What is diabetic eye care? Symptoms, treatment options and more!
At a glance:
Fun Facts and Oddities:
- Diabetic eye disease includes a group of eye conditions that affect people with diabetes. These conditions include diabetic retinopathy, diabetic macular edema (DME), cataract and glaucoma.
- All forms of diabetic eye disease can lead to severe vision loss and blindness.
- Diabetic retinopathy involves changes in retinal blood vessels that can cause bleeding or fluid leakage and distort vision.
- Diabetic retinopathy is the most common cause of vision loss in people with diabetes and a leading cause of blindness in working-age adults.
- DME is a result of diabetic retinopathy, which causes swelling in the area of the retina called the macula.
- Controlling diabetes – by taking prescription medications, being physically active and eating a healthy diet – can prevent or delay vision loss.
- Because diabetic retinopathy often goes unnoticed until vision loss occurs, diabetics should have a comprehensive dilated eye exam at least once a year.
- Early detection, timely treatment and appropriate follow-up of diabetic eye disease can protect against vision loss.
- Diabetic retinopathy can be treated with multiple therapies, used alone or in combination.
About diabetic eye disease
What is diabetic eye disease?
Diabetic eye disease is a group of eye conditions that can affect people with diabetes.
Diabetic retinopathy is the most common diabetic eye disease. Diabetic retinopathy affects blood vessels in the light-sensitive tissue called the retina, which lines the back of the eye. It is the most common cause of vision loss in people with diabetes and the leading cause of visual impairment and blindness in working-age adults.
Diabetic Macular Edema (DME). A consequence of diabetic retinopathy, DME is the accumulation of fluid (edema) in a region of the retina called the macula. The macula is important for sharp, straight-ahead vision used for reading, recognizing faces and driving. DME is the most common cause of vision loss in people with diabetic retinopathy. About half of all people with diabetic retinopathy develop DME. Although more likely to occur when diabetic retinopathy worsens, DME can occur at any stage of the disease.
Diabetic eye disease can include cataracts and glaucoma. Adults with diabetes are 2-5 times more likely to develop cataracts than non-diabetics. Cataracts also tend to develop at an earlier age in people with diabetes. Along with glaucoma, diabetes nearly doubles the risk of glaucoma in adults.
All forms of diabetic eye disease can lead to severe vision loss and blindness. That’s why early diagnosis and treatment are always the best options for diabetics. Because diabetic eye disease often goes unnoticed until vision loss occurs, diabetic patients should have a diabetic eye exam at least once a year.
There are generally two stages of diabetic retinopathy: non-proliferative and proliferative. Nonproliferative diabetic retinopathy (NPDR), the most common form of diabetic retinopathy, occurs when the blood vessels in a person’s retina weaken and tiny bulges protrude from their walls. Proliferative diabetic retinopathy (PDR) is the more severe form of diabetic retinopathy and occurs with the growth of abnormal blood vessels. This can lead to bleeding or scar tissue formation, possibly resulting in retinal detachment and permanent vision loss. Both NPDR and PD can cause diabetic macular edema (DME), which can lead to central vision loss.
Diabetic retinopathy can develop in anyone who has type 1 or type 2 diabetes. The longer a person has diabetes and the less blood sugar is controlled, the more likely that person is to develop the disease. Between 40 and 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy, although only about half are aware of it. In women who develop or have diabetes during pregnancy, diabetic retinopathy can start quickly or get worse. Although it may cause no symptoms at all or mild vision problems, it’s important to remember that diabetic retinopathy can still lead to blindness and must be treated.
Chronic high blood sugar from diabetes is associated with damage to the tiny blood vessels in the retina, resulting in diabetic retinopathy. The retina detects light and converts it into signals that are sent through the optic nerve to the brain. Diabetic retinopathy can cause fluid to leak or bleed (hemorrhage) from blood vessels in the retina, distorting vision. In the most advanced stage, (numerous) new abnormal blood vessels proliferate on the retinal surface, which can lead to scarring and cell loss in the retina.
Diabetic retinopathy can progress through four stages:
- Mild nonproliferative retinopathy. Small areas of balloon-like swelling in the tiny blood vessels of the retina, called microaneurysms, occur at this earliest stage of the disease. These microaneurysms can leak fluid into the retina.
- Moderate non-proliferative retinopathy. As the disease progresses, blood vessels that supply the retina can swell and become distorted. They may also lose their ability to carry blood. Both conditions cause characteristic changes in the appearance of the retina and can contribute to DME.
