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Diabetes is a disease that affects blood vessels throughout the body, particularly vessels in the kidneys and eyes. When the blood vessels in the eyes are affected, this is called diabetic retinopathy. Diabetic retinopathy is the most common eye disease among diabetics and it’s also the leading cause of blindness in American adults.
The retina is a light-sensitive tissue at the back of the eye. When light enters the eye, the retina changes the light into nerve signals. The retina then sends these signals along the optic nerve to the brain. Without a retina, the eye cannot communicate with the brain, making vision impossible.
Major blood vessels lie on the front portion of the retina, and when these blood vessels are damaged due to diabetes, they may leak fluid and lipids (fats) and grow scar tissue made of abnormal new blood vessels, which may grow on the surface of the retina, affecting vision. This leakage, called macular edema, affects the ability of the retina to detect and transmit images. Left unchecked, this may eventually lead to glaucoma, or cataracts, or a complete destruction of the retina, and even eventual blindness.
Diabetic retinopathy usually occurs in both eyes. The most common symptom of diabetic retinopathy is slight changes in vision. Over time, the condition can worsen, causing greater vision loss.
Mild Nonproliferative Retinopathy
At this stage, small blood vessels in the retina might experience small areas of balloonlike swelling called microaneurysms.
Moderate Nonproliferative Retinopathy
As the disease progresses, some of the blood vessels that the retina depends on for nourishment are blocked.
Severe Nonproliferative Retinopathy
In this stage, additional blood vessels become blocked, depriving the retina of blood supply. Once this occurs, the retina sends signals to grow new blood vessels.
This is the most advanced stage of the disease. Additional blood vessels have grown to nourish the retina, but these new fragile blood vessels have grown along the retina and in the surface of the vitreous gel. This does not cause vision loss alone, but if these vessels leak, severe vision loss or even blindness can occur.
All people with diabetes are at risk - those with Type I diabetes (juvenile onset)
and those with Type II diabetes (adult onset). It is important that everyone with diabetes get a dilated eye exam at least once a year to check for the disease. As people with diabetes age, they become even more at risk for getting diabetic retinopathy. It is estimated that 45 percent of diabetic Americans have some form of the disease. Although, everyone who has diabetes is at risk for developing diabetic retinopathy, not everyone develops it. Generally, diabetics don't develop diabetic retinopathy until they've had diabetes for at least 10 years. Changes in blood sugar levels increase the risk. Women with diabetes have a slightly higher risk during pregnancy. It is recommended that all pregnant women with diabetes have dilated eye examinations each trimester to protect their vision.
Diabetic retinopathy often has no early warning signs. Many patients experience no pain or noticeable symptoms during the early stages of the disease. That is why it is recommended that diabetic patients get annual dilated eye exams before the disease progresses more, causing sometimes irreversible symptoms. During the early stages of diabetic retinopathy, reading vision is typically not affected. However, when retinopathy becomes advanced, tiny blood vessels grow along the retina, in the clear, gel-like vitreous humor that fills the inside of the eye.
These vessels are the body's attempt to overcome and replace the ones that have been damaged by diabetes. However, these new vessels are thinner and weaker than normal and may bleed into the vitreous humor, clouding vision. Usually, the first few times this happens, tiny spots of blood are left floating in the way of vision, often dissipating after a few hours.
Within a few days or weeks, these spots can be followed by a much greater leakage of blood, which tend to happen more than once, often during sleep. Vision may become completely blurred and may take anywhere from a few days to months or even years to clear. In extreme cases, the blood does not clear and the only vision remaining is the ability to differentiate light from darkness.
Patients normally notice specks or spots of blood (that appear gray or black) floating in their vision. If this occurs, see your eye doctor immediately before additional serious bleeding occurs. If treatment is not performed, proliferative retinopathy can cause complete vision loss.
A dilated eye exam is the only way to detect changes inside the eye before loss of vision begins. People with diabetes should have an eye examination at least once a year. More frequent exams may be necessary after diabetic retinopathy is diagnosed.
Tests given for detection:
Visual acuity test: The standard eye chart test is given to measure clarity of vision.
Pupil dilation: Drops are placed into the eye to widen the pupil for a clear view of the retina. After the examination, close-up vision may remain blurred for several hours, and the patient will need dark glasses for sunlight and other bright lighting conditions.
Ophthalmoscopy: This is an examination is done with two instruments:
- A handheld device with a bright light and a special magnifying lens provides a narrow magnified view of the retina
- A headset with a bright light and a special magnifying glass for a wide view of the retina
Tonometry: A standard test that determines the fluid pressure inside the eye. Elevated pressure is a possible sign of glaucoma, more common in people with diabetes.
Fluorescein angiography: This is a test for macular edema in which a harmless orange-red dye called fluorescein is injected into a vein in the arm. The dye travels to the blood vessels in the retina. A special camera, with a green filter, flashes a blue light into the eye and takes multiple photographs. The pictures will be analyzed to identify any damage to the lining of the retina or unusual blood vessels.
Treatments are very effective in reducing vision loss from this disease. In fact, even people with advanced retinopathy have at least a 90 percent chance of keeping their vision if they get treatment before the retina is severely damaged.
Usually, there is no treatment for the first three stages of diabetic retinopathy unless a macular edema is detected. However, it is recommended that patients with diabetes control their blood pressure, blood sugar, and cholesterol. The fourth stage, known as proliferation retinopathy, is treated by using a laser. During this treatment, surgeons use the laser to shrink the abnormal blood vessels by directing the beam to the affected areas of the retina. Optimally, this treatment is performed before new blood vessels have begun to bleed. That’s why annual dilated eye exams are so important - to catch the disease before it progresses to that stage. If bleeding has progressed beyond the point of laser treatment, a procedure called a vitrectomy might be necessary to remove blood from the center of the eye.
Laser treatments for Diabetic Retinopathy
Laser treatments are available for:
A procedure called scatter laser treatment dissolves the abnormal blood vessels that form at the back of the eye. Rather than focusing on a single spot, hundreds of tiny laser zaps shrink the abnormal blood vessels from the center of the retina. Side vision is typically affected by this treatment in order to save the remaining central sight and may need repeating if new blood vessels appear.
This laser surgery, called focal laser treatment, if performed early enough can reduce vision loss from macular edema by half. During the surgery, a high-energy beam of light is aimed directly onto the damaged blood vessels. It seals the vessels and stops them from leaking. Sometimes, more than one treatment may be needed to completely control the leaking fluid.
A vitrectomy is usually recommended in the advanced stage of proliferative retinopathy in cases that have a lot of blood in the vitreous. This procedure removes the blood-filled vitreous and replaces it with a clear substitute fluid. Your doctor may wait several months to see if the blood will dissipate on its own before proceeding with a vitrectomy. This procedure is performed under either local or general anesthesia in a surgical suite, and retinal repair may be needed. It involves removing the cloudy vitreous and replacing it with a special salt solution.
As always, Harvard Eye is first and foremost concerned about what is best for each individual patient. Call us today for your personalized consultation!
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