Treatment For Diabetic Retinopathy
With the progression of diabetic retinopathy, areas that cannot be fed cause new vessel formation. Hemorrhages developing in these vessels are on the retinal surface; It causes membrane development, detachment of the retina, and many other eye problems that may occur in the eye.
Regular eye check-ups are very important in this slowly progressing disease. The disease can be successfully treated with early diagnosis, but if treatment is delayed, diabetic retinopathy can cause permanent vision loss and blindness. Diabetic retinopathy is classified as nonproliferative diabetic retinopathy (early stage) or proliferative diabetic retinopathy (late-stage) (advanced stage).
What parts of the eye does diabetes affect?
When does diabetes affect the eyes and how does it cause vision loss?
Diabetes duration is closely connected to ocular problems. Retinopathy occurs at varying rates 20 years after the beginning of diabetes in virtually all instances of Type I diabetes and in more than 60% of cases of Type II diabetes.
What is the main pathology of diabetic retinopathy?
Diabetes causes basement membrane thickening in the capillary wall, loss of intramural pericytes, and endothelial cell damage. The increase in erythrocyte and thrombocyte aggregation and high fibrinogen levels also help vascular occlusion.
Thus, the developing capillary and arteriolar occlusion causes retinal hypoxia, which in turn causes the release of angiogenic factors from the retina, these factors cause the formation of new vessels in various regions of the eye (retina, optic disc, iris, anterior chamber angle). These veins are abnormal veins that bleed easily.
Is there a distinction between Type I and Type II diabetes in terms of eye involvement?
Proliferative diabetic retinopathy (PDR) is more common in Type I cases, and diabetic macular edema is more common in Type II diabetic cases. The frequency of PDR increases in type II diabetic patients who use insulin. Temporary papilla edema may develop in Type I, and permanent optic atrophy may develop due to ischemic optic neuropathy in Type II diabetes.
How many types of retinopathy develop in diabetes?
Diabetes causes two types of retinopathy.
1- Non-proliferative
• Mild: At least 1 microaneurysm (MA) or hemorrhage
• Moderate: Multiple MA/hemorrhage, hard-soft exudates, macular edema, and venous changes
• Severe: 4-2-1 rule
• MA/ in 4 quadrants hemorrhage
• Venous loop in 2 quadrants
• IRMA (intraretinal microvascular anomaly) in 1 quadrant
2- Proliferative
• Optic disc neovascularization
• Retinal neovascularization
• Pre-retinal hemorrhage
• Vitreous hemorrhage
• Tractional retinal detachment
• Iris and anterior chamber angle neovascularization
What exactly is diabetic macular edema?
They are separated from the non-edematous retina by hard exudates. Diffuse edema is a generalized leakage from abnormally permeable and dilated capillaries. When they involve the fovea, both have decreased vision. Focal and grid laser treatment may be required in the treatment of macular edema.
Is there an impact of intensive insulin treatment on retinopathy?
Retinal capillary loss and leakage levels are lower in those receiving intensive insulin therapy than in those receiving conventional insulin therapy. However, it should be kept in mind that macular edema becomes more severe at the beginning in those receiving intensive treatment. This edema later regresses.
Does diabetic retinopathy have a relationship with age, at what age is it seen earliest?
Diabetic retinopathy becomes more common as people become older. The most major reason for this is the lengthening of diabetes. Retinopathy does not appear before puberty. After the diagnosis of diabetes, retinopathy develops before 5-6 years in Type I cases. However, the period before puberty is added as a risk factor.
Does long-term treatment of diabetics affect retinopathy?
Regulation of diabetes delays the onset of retinopathy. However, conventional (twice a day) insulin therapy does not affect the progression of retinopathy as positively as intensive insulin therapy after the development of retinopathy.
Does systemic hypertension, smoking, and alcohol use have an effect on retinopathy?
Systemic hypertension is linked to the development and progression of diabetic retinopathy. It should not be forgotten that hypertension is a risk factor for diabetic retinopathy. Smoking and large amounts of alcohol use are also known to accelerate the progression of retinopathy.
Is education related to vision loss?
Education and socio-economic status have an indirect relationship with the development of diabetic retinopathy and vision loss. Proliferative diabetic retinopathy develops earlier in women with type I with lower education levels.
Is there a gender difference in diabetic retinopathy?
In women under 50 years of age, retinopathy develops up to two years earlier than in men. Over the age of 50, there is no distinction between them.
Does aspirin have an effect on retinopathy?
Studies have shown that aspirin therapy given as 650 mg per day does not change the course of diabetic retinopathy, does not reduce the risk of proliferative diabetic retinopathy, vision loss, and does not increase the risk of vitreous hemorrhage.
Is there a relationship between glaucoma and diabetic retinopathy?
Elevated intraocular pressure is approximately twice as common in diabetics than in the normal population. It is likely due to a common genetic cause. Another view is that the optic nerve circulation is affected in diabetics and therefore these patients are more sensitive to increased intraocular pressure.
Does diabetes cause glaucoma?
Apart from the frequent co-occurrence of diabetes and glaucoma, diabetes itself causes neovascular glaucoma (new vascularization in the iris and anterior chamber angle, closure of the angle with fibrovascular tissue, and the inability to get out of the intraocular fluid increases intraocular pressure).
Is there a relationship between proteinuria and retinopathy?
Proteinuria (0.3 g/l) is a risk factor for the development of proliferative diabetic retinopathy in type I diabetic patients.
Effect of refractive errors on diabetic retinopathy:
High myopia has a protective effect against the development of PDR (proliferative diabetic retinopathy). However, this positive effect is not in question against nonproliferative diabetic retinopathy (NDR).