- Severe non-proliferative retinopathy. Many more blood vessels become blocked, causing areas of the retina to lose blood supply. These areas secrete growth factors that signal the retina to grow new blood vessels.
- Proliferative diabetic retinopathy (PDR). At this advanced stage, growth factors secreted by the retina trigger the proliferation of new blood vessels that grow along the inner surface of the retina and into the vitreous humor, the fluid that fills the eye. The new blood vessels are fragile, causing them to leak and bleed more easily. Accompanying scar tissue may contract and cause retinal detachment – the pulling away of the retina from the underlying tissue, as if wallpaper were peeling from a wall. Retinal detachment can lead to permanent vision loss.
What are the symptoms?
The early stages of diabetic retinopathy are usually asymptomatic. The disease often progresses unnoticed until it affects vision. Bleeding from abnormal retinal blood vessels can cause the appearance of “floating” spots. These spots sometimes disappear on their own. But without prompt treatment, bleeding often occurs, increasing the risk of permanent vision loss. When diabetic macular edema (DME) occurs, blurred vision may occur.
Diabetic retinopathy and DME are detected during a comprehensive dilated eye exam that includes:
- Testing of visual acuity. This vision chart test measures a person’s ability to see at different distances.
- Tonometry. This test measures pressure in the eye.
- Pupil dilation. Drops applied to the surface of the eye dilate (widen) the pupil so a doctor can examine the retina and optic nerve.
Optical Coherence Tomography (OCT). This technique is similar to ultrasound, but uses light waves instead of sound waves to capture images of tissues in the body. OCT provides detailed images of tissues that can be penetrated by light, such as z. B. the eye.
A comprehensive dilated eye exam allows the doctor to examine the retina for the following:
- Changes in blood vessels
- Leaky blood vessels or warning signs of leaky blood vessels, such as z. B. Fatty deposits
- Swelling of the macula
- Lens modifications
- Damage to nerve tissue
If DME or severe diabetic retinopathy is suspected, a fluorescein angiogram can be used to look for damaged or leaking blood vessels. This test involves injecting a fluorescent dye into the bloodstream, often into a vein in the arm. Images of retinal blood vessels are taken when dye reaches the eye.
Vision loss from diabetic retinopathy is sometimes irreversible; however, early detection and treatment can reduce the risk of blindness by 95 percent. Because diabetic retinopathy often has no early symptoms, diabetics should have a comprehensive dilated eye exam at least once a year. People with diabetic retinopathy may need more frequent eye exams. Women with diabetes who become pregnant should undergo a comprehensive dilated eye exam as soon as possible. Additional examinations during pregnancy may be required.
Studies such as the Diabetes Control and Complications Trial (DCCT) have shown that controlling diabetes slows the onset and worsening of diabetic retinopathy. DCCT study participants who kept their blood glucose levels as close to normal as possible were significantly less likely to develop diabetic retinopathy and kidney and nerve disease than those without optimal glucose control. Other studies have shown that controlling elevated blood pressure and cholesterol can reduce the risk of vision loss in diabetics.
Treatment of diabetic retinopathy is aimed at treating diabetic retinopathy and diabetic macular edema. Comprehensive dilated eye exams are needed more often when diabetic retinopathy becomes more severe. People with more severe retinopathy need more frequent monitoring, customized by your eye doctor.
What are my treatment options?
Treatment options depend on the type of diabetic eye disease, but may include medications, lasers and sometimes surgery.
If early nonproliferative diabetic retinopathy is present, treatment of the eye may not be needed if blood glucose levels are well maintained. If severe non-proliferative or proliferative diabetic retinopathy is present, laser procedures, surgery or injectable medications are available and can reverse, slow or stop the progression of diabetic retinopathy.
Based on your vision diagnosis during your exam, our diabetic eye specialists will discuss the most appropriate treatment options with you.
For decades, PDR has been treated with scatter laser surgery, sometimes called panretinal laser surgery or panretinal photocoagulation. Treatment involves 1,000 to 2,000 tiny laser burns in areas of the retina away from the macula. These laser burns are said to cause abnormal blood vessels to shrink. Although treatment can be completed in one session, sometimes two or more sessions are required. While central vision can be preserved, scatter laser surgery can result in some loss of lateral (peripheral), color and night vision. Scatter laser surgery works best before new, fragile blood vessels begin to hemorrhage. Recent studies have shown that anti-VEGF treatment is not only effective in treating DME, but is also effective in slowing the progression of diabetic retinopathy, including PDR, so anti-VEGF is increasingly used as a first-line treatment for PDR.
