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There are many patients with Diabetes Mellitus who believe that it is simply an inability to effectively metabolize and process glucose. Unfortunately, the reality is that the effects of diabetes are considerably more widespread and actually affect many organs and tissues throughout your body. Diabetes causes damage to the small blood vessels throughout the body. When diabetes damages these small blood vessels it can impair the normal circulation of blood in organs and tissues. It is quite common for patients with diabetes to experience difficulty with the circulation in their legs, kidneys, heart, brain and eyes—especially the very small blood vessels of the eye found in the Retina. When diabetes causes damage to the small blood vessels in the retina, it is called Diabetic Retinopathy.
Diabetic Retinopathy is the most frequent cause of new cases of blindness among adults aged 20-74 years old. However, with early diagnosis and treatment, progression of the disease and its associated vision loss can at a minimum be slowed, and in many cases vision loss from Diabetic Retinopathy can be prevented.
Diabetic Retinopathy tends to appear and progress in Stages beginning with Mild Nonproliferative Retinopathy, progressing to Moderate Nonproliferative Retinopathy, further advancing to Severe Nonproliferative Retinopathy and without proper attention progressing into the most severe stage, Proliferative Retinopathy.
Mild Nonproliferative Retinopathy is the earliest stage of Diabetic Retinopathy. It is characterized by the presence of “dot” and “blot” hemorrhages and “microaneurysms” in the Retina. Microaneurysms are areas of balloon like swelling of the tiny blood vessels in the Retina caused by the weakening of their structure. Mild Nonproliferative Retinopathy can be present without any change in your vision. Mild Nonproliferative Retinopathy usually does not require treatment unless it progresses or is accompanied by Diabetic Macular Edema.
If you have Mild Nonproliferative Retinopathy, Drs. Stahl and Knowles will make specific recommendations about how often you will need to be reexamined and whether any additional testing might be required by a Retina Specialist.
Moderate Nonproliferative Retinopathy is the second and slightly more severe stage of Diabetic Retinopathy. It is similar to the mild stages, but with more extensive changes. During this stage, some of the small blood vessels in the Retina may become damaged enough so that they close off. The closure of these tiny blood vessels causes a decrease in the supply of nutrients and oxygen to certain areas of the Retina that is termed ischemia.
Severe Nonproliferative Retinopathy is the next stage of Diabetic Retinopathy. Severe Nonproliferative Retinopathy is characterized by an extensive amount of retinal blood vessel damage and ischemia. Patients with severe Nonproliferative Retinopathy are at a high risk of going to the next stage of retinopathy-the proliferative stage.
Proliferative Retinopathy is the most severe stage of Diabetic Retinopathy and carries a significant risk of vision loss. In an attempt to compensate for the lack of oxygen supply, areas of the Retina send signals to stimulate the growth of new blood vessels in order to try and reestablish the supply of oxygen. These chemical signals stimulate the growth of new, but abnormal blood vessels, a process called neovascularization. When Retinal Neovascularization is present, you have progressed into the stage of Diabetic Retinopathy called Proliferative Retinopathy. It might seem that new blood vessel growth or neovascularization is a desirable event, as it will provide the Retina with greater blood flow and thus more oxygen and nutrients. However this is not the case at all. Retinal Neovascularization is formed from new blood vessels that are extremely fragile and tend to break easily and hemorrhage into the Vitreous. If left untreated, Proliferative Retinopathy may lead to bleeding into the Vitreous and Retinal Detachment with profound vision loss.
It may be possible for patients to have Proliferative Retinopathy and Retinal Neovascularization and yet still have good vision. Even if Proliferative Retinopathy and Retinal Neovascularization do not appear to be causing any vision loss, it is critical that this stage be treated as quickly as possible in order to stop the progression and preserve good vision.
Normally, the small blood vessels in the Retina do not leak. One of the early effects of diabetes is to cause the blood vessels in the Retina to begin to leak by weakening the inner lining of the blood vessels so that they become porous. Leakage from the retinal blood vessels may cause the center of the Retina, the Macula, to actually swell, a condition called Diabetic Macular Edema. Diabetic Macular Edema can occur in any stage of Diabetic Retinopathy.
The Macula is responsible for central vision, and thus Diabetic Macular Edema can result in vision loss of varying severity. The most effective and accurate ways to observe and diagnose Diabetic Macular Edema are to perform a careful dilated examination usually accompanied with a Fluorescein Angiogram (FA) and an Ocular Coherence Tomography (OCT). Using the Fluorescein Angiogram, it is possible to precisely and directly observe the severity and location of “leaky” blood vessels. By using OCT, it is possible to detect very slight thickness changes in the Macula that may indicate the presence of leakage. It is important that leaking blood vessels be found as early as possible so that they can be most effectively sealed with Retinal Laser Photocoagulation Treatment. In most cases, early laser treatment will reduce the swelling and prevent further vision loss, but will not restore vision that has already been compromised.
