a scattering over the whole retina. This destroys the starved area of the retina.
Serious diabetes retinopathy cases may require eye surgery.

This is usually diagnosed due to bleeding in the eye, late-stage proliferative retinopathy or ineffective laser treatment. This type of diabetic retinopathy eye surgery is called a vitrectomy.

BACKGROUND RETINOPATHY

Background retinopathy, also known as simple retinopathy, involves tiny swellings in the walls of the blood vessels. Known as blebs, they show up as small dots on the retina and are usually accompanied by yellow patches of exudates (blood proteins).
Background diabetic retinopathy requires regular monitoring by an ophthalmologist. It is therefore important to attend regular retinopathy screening appointments.

DIABETIC MACULOPATHY

The macula is the most well-used area of the retina and provides us with our central vision. Maculopathy refers to a progression of background retinopathy into the macular.
This can cause vision problems such as difficulty with reading and or seeing faces in the centre of your vision.

PROLIFERATIVE RETINOPATHY

Proliferative retinopathy is an advanced stage of diabetic retinopathy in which the retina becomes blocked causing the growth of abnormal blood vessels.

These can then bleed into the eyes, cause the retina to detach, and seriously damage vision. If left untreated, this can cause blindness. If proliferative retinopathy is regularly monitored and treated, the development of retinopathy can help be limited and more severe damage may be prevented.



How is Diabetic Retinopathy diagnosed?

Diabetic retinopathy generally starts without any noticeable change in vision. However, an ophthalmologist, or eye specialist, can detect the signs.

It is crucial for people with diabetes to have an eye examination at least once or twice annually, or when recommended by a physician.

The following methods are commonly used to diagnose diabetic retinopathy:

Dilated eye exam

The doctor administers drops into the patient’s eyes. These drops dilate the pupils and allow the doctor to view the inside of the eye in a more detailed way.

Photographs are taken of the interior of the eye. During the eye examination, the doctor can detect the presence of:

  • abnormalities in the blood vessels, optic nerve, or retina
  • cataracts
  • changes in eye pressure or overall vision
  • new blood vessels
  • retinal detachment
  • scar tissue

These drops may sting, and the bright lights of the photographs can startle the person receiving the test. In high-risk individuals, the eye drops may cause an increase in ocular pressure.

Fluorescein angiography

Drops are used to dilate the pupils, and a special dye called fluorescein is injected into a vein in the patient’s arm. Pictures are taken as the dye circulates through the eyes. The dye may leak into the retina or stain the blood vessels if the blood vessels are abnormal.

This test can determine which blood vessels are blocked, leaking fluid, or broken down. Any laser treatments can then be accurately guided. For around 24 hours after the test, the skin may turn yellowish, and urine dark orange, as the dye exits the body.

Optical coherence tomography (OCT)

This noninvasive imaging scan provides high-resolution cross-sectional images of the retina, revealing its thickness. After any treatments, scans may be used later to check how effective treatment has been.

OCT is similar to ultrasound testing but uses light rather than sound to produce images. The scan can also detect diseases of the optic nerve.



Prevention of Diabetic Retinopathy?

For the majority of people with diabetes, Diabetic Retinopathy is an inevitable consequence.

However, patients with diabetes who successfully manage their blood sugar levels will help to prevent the onset of a severe form of Diabetic Retinopathy.

High blood pressure, or hypertension, is another contributing factor. Patients with diabetes need to control their blood pressure by:

  • eating a healthy and balanced diet
  • regularly exercising
  • maintaining a healthy body weight
  • smoking cessation
  • strictly controlling alcohol intake
  • taking any antihypertensive measures according to their doctor’s instructions
  • attending regular screenings

Early detection of symptoms increases the effectiveness of the treatment.



Treatment Options of Diabetic Retinopathy?

Treating Diabetic Retinopathy depends on several factors, including the severity and type of Diabetic Retinopathy, and how the person with Diabetic Retinopathy has responded to previous treatments.

With NPDR, a doctor may decide to monitor the person’s eyes closed without intervening. This is known as watchful waiting.

Individuals will need to work with their doctor to control diabetes. Good blood sugar control can significantly slow the development of DR.

In most cases of PDR, the patient will require immediate surgical treatment. The following options are available:

Focal laser treatment, or photocoagulation

The procedure is carried out in a doctor’s office or an eye clinic. Targeted laser burns seal the leaks from abnormal blood vessels. Photocoagulation can either stop or slow down the leakage of blood and buildup of fluid in the eye.

People will usually experience blurry vision for 24 hours following focal laser treatment. Small spots may appear in the visual field for a few weeks after the procedure.

Scatter laser treatment, or pan-retinal photocoagulation

Scattered laser burns are applied to the areas of the retina away from the macula, normally over the course of two or three sessions. The macula is the area at the center of the retina in which vision is strongest.

The laser burns cause abnormal new blood vessels to shrink and scar. Most patients require two or three sessions for the best results.

Individuals may have blurry vision for 24 hours following the procedure, and there may be some loss of night vision or peripheral vision.

Vitrectomy

This involves the removal of some of the vitreous from within the eyeball. The surgeon replaces the clouded gel with a clear liquid or gas. The body will eventually absorb the gas or liquid. This will create new vitreous to replace the clouded gel that has been removed.

Any blood in the vitreous and scar tissue that may be pulling on the retina is removed. This procedure is performed in a hospital under general or local anaesthetic.

The retina may also be strengthened and held in position with tiny clamps.

After surgery, the patient may have to wear an eye patch to gradually regain use of their eye, which can tire after a vitrectomy.

If gas was used to replace the removed gel, the patient should not travel by plane until all gas has been absorbed into the body. The surgeon will tell the patient how long this should take. Most patients will have blurry vision for a few weeks after surgery. It can take several months for normal vision to return.

Surgery is not a cure for diabetic retinopathy. However, it may stop or slow the progression of symptoms. Diabetes is a long-term condition, and subsequent retinal damage and vision loss may still occur despite treatment.



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