Dr Miloni Shah
Diabetes mellitus, commonly known as Diabetes; can affect multiple organs. Eyes get commonly affected too. In the eye, it can cause several manifestations, but the most common being diabetic retinopathy which affects the small blood vessels of the retina, which is the back part of the eye.
Who are at risk of developing Diabetic Retinopathy?
It is more common in people with type 1 diabetes.
- Duration of diabetes: Longer the duration of Diabetes, the more the chance of developing Diabetic retinopathy. It is relatively uncommon if you have had diabetes for less than five years. The chance of having retinopathy increases as high as 90%; when the duration of diabetes is more than 30 years.
- Poor blood sugar (glucose) control. Studies have shown that those people with poor control of their diabetes are more likely to develop various complications, including retinopathy.
However, it is also possible that people who have controlled sugars can still have developed diabetic retinopathy.
- High blood pressure (hypertension). If blood pressure is not well controlled then this will increase your risk of developing retinopathy.
- Kidney disease (nephropathy). Having kidney disease as a result of your diabetes is associated with worsening retinopathy.
- Extra care needs to be taken if you are pregnant. Since, during pregnancy retinopathy tends to worsen, especially if your blood glucose is poorly controlled.
- Other risk factors include smoking, obesity and having a high cholesterol level.
How does diabetic retinopathy happen?
- Diabetic retinopathy happens over several years, especially in those who have uncontrolled or poor control of sugars.
- The damage to the eyes starts when high sugar levels damage the blood vessels supplying the retina, causing them to leak fluid or bleed. To make up for these blocked blood vessels, eyes then grow new blood vessels that don’t work well. These new blood vessels tend to leak and/or bleed easily.
What are the symptoms one may experience?
A diabetic person may not experience any symptoms in the eyes during the early stages of the disease.
Background retinopathy or non-proliferative diabetic retinopathy (NPDR) which can be graded as mild, moderate and severe NPDR does not change the vision by itself.
However,the accumulation of fluid inside the retina called diabetic macular edema (DME) is the most common cause of vision loss in cases of NPDR. This results in blurred or cloudy vision.
Proliferative Diabetic retinopathy(PDR) occurs when damaged blood vessels in the retina make chemicals called growth factors. These can cause new tiny blood vessels to grow (proliferate) from the damaged blood vessels. This is an attempt to repair the damage. However, these new blood vessels are not normal. They are delicate and can easily bleed(vitreous hemorrhage), obscuring your vision or can even cause black spots to appear(floaters) in front of your eye. In this type of retinopathy, without laser treatment, vision is likely to become badly affected.
The fibrous growth with such new vessels if left untreated can lead to detachment of retina (tractional retinal detachment). Vitreous hemorrhage and tractional retinal detachment are two causes of severe vision loss in the eye and often require surgery.
At times, such new vessels can form in the front of the eye blocking the drainage channels causing increased pressure (glaucoma). Neo-vascular glaucoma an advanced disease in such cases is often vision threatening if not immediately addressed.
What can be done to prevent Diabetic Retinopathy?
Control of sugars is the ultimate and the best way to lower the risk of developing orprogression of diabetic retinopathy. A healthy diet, regular physical activity, regularly checking your blood sugar levels and following doctor’s instructions and being compliant with your diabetes medications can all help in the control of diabetic retinopathy.
HbA1c is a more reliable way of knowing the control of sugar over the past 3 months and should be done regularly. The goal should be to keep it below 7%.
Control of other risk factors like high blood pressure or high cholesterol along with diabetes decreasesyour risk for diabetic retinopathy. Smoking is a significant yet modifiable risk factor that needs attention as well.
What is a role of an Ophthalmologist?
If you have diabetes, then it is very important to get your eyes checked routinely. Early diagnosis and prompttreatment can prevent future loss of vision. Therefore, you must have regular eye checks to detect retinopathy before your vision becomes badly affected. You should have an eye check at least once a year.
In a newly diagnosed Type 2 DM, baseline eye and fundus evaluation are mandatory.
If necessary, an ophthalmologist may subject you to various investigations such as Fundus photography, which may help to compare with previous examinations), OCT or fundus angiography.
Even if your visit shows you do not have any retinopathy then you should still look after your diabetes and have a healthy lifestyle to reduce the risk of retinopathy developing in the future.
I have diabetic retinopathy… what is the next step?
If you are found to have no retinopathy or mild (background) retinopathy, and your vision is not affected, you will be called for regular check-ups. The retinopathy may not progress to more serious forms, particularly if your diabetes and blood pressure are well controlled. If more severe changes are detected then an ophthalmologist will suggest various treatment options
Certain treatments include:
- Injections: Anti VEGF can help in the treatment of DME. Various Anti-VEGF injections are available in the market and your ophthalmologist can help decide which is suited best for you.
Sometimes Intravitreal steroids injections are also given.
- Laser treatment:Laser treatment is used mainly if you have new vessels growing (proliferative retinopathy), or if any type of retinopathy is affecting the macula. It is not a surgery per se and is an outpatient department procedure. It does not help in increasing the lost vision but can help to halt the progression of the disease. A burn can seal leaks from blood vessels, and stop new vessels from growing further. The burns are so tiny and accurate that they can treat a tiny abnormal blood vessel. Several hundred burns may be needed to treat retinopathy. Multiple sittings may be needed, depending onthe treatment.
Also, one must remember, sometimes despite laser, the retinopathy can progress subjecting to other modes of treatment such as surgery.
If the retinopathy is beyond observation, injections or laser, then your ophthalmologists can give you the option of surgery. Sometimes multiple interventions may be needed, depending on the severity of the disease.
Remember, diabetes doesn’t necessarily lead to vision loss. Taking an active role in diabetes management can go a long way toward preventing complications.
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