It is also possible to have Diabetic Macular Edema and not have vision loss. Any diagnosis of Diabetic Macular Edema is an indication that breakdown of the retinal blood vessels from diabetes is beginning and requires careful monitoring. In the discussion about your stage of Diabetic Retinopathy, Drs. Stahl and Knowles will also make specific recommendations about how often you will need to return for eye examinations and the need for additional photographs, Fluorescein Angiograms or OCT Studies. Please be sure to keep these appointments, as they are critical in helping you maintain your eye health and vision.
It is critical for all patients with diabetes to have regular eye exams since with early and aggressive treatment of Diabetic Retinopathy it is often possible to maintain vision and prevent severe vision loss.
The National Institutes of Health and the National Eye Institute have funded a number of large scale, multi-center, controlled studies that have produced important clinical care guidelines for Diabetic Retinopathy.
Early Treatment Diabetic Retinopathy Study (ETDRS)
Diabetes Control and Complications Trial (DCCT)
Diabetic Retinopathy Study (DRS)
Diabetic Retinopathy Vitrectomy Study (DRVS
During the early stages of Mild Nonproliferative Retinopathy, Moderate Nonproliferative Retinopathy and the beginning of Severe Nonproliferative Retinopathy, it is not likely that you will need Laser Treatment, unless you have Diabetic Macular Edema. However, in order to prevent the progression of Diabetic Retinopathy it is quite important to maintain good overall health. First, tight control of blood sugar levels is key for protecting the health of the small blood vessels. Patients should work to reduce any and all risk factors for vascular disease including controlling their blood pressure, not smoking, reducing dietary fat consumption to lower cholesterol and trigycerides and exercising regularly.
Proliferative Retinopathy is treated with a Retinal Laser Photocoagulation procedure called “Scatter Laser Treatment”. The goal of Scatter Laser Treatment is to shrink abnormal blood vessels. Drs. Stahl and Knowles will refer you a Retina Specialist if you require a Diabetic Laser Treatment. Typically, a Scatter Laser Treatment requires the placement of approximately 1,000 to 2,000 laser spots in areas of the Retina away from the Macula, causing the abnormal blood vessels to shrink. Since Scatter Laser Treatment requires a large number of laser spots, it is often necessary to use two or more sessions to complete the laser treatment.
Sometimes patients who have had Scatter Laser Photocoagulation will experience some loss of their side or peripheral vision, some loss of night vision and a decrease in color vision. However, Scatter Laser Treatment is necessary to preserve the rest of your vision and stop the progression of the disease.
If this is unsuccessful in stopping the progression of the Proliferative Retinopathy, or when a Vitreous Hemorrhage occurs and does not clear on its own, or when a Retinal Detachment develops, then a Vitrectomy is often helpful. A Vitrectomy involves inserting instruments into the eye, and removing the vitreous gel, any blood present in the vitreous cavity, and removing the scar tissue that has grown on the surface of the Retina.
Diabetic Macular Edema is best treated with one of two types of Retinal Laser Photocoagulation procedures: “Focal Laser Treatment” and “Grid Laser Treatment”. Focal Laser treatment is used to close leaking micro aneurysms in a limited area and Grid Laser treatment is used to treat a more diffuse swelling in the Macula.
With either type of Laser Treatment for Macular Edema, a Retina Specialist will place laser spots in the areas of retinal leakage surrounding the Macula. These spots act to slow the leakage of fluid and reduce the amount of fluid in the Retina. It is usually possible to complete these Laser Treatments in one session, however depending on the results additional treatment may be necessary.
You may need to have Laser Treatment for Macular Edema more than once to control the leaking fluid. If you have Macular edema in both eyes and require laser surgery, generally only one eye will be treated at a time
Laser treatment of Diabetic Macular Edema works to stabilize vision. In fact, Laser Treatment may reduce the risk of vision loss by 50 percent. In a small number of cases, if vision is lost, it may be improved. It is important to restate that this treatment is performed to keep vision form further declining but does not usually result in improvement in vision already lost. This is why it is so crucial to have regular eye examinations; the goal is to diagnose vision-threatening disease before vision is compromised.
Diabetic Retinopathy is a common eye disease that affects a large number of patients with Diabetes Mellitus. With early detection and treatment, vision loss from Diabetic Retinopathy can be prevented.
Stahl Vision Laser & Eye Surgery Center in Dayton Ohio is conveniently located for patients concerned about Diabetic Eye Problems such as Diabetic Retinopathy or needing a Diabetic eye examination from Sidney, Springfield, Urbana, Dayton, Cincinnati, West Chester, Eaton, Xenia, Jamestown, Franklin, Springboro, Waynesville, Lebanon, Mason, Oxford, and Middletown Ohio. Please call Stahl Vision at 937.643.2020 to schedule an appointment.