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Diabetic Retinopathy

Article
Eye & Vision
Diseases & Conditions
+1
Contributed byNizamuddin SHM, MD, FRCS+1 moreJul 28, 2019

What are the other Names for this Condition? (Also known as/Synonyms)

  • Advanced Stage, Proliferative Diabetic Retinopathy
  • Diabetic Eye Disease
  • Early Stage, Non-Proliferative Diabetic Retinopathy

What is Diabetic Retinopathy? (Definition/Background Information)

  • Retinopathy is acute or chronic damage to the retina secondary to systemic metabolic conditions such as diabetes and hypertension (high blood pressure)
  • The retina is the structure in the eye that “takes pictures” and transmits the images to the brain. It is a light-sensitive lining in the back of the eye
  • An excess of sugar in blood can lead to damage throughout the body, as well as the eyes. After a long period of time, diabetes can have a negative impact on the circulatory system of the retina
  • The condition known as Diabetic Retinopathy occurs as a consequence of damaged blood vessels that nourish the retina; and usually, both the eyes are affected. These blood vessels leak fluids and blood that result in the clouding of vision and inflammation of retinal tissue
  • It is common for many individuals with diabetes to develop Diabetic Retinopathy. The longer an individual is affected by diabetes, the greater are the chances of developing the condition. Individuals born with diabetes or having a family history of diabetes are more susceptible to Diabetic Retinopathy
  • Moreover, individuals with type II diabetes, women who are pregnant, or those with other medical conditions have a higher risk for developing Diabetic Retinopathy
  • The signs and symptoms of Diabetic Retinopathy, as the condition develops, could include blurred vision, dark spots (floaters) in the vision field, distorted vision, shifting vision, etc.
  • The condition can lead to severe vision abnormalities such as a vitreous hemorrhage, tractional retinal detachment, uncontrolled increase in intraocular pressure (glaucoma), and ultimately painful blind eye. But, it is important to note that blindness due to Diabetic Retinopathy can be completely prevented provided periodic visits to the eye specialist are undertaken and the condition regularly monitored
  • A thorough physical examination of the eye and a complete medical history of diabetes is the first step towards establishing a diagnosis of Diabetic Retinopathy followed by thorough tests of the retina and macula
  • The treatment measures for Diabetic Retinopathy depend on the severity and stage of the condition and are aimed at attempting to slow or stop progression of the condition. These measures may include photocoagulation (laser therapy) and intravitreal injections against vascular endothelial growth factors (Bevacizumab, Ranibizumab, Aflibercept, Dexamethasone Implant, etc.)
  • The prognosis of Diabetic Retinopathy depends upon many factors, such as the duration of eye symptoms, the duration of diabetes, how well the diabetes is controlled, the response to treatment, and the extent of damage that has already occurred prior to the diagnosis of Diabetic Retinopathy

Who gets Diabetic Retinopathy? (Age and Sex Distribution)

  • Individuals born with diabetes or having a family history of diabetes are more susceptible to Diabetic Retinopathy
  • It affects both males and females at any age
  • There is no geographical distribution observed and the condition occurs worldwide. However, it has been observed that individuals of Hispanic descent have a higher risk for developing the condition

What are the Risk Factors for Diabetic Retinopathy? (Predisposing Factors)

The risk factors for Diabetic Retinopathy may include:

  • Individuals with diabetes, either type 1 or type 2, are at risk for Diabetic Retinopathy; especially, if the diabetes is poorly-controlled. The longer the individual has diabetes, the likelier is the chance of developing Diabetic Retinopathy
  • Individuals of Hispanic origin have a higher risk for the condition
  • Individuals with medical conditions such as high blood pressure or high cholesterol
  • Pregnant women have a greater risk for developing Diabetic Retinopathy. Those who develop gestational diabetes during pregnancy have an increased risk for developing diabetes as they get older

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Diabetic Retinopathy? (Etiology)

The causative factors of Diabetic Retinopathy may include:

