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StahlVision:  Diabetes

    Diabetic retinopathy is a complication of diabetes mellitus. Diabetes damages the normal circulation of the body. That is why diabetics have problems with the circulation to their legs, kidneys, heart, brain and eyes. 

     Initially, diabetes causes the blood vessels in the back of the eye, called the retina, to leak and break.  These early signs of diabetes are called background diabetic retinopathy and requires close observation.  There is some evidence that controlling blood sugars, controlling blood pressure, dieting, exercising, and lowering trigylcerides at this point can lower your risk of having background diabetic retinopathy progress.

     With continued leakage of blood vessels, the center part of the retina can swell.  This results in a complication called macular edema or retinal swelling, and is accompanied by vision loss. These leaking vessels can be treated by sealing them with a laser to resolve the swelling and prevent further vision loss. It is important to know that you may have excellent vision and may still have significant macular edema. Macular edema is the diagnosis often aided by having a fluoresein angiogram with your eye care professional.

      As the diabetic retinopathy advances, the normal retinal blood vessels begin to close, resulting in a condition called retinal ischemia. In this condition, the retina is now being deprived of sufficient oxygen and nourishment to maintain its normal health. In an effort to compensate for this lack of normal circulation, the retina begins to grow new abnormal blood vessels called neovascularization resulting in a condition called proliferative diabetic retinopathy. The abnormal vessels are quite fragile and often lead to a severe loss of vision due to hemorrhaging, scar tissue formation, and finally retinal detachment. The abnormal blood vessel growth, neovascularization, can often be stopped with laser treatment or surgical removal of the vitreous, called vitrectomy. Just as with macular edema, it is possible to have extensive neovascularization still have excellent vision for some time.

     It is critically important for diabetics to have a comprehensive eye exam at least once a year to evaluate the presence of retinopathy. Simply using dilated or undilated photographs of the retina to screen patients with diabetes is a poor substitute for a complete eye examination by an eye care professional. Taking a single field photograph, even with trained photograph readers, may only produce a sensitivity of detection of diabetic retinopathy of 38% as compared to the “gold standard” of a dilated retina exam by an eye care professional. Moreover, “photographic screening” will NOT detect other significant eye diseases such as glaucoma and cataracts, which may be associated eye complications with diabetes. However, it may be necessary for your eye care professional to take retinal photographs or perform fluorescein angiography on a regular basis to carefully document subtle changes in the retinal circulation. Most insurance carriers use the percentage of diabetics that have had a yearly eye exams as one of the yardsticks of “quality of care” and they encourage their participants to have annual eye exams. 

     Current ADA’s (American Diabetic Association) recommendations are in agreement with yearly eye exams. Also, it is important to note preliminary results of a study reported recently at the American Diabetic Association annual meeting indicated that patients with glucose intolerance (but not frank diabetes) may also develop retinopathy. Thus the ADA’s guidelines may be changing in the future to take this into account.    

      There is good reason to comply with these guidelines. Early and aggressive treatment of diabetic retinopathy has been proven to be extremely successful in prolonging vision and preventing severe vision loss. Large scale, multi-center, double blind studies give us guidelines of those patients that may benefit from laser treatments to preserve vision and delay progression of vision loss.  Many of the studies have found that with laser treatment patients were HALF as likely to go on to lose further vision than if left untreated (both for diabetic macular edema and proliferative diabetic retinopathy).  This is a HUGE therapeutic index!

      The overall maintenance of your health is important in maintaining your retinal circulation, as well as the circulation to your heart and kidneys. All diabetics should work to lower their vascular risk factors, including not smoking, controlling hypertension, exercise, lowering cholesterol and triglycerides, eating a low fat diet and following your family doctor's instructions carefully.

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