Diabetes mellitus is a condition which impairs the body's ability to use and store sugar. Elevated blood sugar levels, excessive thirst with an increase in urine excretion, and changes in the body's blood vessels are all characteristic of the disease. Diabetes may cause serious changes in the eyes as well. Conditions such as cataracts, glaucoma, occasional blurring and, most importantly, changes in the blood vessels at the back of the eye all may effect sight.
What is Diabetic Retinopathy?
Diabetic retinopathy is a complication of diabetes that affects the eyes. It is caused by the deterioration of the blood vessels nourishing the retina at the back of the eye. These weakened blood vessels may leak fluid or blood, develop fragile brush-like branches, and become enlarged in certain places. When leaking blood or fluid damages or scars the retina, the image sent to the brain becomes blurred.
The risk of developing diabetic retinopathy is high for patients who have had diabetes for a long time. About 60% of patients having diabetes for 15 years or more have some blood vessel damage in their eyes. When diabetes develops at an early age in childhood or teenage years, it is known as juvenile diabetes. Juvenile diabetics are particularly likely to develop diabetic retinopathy at an early age. However, only a small percentage of those developing retinopathy will have serious problems with vision, and an even smaller percentage ever become blind. In spite of this, diabetic retinopathy is the leading cause of new blindness among adults in the United States, and diabetic patients are said to be 25 times more prone to blindness than non-diabetics.
What is Background Retinopathy?
There are two forms of diabetic retinopathy. In one form, background retinopathy, blood vessels within the retina change. Some vessels decrease in size and others enlarge and form balloon-like sacs, which obstruct the flow of blood through the vessels. These vessels leak and hemorrhage causing swelling of the retina or forming deposits called exudates.
Background retinopathy is considered an early stage of diabetic retinopathy. Fortunately, sight is usually not seriously affected and the condition does not progress in about 80% of diabetic patients. In some cases, however, the leaking fluid collects in the macula, the center portion of the retina, which is responsible for central vision. Straight-ahead images, reading and close work may then become blurred, and loss of central vision can result in legal blindness. Background retinopathy is a warning sign and can progress to more serious, sight-endangering stages.
What is Proliferative Retinopathy?
The second form is proliferative retinopathy. This begins in the same manner as background retinopathy with the addition of new blood vessel growth on the surface of the retina or the optic nerve. These fragile new blood vessels may rupture and bleed into the vitreous, the clear gel-like substance that fills the center of the eye. If the leaking blood clouds the normally clear vitreous, light passing from the lens through the vitreous to the retina is blocked and images are distorted. Additionally, scar tissue forming from the mass of ruptured blood vessels in the vitreous may tighten and pull on the retina, tugging it away and detaching it from the back of the eye. Blood vessels may even grow on the iris and cause a form of glaucoma. Severe loss of sight and even blindness may result from these conditions.
Causes and Symptoms
The cause of diabetic retinopathy is not completely understood; however, it is known that diabetes weakens small blood vessels in various areas of the body. Pregnancy and high blood pressure may worsen this condition in diabetic patients. Though gradual blurring of vision may occur, sight is usually unaffected by background retinopathy, and changes in the eye can go unnoticed unless detected by a medical eye examination.
When bleeding occurs in proliferative retinopathy, the patient has hazy or complete loss of sight. Though there is no symptom of pain, this severe form of diabetic retinopathy requires immediate medical attention.
Detection and Diagnosis
A comprehensive eye examination by your eye doctor is the best protection against the progression of diabetic retinopathy. Diabetic patients should be aware of the risks of developing sight disturbances and should have their eyes examined regularly. (Non-diabetic patients should also have their eyes examined periodically because these examinations help to detect the presence of diabetes and other diseases.)
To detect diabetic retinopathy, the doctor painlessly examines the interior of the eye using an instrument called an ophthalmoscope. The interior of the eye may also be photographed to provide further information.
If diabetic retinopathy is noted, a special method of examination may be used by the retinal specialist to see which blood vessels are bleeding or leaking fluid. First, a fluorescent dye is injected into the patient's arm. The dye travels through the bloodstream and passes into the blood vessels of the retina. Photographs are taken rapidly as it leaks through the retina's blood vessels. This technique, called fluorescein angiography, is sometimes used by retinal specialists, and other eye doctors to determine if further treatment is necessary.
Treatment
When diabetic retinopathy is diagnosed, the doctor considers the patient's age, history, lifestyle, and the degree of damage to the retina before deciding on treatment or continued monitoring of the progress of the disease. In many cases treatment is not needed; in others, treatment is recommended to halt the damage of the diabetic retinopathy and sometimes to improve sight.
Probably the most significant treatment is the use of laser surgery to seal or photocoagulate the leaking blood vessels. This procedure focuses a powerful beam of laser light energy onto the damaged retina. Small burst of the laser's intense heat stops the bleeding by sealing leaking vessels and forming tiny scars inside the eye. These scars reduce abnormal blood vessel growth and help bond the retina to the back of the eye. This treatment does not require an incision and may be performed in the office. If diabetic retinopathy is detected early, photocoagulation by laser surgery may stop continued damage. Even in advanced stages of the disease, it can reduce that chance that a patient will have severe visual loss.
However, photocoagulation cannot be used in all patients. Depending on the location and extent of diabetic retinopathy, and if the vitreous is too clouded with blood, another treatment must be used. In this surgical procedure, called a vitrectomy, the blood-filled vitreous is removed from the eye and replaced with a clear, artificial solution. About 70% of vitrectomy patients notice an improvement in sight. The ophthalmologist may recommend a vitrectomy soon after the vitreous becomes clouded by blood, or wait up to a year to see if the eye clears itself naturally. The timing for each patient depends on the extent of damage to the eye and to the condition of the other eye. If, However, diabetic retinopathy causes the retina to detach from the back of the eye, severe sight loss or blindness can result unless surgery is performed immediately to reattach the retina.
Successful treatment of diabetic retinopathy not only depends on early detection with monitoring and treatment, but also on the patient's attitude and self-care. All medications should be taken and diet to control diabetes should be followed as directed. Although physical activity presents few problems with background retinopathy, it can increase bleeding in proliferative retinopathy. Exercise for patients with proliferative retinopathy should be moderate, and straining or leaning over with head down should be avoided.
Who can treat Diabetic Retinopathy?
Both general ophthalmologists and retinal specialists can treat diabetic retinopathy. Retinal specialists are ophthalmologists with extra training and experience in treating specifically diseases affecting the retina such as diabetic retinopathy.
Loss of Vision is Largely Preventable
Early detection of diabetic retinopathy is the best protection against sight loss. Even when symptoms are not noticed, the diabetic patient should schedule yearly eye examinations at least once a year. Medical eye examination should be schedule more frequently after diabetic retinopathy is diagnosed. In most cases, with careful monitoring, treatment can begin before sight is affected.
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