Diabetic Retinopathy

Understanding diabetic retinopathy
Diabetes is a disease that causes blood sugar (glucose) to accumulate in the blood. It can damage almost every major organ in your body and be fatal if not controlled. The disease affects millions of adults and children and can develop gradually over many years, often with no symptoms. It is also the sixth leading cause of death in the United States.

Diabetes can contribute to eye disorders and blindness, heart disease, stroke, kidney failure, amputation and nerve damage. It can also affect pregnancy and cause birth defects.

While there is no cure for diabetes, eating right, maintaining a healthy weight and getting plenty of exercise can help prevent the disease. If you have diabetes, diet and exercise along with medications that control blood sugar can help you continue to live a healthy and active life. Click here to learn more about diabetes

What is diabetic retinopathy?
Diabetes damages blood vessels in the rear of the eye. This condition is called diabetic retinopathy. It can lead to vision loss or blindness. You already may have diabetic retinopathy, or be at risk for it. But you can take steps to reduce your risk of vision loss from this condition.

Diabetes and vision loss
A glance out the window helps you choose between a sweater and raincoat. Reading to your grandchild turns a normal day into something special. Having diabetes may threaten your visual link with the world. That’s frightening. But you can work with your healthcare team to manage your diabetes and keep diabetic retinopathy under control.

Diabetic retinopathy and its symptoms
At first, diabetic retinopathy may cause no vision loss or other symptoms. But over time, it can still harm vision. If you have symptoms of diabetic retinopathy, they may include : 

  • Having blurry, darkened, or cloudy vision.
  • Seeing floaters (dark spots) or black lines.

If you become pregnant
Pregnancy can make diabetic retinopathy worse. If you’re thinking of having a baby, see your eye doctor right away. He or she should examine your eyes before you become pregnant, if possible. You should also be examined during your pregnancy, especially during the first 3 months.

Learning about diabetic retinopathy
Your healthcare team will help you learn more about diabetic retinopathy and how to control it. When you meet your doctors, ask questions. Take notes, or have a family member or friend take notes. Ask for written instructions from your healthcare team.

Your ophthalmologist 
Ophthalmologists are medical doctors. They oversee vision care, diagnose and treat eye disorders, and perform surgery on the eye. Together, you and your ophthalmologist will design a treatment plan to protect your vision. Keeping your appointments and following your treatment plan will help you save your sight.

Anatomy of the Eye
The eye receives and processes light. The retina (the inside lining of the eye) turns light into nerve signals. These become visual images in the brain. Tiny capillaries (blood vessels) bring blood to nourish the retina.

How you see 
Light enters the eye through the pupil. The light passes through the clear tissue of the lens and the vitreous (the clear gel that fills the eye). The light then strikes the retina, where special cells send signals to the brain. The brain turns these signals into visual images resulting in what you see.



The healthy retina
A healthy retina includes:

  • The macula, the area of the retina where sharp central vision takes place.
  • The fovea, the most sensitive part of he macula.
  • The periphery, which surrounds the macula. This provides peripheral (side) vision what we see outside our sharp central vision.
  • Capillaries that nourish the retina with blood.


Diabetes and the eye
Diabetes can cause capillaries on the retina to leak or collapse. Then fragile new capillaries may grow on the retina, causing more damage. Both types of damage to the retina are forms of diabetic retinopathy.

An unhealthy retina
Damaged capillaries can interfere with vision. They can also reduce the amount of blood nourishing the retina. Reduced blood flow causes fragile new capillaries to grow on the retina (neovascularization). As diabetic retinopathy progresses, vision loss can get worse.

Damage from existing capillaries
Existing capillaries may:

  • Form microaneurysms (bulges in the capillary wall). These may leak fluid and fatty substances (hard exudates). This leakage can cause macular edema (swelling).
  • Close up, forming cotton wool spots (soft exudates).
  • Cause bleeding on the retina (dot-blot hemorrhages).


Damage from new capillaries
Fragile new capillaries may: 

  • Bleed into the vitreous.
  • Cause the vitreous to pull on the retina (traction).

Traction can cause bleeding, create scar tissue, or dislodge the retina from the back of the eye (tractional retinal detachment).