  • An excess buildup of sugar in the bloodstream over time can cause a blockage of blood vessels that nourish the retina. With the blood supply cut-off, the eye tries to produce new blood vessels; however, these blood vessels do not develop correctly and they leak easily
  • Two types of Diabetic Retinopathy exist, which are indicative of the severity of the condition:
    • Early Diabetic Retinopathy
    • Advanced Diabetic Retinopathy

Early Diabetic Retinopathy:

  • It is the more common form of Diabetic Retinopathy. It is also known as Non-Proliferative Diabetic Retinopathy (NPDR)
  • In this form, no new blood vessels are growing. The walls of the blood vessels weaken and micro-aneurysms, or tiny bulges, obtrude from the walls of the smaller vessels, potentially leaking blood and fluid into the retina
  • In NPDR, the larger vessels can start to dilate and become asymmetrical in diameter

Advanced Diabetic Retinopathy:

  • As more vessels become blocked, NPDR can develop into Advanced Diabetic Retinopathy, also known as Proliferative Diabetic Retinopathy
  • In this more severe type, blood vessels that are damaged close off, which results in the proliferation of new, abnormal blood vessels in the retina. These blood vessels can leak into the vitreous cavity, which is the clear, jelly-like substance in the center of the eye
  • The growth of these new, abnormal blood vessels can cause scar tissue formation, which could result in the retina detaching from the back of the eye
  • The pressure may build up in the eye, if the new blood vessels inhibit the regular flow of fluid out of the eye. If the optic nerve that carries images from the eye to the brain becomes damaged as a result of this condition, it can result in glaucoma

What are the Signs and Symptoms of Diabetic Retinopathy?

The signs and symptoms of Diabetic Retinopathy may not occur during the early stages of the condition. As the condition progresses, the signs and symptoms may include:

  • Blurred vision
  • Spots, described as dark strings, floating in one’s vision field; these are known as floaters
  • Shifting vision
  • Distorted vision (object appears distorted, twisted, and smaller /bigger than their actual size)
  • Dark or blank areas in vision
  • Vision loss
  • Damaged color vision

It is common for Diabetic Retinopathy to affect both the eyes (bilateral condition).

How is Diabetic Retinopathy Diagnosed?

Diabetic Retinopathy may be diagnosed using the following methods:

  • A thorough physical examination of the eye correlated with a complete medical history of diabetes and/or vision difficulties is the first step in the diagnosis of Diabetic Retinopathy
  • Testing of the retina and macula that could include:
    • Visual acuity measurements to examine the degree to which the central vision has been impaired
    • Refraction testing to define a need for a change in the prescription of eyeglasses
    • Tests to evaluate the ocular structures, such as dilation, to evaluate the retina through the pupil
    • Tests to measure the eye pressure
  • Retinal photography or tomography will likely be used to record the current status of the retina
  • Fluorescein angiography could also be used to determine the existence of abnormal blood vessel growth or lack of them, called ischemia
  • Optical coherence tomogram (OCT) is used commonly to diagnose the swelling of the central part of retina known as macular edema

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Diabetic Retinopathy?

Diabetic Retinopathy can lead to severe vision-related complications, such as a vitreous hemorrhage, retinal detachment, glaucoma, and painful blind eye.

  • When a vitreous hemorrhage occurs, the new blood vessels bleed into the vitreous humor, which is the clear jelly-like substance that exists in the center of the eye
  • A small amount of bleeding might result in only a few dark spots, known as floaters. If the bleeding is more severe, the blood can satiate the entire vitreous cavity and cause a block in vision
  • If the vitreous hemorrhage is allowed for longer period of time, it may invite proliferation of blood vessels which can cause the retina to detach from its position and ultimately lead to blindness

How is Diabetic Retinopathy Treated?