In some cases of proliferative diabetic retinopathy (PDR), the new blood vessels can cause severe bleeding called vitreous hemorrhage. This hemorrhage can block vision and the ability of your ophthalmologist to perform laser treatments. In addition, neovascularization can lead to retinal detachment, putting the patient at risk for severe vision loss. In these cases your retina specialist may recommend surgery to remove the blood or repair the retinal detachment.
In non-proliferative diabetic retinopathy (NPDR), leaky blood vessels can cause diabetic macular edema (DME) and vision loss. The goal of the laser for DME at NPDR is to stop the leakage and prevent further vision loss. In some cases of severe NPDR, a peripheral laser is used to prevent the development of proliferative retinopathy.
If the number of new vessels is large, laser treatment can often prevent vision loss. The type of laser treatment performed when many vessels are present is called panretinal photocoagulation. This type of laser treatment is usually performed in two or more separate sessions. The idea is to use laser to destroy any dead areas of the retina where blood vessels have been occluded. When these areas are treated with the laser, the retina stops producing new blood vessels and existing ones tend to diminish or disappear.
Panretinal photocoagulation can have side effects and usually does not improve vision; It is a means of keeping vision stable to prevent further loss. After laser treatments, patients may still have poor vision or continue to lose vision. But if laser is indicated, there is a chance that laser treatment will prevent severe vision loss.
Panretinal photocoagulation is placed in the periphery of the retina, not the center, and lateral vision may be diminished. These peripheral areas are treated to preserve as much as possible of the central vision and to spare the eye itself. Night vision may also be impaired. After laser, blurred vision is very common. Normally this fuzziness disappears, but in a small number of patients some fuzziness may remain forever.
DME can be treated with several therapies, which can be used alone or in combination.
Anti-VEGF injection therapy. Anti-VEGF drugs are injected into the vitreous gel to block a protein called vascular endothelial growth factor (VEGF), which can stimulate abnormal blood vessels to grow and leak fluid. Blocking VEGF can reverse abnormal blood vessel growth and reduce fluid in retina. Available anti-VEGF drugs include Avastin (bevacizumab), Lucentis (ranibizumab) and Eylea (aflibercept). Lucentis and Eylea are approved by the U.S. Food and Drug Administration (FDA) for the treatment of DME. Avastin has been approved by the FDA to treat cancer, but is commonly used to treat a variety of eye conditions, including DME and severe diabetic retinopathy.
Avastin, Lucentis and Eylea vary in cost and frequency of injection, and treatment is individualized to the patient.
Focal/grating laser surgery of the macula. Focal/grid laser surgery of the macula involves small laser burns to leaky blood vessels in areas of edema near the center of the macula. Laser burns for DME slow fluid leakage and reduce swelling in the retina. The procedure is usually completed in one session, but some people may need more than one treatment. Focal/grating laser can be used with or without anti-VEGF injections.
Corticosteroids. Corticosteroids, either injected into the eye or implanted, can be used alone or in combination with other medications or laser surgery to treat DME. The Ozurdex (dexamethasone) implant is for short-term use, while the Iluvien (fluocinolone acetonide) implant lasts longer. Both release a sustained dose of corticosteroids to suppress DME. Use of corticosteroids in the eye increases the risk of cataract and glaucoma. DME patients using corticosteroids should be monitored for elevated intraocular pressure and glaucoma.
A vitrectomy is the surgical removal of the vitreous gel in the center of the eye. The procedure is used to treat severe bleeding into the vitreous and is performed under local or general anesthesia. Ports (temporary watertight openings) are placed in the eye so the surgeon can insert and remove instruments such as a tiny light or a small vacuum cutter called a vitrector. A clear saline solution is carefully pumped into the eye through one of the ports to maintain eye pressure during surgery and replace the removed vitreous or blood from diabetic retinopathy. The same instruments used during vitrectomy can also be used to perform laser treatments, remove scar tissue or repair a detached retina.
Vitrectomy is usually performed on an outpatient basis. After surgery, the eye is treated with eye drops while the surgeon monitors the healing of the eye.
Take the first step
If you have diabetes, a careful, comprehensive eye exam by one of our diabetic eye specialists is the first step. Our doctors use highly specialized technology – and years of training and experience – to examine your eyes and check for the presence of disease. During your examination, your doctor will discuss with you personally the health of your eyes, how your condition affects your vision and what treatment options are available. Bottom line: trust the experts. Insist on Eye Consultants of Pennsylvania.