How your vision can change
Diabetic retinopathy may progress from its early stage (non-proliferative) to its later stage (proliferative). Either stage may cause vision loss. There may be little or no vision loss at first. But even without early vision loss, diabetic retinopathy still damages the retina. Severe vision loss, even blindness may occur later.

Nonproliferative diabetic retinopathy 
At this stage, capillaries in the retina have been damaged. But there’s no growth of fragile new capillaries on the retina. This stage of diabetic retinopathy may cause no symptoms. Or it may result in some vision loss. This stage is also called background diabetic retinopathy. 

Proliferative diabetic retinopathy 
At this stage, fragile new capillaries begin to grow on the retina. This capillary growth may result in bleeding or traction, causing severe vision loss. This stage is more common in people who have had diabetic retinopathy for along time.

What you may see 
As diabetic retinopathy progresses, seeing clearly may become more difficult. Vision may become more difficult. Vision may quickly get worse without warning. Or it may slowly worsen over time.

No vision loss yet 
Problems such as leakage, closed capillaries, or capillary growth may be present. But they may not yet have affected your vision.

Slight to moderate vision loss
Problems with capillaries such as swelling due to focal leakage (leakage near the fovea), cotton wool spots, or capillary closure may result in the first signs of vision loss.

Moderate to severe vision loss
Vision may decline even more because of swelling due to diffuse leakage (leakage throughout the macula) or other worsening problems with capillaries

Cloudy, blurry vision
This often results when weak new capillaries growing into the vitreous begin to bleed.

Severely reduced vision 
Capillary growth and scar tissue in the vitreous may result in traction. Traction may cause the retina to detach from the back of the eye (tractional retinal detachment). If this occurs, vision may be severely impaired.

Managing your health
You can greatly reduce your risk of vision loss from diabetic retinopathy by managing your overall health. Start by closely managing your diabetes. And take care of other health problems that can make diabetic retinopathy worse.

Manage your diabetes
The best way to protect your vision is to keep your blood sugar level in a healthy range. Check your blood sugar regularly. Follow your diabetes management plan. And work with your primary care physician or endocrinologist (diabetes doctor) if you are having trouble keeping your blood sugar in a healthy range.

Control your risk factors
Other factors that damage blood vessels can make diabetic retinopathy worse. These include: 

  • High blood pressure
  • Smoking
  • High cholesterol

Work with your healthcare team to control these problems and help lower your risk. A diabetes educator these problems and help lower your risk. A diabetes educator can help you control blood pressure and high cholesterol. He or she can also recommend stop-smoking programs.

Using the amslers grid
An amsler grid helps you track changes in your vision. Use the grid below. Or use one supplied by your eye doctor. Use the grid as often as he or she suggests. Keep the grid where you’ll remember to use it. If you notice any vision changes even if your vision improves call your ophthalmologist.


How to use the amsler grid 

  1. Use it in a well lighted area.
  2. Wear glasses or contacts if you usually wear them.
  3. Hold the grid at your normal reading distance (about 16 inches)
  4. Cover your left eye.
  5. Look at the dot in the grid’s center with your right eye.
  6. While looking at the dot, notice if any of the lines appear wavy or disappear, of if the boxes change shape.
  7. Jot down any changes from the last time you used the grid.
  8. Repeat with your other eye.
  9. If you have noticed any vision changes, call your ophthalmologist right away.


Evaluating your eyes
You need to visit your ophthalmologist for a complete dilated eye exam at least once yearly (more often if you’re pregnant). During the exam, he or she will review your medical history, check your vision and examine your eyes.

Your medical history 
Your ophthalmologist will ask you about:

  • Your diabetes type, history, treatments (such as insulin), and how you monitor your blood sugar level.
  • Your family’s health, including whether any relative has had diabetes or diabetic retinopathy.
  • Any diseases, surgeries, or other medical procedures you’ve had.
  • Any medications, herbs, or supplements you use, including those you buy over-the counter.

Your eye exam
Your ophthalmologist uses an eye chart and other special tools to check your vision. Then he or she will examine your eyes for signs of disease. After eye drops dilate (widen) your pupils, you may have one or more of the following tests:

  • Tonometry. This measures fluid pressure inside your eye.
  • Slit lamp exam. This lets your doctor view the structures of the eye.
  • Ultrasound. This uses sound waves to create an image of your eye. It may be used if there is blood in the vitreous.