The treatment measures for Diabetic Retinopathy depend on the severity and stage of the condition and are aimed at attempting to slow or stop progression of the condition. These measures may include:

  • During the early stage of Non-Proliferative Diabetic Retinopathy, the treatment usually involves regular monitoring of the condition. Keeping blood sugar levels under control, through appropriate advice of the healthcare provider, can avoid progression of Diabetic Retinopathy
  • In cases where the condition has progressed, leaking fluids from the blood vessels in the retina can result in macular edema. Photocoagulation, a type of laser treatment, may be used to stop blood and fluid leakage into the retina. The laser is used to make small burns in the retina where the abnormal blood vessels exit, causing it to seal off the leaks
  • Individuals with Proliferative Diabetic Retinopathy may require panretinal photocoagulation (PRP) laser therapy, which creates a pattern of laser burns scattered across the retina. This technique causes the abnormal blood vessels to shrink and disappear. As a result, some side vision could be lost in return for safeguarding central vision
  • Intravitreal injections against vascular endothelial growth factors (anti-VEGF Bevacizumab, Ranibizumab, Aflibercept, Dexamethasone Implant, etc.) are being used more commonly than laser photocoagulation with excellent improvement of vision. The downside of these anti-VEGF treatments is that they have to be repeated monthly, and sometimes, PRN (pro re nata or as needed) over one to three years
  • It is possible for some bleeding into the vitreous cavity to clear up on its own. However, if substantial amount of blood leaks and causes cloudy vision, laser photocoagulation cannot be used. Instead, a surgical procedure known as a vitrectomy is used to remove the mixture of vitreous filled and blood and replaced with a clear fluid. Replacement of this fluid also helps in maintaining the regular shape of the eye
  • For individuals with substantial vision loss, special low-vision devices, such as telescopic and microscopic lenses, video magnification systems, and hand and stand magnifiers, may be prescribed. Use of such devices can help make the most of the remaining vision the patient has

How can Diabetic Retinopathy be Prevented?

Diabetes does not always lead to vision loss. Taking an active role in managing diabetes is beneficial in the prevention of Diabetic Retinopathy. Certain preventive methods for Diabetic Retinopathy may include:

  • Eating healthy and incorporating physical activity into one’s daily routine
  • Making an effort to complete 150 minutes of moderate physical activity each week, which may include walking, jogging, biking, etc.
  • Monitoring blood glucose levels regularly and consistently; the healthcare provider may advise on the frequency of testing for blood sugar level based on each individual’s condition
  • Regularly undertaking hemoglobin A1C tests (also known as glycosylated hemoglobin test). This test is an indicator of the average blood sugar level in one’s body for a 2-3 month period before the test
  • Keeping blood pressure and cholesterol levels in check; eating healthy, losing excess weight, and exercising
  • Quitting smoking, as it increases the risk for developing diabetes complications including Diabetic Retinopathy

It is advised to immediately contact one’s physician, if any changes to one’s vision are noticed, or if the vision becomes spotty, blurry, or hazy.

What is the Prognosis of Diabetic Retinopathy? (Outcomes/Resolutions)

The prognosis of Diabetic Retinopathy depends upon a set of several factors that include:

  • The duration of eye-related symptoms
  • The duration of diabetes
  • How well diabetes is controlled
  • The response of Diabetic Retinopathy to treatment
  • The extent of damage that has already occurred prior to a diagnosis of Diabetic Retinopathy

In general, the longer the duration of undetected diabetes, the more severe the damage to the eye can take place. Also, a poor response to treatment measures results in a worse prognosis.

Additional and Relevant Useful Information for Diabetic Retinopathy:

  • The World Health Organization (WHO) estimates that about 1% of world blindness is caused by diabetes
  • It is estimated that over 10,000 eyes become blind each year due to diabetes within the United States of America
  • The treatment for Diabetic Retinopathy is expensive and demands significant costs. But, this represents only (approximately) 1/8th of the social security payment costs for vision loss
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On the Article

Krish Tangella MD, MBA picture
Approved by

Krish Tangella MD, MBA

Pathology, Medical Editorial Board, DoveMed Team
Nizamuddin SHM, MD, FRCS picture
Reviewed by

Nizamuddin SHM, MD, FRCS

Ophthalmology, Medical Editorial Board

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