Fluorescein angiography

Fluorescein angiography uses special photographs of the retina to reveal changes in the capillaries. Before this procedure, dye is injected into your arm or hand. The dye highlights capillaries in the retina. Photographs are taken before and after the dye is injected. During the procedure you may briefly feel some nausea. After the procedure, your skin, eyes, and urine may appear yellow for a few hours.



What’s the next step? 

Your ophthalmologist will work with you to design a treatment plan that’s best for you. You may need more than one type of treatment: 

  • Laser photocoagulation, to control leaking capillaries and prevent growth of new capillaries
  • Vitrectomy, to remove a cloudy vitreous and scar tissue
  • Cryotherapy, to shrink capillaries and repair the retina
  • Other surgery or medications as recommended by your ophthalmologist

Having laser treatment
Laser photocoagulation uses a laser (a hig-energy light source) to treat diabetic retinopathy. But it may slow or halt the progress of the disease.

How is the laser used?
During the procedure, a laser beam is focused on the retina. The laser seals weak capillaries. It also slows or stops new capillary growth.

Types of laser treatment 
The type of treatment you receive depends on the extent and location of damaged capillaries. Treatment may take from a few minutes to a half hour or so. You may need more than one treatment session or type of treatment.

Preparing for laser treatment
Tell your ophthalmologist about all medications, herbal remedies, or supplements you use, such as aspirin, ibuprofen, blood thinners, or gingko. Bring dark sunglasses to wear on the way home. Arrange for someone to drive you home after surgery.

During laser treatment 
Laser treatment may be done at the doctor’s office, hospital, or eye center. You’ll be awake during treatment. The doctor uses eyedrops to dilate your pupil. The doctor will then hold a special contact lens against your eye.

Contolling pain
Laser treatment may cause some discomfort. If so you’ll be given medication to control it. If the discomfort continues, tell your doctor. 

After laser treatment
You may be given a patch to protect your eye for a few days. Ask your doctor how long you need to avoid lifting exercising, or swimming. Also ask when you can return to work.

When to call your doctor
If you have sudden pain or notice decreasing vision after surgery, call your ophthalmologist.

Having vitrectomy
If blood or debris in the vitreous is clouding your vision, your doctor may recommend vitrectomy. This surgery removes the cloudy vitreous. The vitreous is replaced with fluid or gas. If vision problems continue after vitrectomy, you need additional surgery.

Preparing for vitrectomy
Before your surgery, tell your doctor about medications, herbal remedies, or supplements you use. These may include aspirin, ibuprofen, blood thinners, or gingko. Before surgery, you’ll meet with an anaesthetist ( a doctor who provides medication to control pain). You’ll meet to discuss your anesthesia (pain medication).

During vitrectomy 
Tiny instruments are inserted through small incisions in the sclera. The vitreous is removed. It’s replaced with saline (salt water) solution or a gas bubble to hold the retina in place. Surgery may take several hours. 

When to call your doctor if-pain or vision loss worsens after you go home, call your ophthalmologist.

After vitrectomy
Have an adult friend or family member drive you home after the procedure. Wear dark sunglasses on the way home. You’ll be told how to care for your patch or bandages. Don’t rub, bump, or touch your eye. You’ll receive medication to control pain.

Risks and complications of vitrectomy 

  • Swollen or droopy eyelid
  • Double or blurry vision
  • Bloody sclera
  • Watery or red discharge
  • Pain
  • Cloudiness in lens (cataract)
  • Residual vision loss

You are the most important member of your healthcare team. Work with your doctors and other healthcare providers to manage your diabetes. Keep visiting your ophthalmologist for regular eye exams and vision care.

Keep your medical appointments 
Diabetes can harm blood vessels throughout your body as well as inside your eyes. Protect your health and vision with regular medical exams: 

  • Keep scheduled appointments with your healthcare providers.
  • Have lab work such as blood or urine tests done as directed.
  • Visit your ophthalmologist for an eye exam at least yearly.


Finding helps with vision care 
Your healthcare team will help you protect your vision. If you have questions, ask your doctors or other healthcare providers. Share your concerns with your family, friends, or clergy. For help with diabetes and vision care, call or write your state or local commission on the blind.

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