Diabetes causes refractive errors:
Diabetes can cause temporary refractive errors. Myopia develops in hyperglycemia, and hyperopia develops in hypoglycemia. Therefore, it should be kept in mind that metabolic control may be poor in visual acuity changes not caused by retinopathy.
Does diabetes affect both eyes equally?
In diabetic retinopathy, there is usually asymmetry between the two eyes. The rate of asymmetric cases is less than 10%.
What tests can detect diabetic retinopathy?
Why is fundus fluorescein angiography used in diabetes?
The presence of diabetic retinopathy can be detected by the appearance of microaneurysms (MA), hemorrhage, hard and soft exudates, diameter changes of the veins, IRMA, and neovascularization in the fundus. However, FFA is required for the complete diagnosis and treatment of macular edema, and there may be leaky MAs that are not seen by ophthalmoscopy. Apart from these, sometimes even in very severe diabetic retinopathy, midperipheral retinal ischemia may not give any ophthalmoscopic findings. For these reasons, FFA is used in the diagnosis and sometimes follow-up of diabetic retinopathy.
Does pregnancy affect diabetic retinopathy, is it necessary to terminate the pregnancy early?
The effect of pregnancy on the eyes of a diabetic woman is largely related to the state of retinopathy at the beginning of pregnancy. As a result, it is advised that diabetic women have children as soon as feasible. It has been shown that 50% of the cases with non-proliferative diabetic retinopathy (NDR) have retinopathies during pregnancy, but 5% of them pass into the proliferative period. Retinal pathologies are stretched in most of the cases after birth. Retinal pathologies are exacerbated in 46% of patients with proliferative diabetic retinopathy (PDR) at the beginning of pregnancy.
However, only 26% of patients who received adequate laser treatment before pregnancy were able to develop new vessels. 86% of the patients who underwent laser treatment during pregnancy responded to this treatment method. Previous pregnancies do not increase the risk of diabetic retinopathy and do not change the response to laser therapy. Due to laser treatment and vitreoretinal surgical techniques, it is not necessary to terminate the pregnancy early due to eye complications.
Women who develop diabetes while pregnant (gestational diabetes) are not at risk for retinopathy.
Pregnant women should be checked at the beginning of their pregnancy, if they have NDRs, they should have an eye check every three months if PDR is present.
How often should diabetic patients undergo eye examination?
Vision-threatening retinopathy is not seen in Type I cases in the first 5-6 years after the onset of diabetes and before puberty. In type II cases, when diabetes is diagnosed, retinopathy can also be determined. The rate of those with retinopathy in the eye control performed as soon as the diagnosis of diabetes is made has been reported as 3%. This rate must be much higher in our country. If there is no evidence of diabetes in the fundus in diabetics, annual controls are sufficient. Cases with NDR should be checked every 6 months, and cases with PDR every 2-3 months.
When should eye check-ups be done for those with a family history of diabetes?
These cases are no different from other normal people. However, everyone should be examined after the age of 40, especially for glaucoma.
Do other eye diseases have an effect on retinopathy?
In eye diseases such as retinitis and uveitis, which cause widespread damage to the retina, and in age-related macular degeneration, retinopathy does not develop or its severity is mild.
Are there risks of cataract surgery in diabetics, can intraocular lenses be fitted to these patients?
The intraoperative risk of diabetic cataracts does not exist unless there is neovascularization in the iris. Today, intraocular lenses can be inserted even in cases with very severe PDR. However, it should be known that diabetic retinopathy may worsen after cataract surgery. It is very important that laser treatments are performed on time in these cases.
Is there a relationship between systemic complications of diabetes and eye complications?
The severity of retinopathy increases with systemic complications, especially neuropathy and nephropathy.
Treatment options in diabetic retinopathy
What should be done to detect diabetic retinopathy? First of all, the patient's visual acuity should be measured and then the retina (bottom of the eye) should be scanned in detail by dilating the pupils with drops. After the affected areas are identified, a test called FFA is performed if deemed necessary. Thanks to a dyed substance given from your vein, a photograph of the bottom of your eye are taken and leaky veins and areas that cannot be fed are detected.
This method makes the treatment decision easier. Since it reduces the risk of vision loss by 50%, LFC (Laser photocoagulation) treatment and intraocular drug injection treatment are performed in both eyes regardless of visual acuity in clinically significant macular edema. The main purpose of the treatment is to close the bleeding and leaky vessels and to protect the patient's vision level. In order to avoid the progression of Diabetic Retinopathy, it is beneficial for diabetics to keep their blood sugar, blood cholesterol, and blood pressure (arm blood pressure) levels under control.
Women who develop diabetes while pregnant (gestational diabetes) are not at risk for retinopathy. This method is called scatter (non-intensive) laser treatment. The aim of laser treatment is to help close abnormal blood vessels. The doctor creates 1000-2000 laser burns away from the macula area to close the abnormal vessels in the retina layer of the eye. Since it is necessary to create a large number of laser burns in the treatment, the treatment is usually completed in two or more sessions.
Although there may be a decrease in peripheral vision after treatment, your current level of vision can be preserved with laser treatment. Your color vision and night vision may suffer as a result of laser treatment. Laser therapy is more effective when applied before the abnormal blood vessels begin to bleed. Diabetic patients should regularly have a detailed eye examination of the dilated pupil, and even if bleeding begins, laser treatment is still possible, depending on the level of bleeding.
What is used in the treatment of diabetic retinopathy?
The most commonly used treatment in the treatment of diabetic retinopathy is laser therapy. When laser treatment is not effective, surgery (vitreoretinal) surgery is required in approximately 1/3 of the cases. In cases where neovascular glaucoma develops, tube implantations and cryo applications are required together with vitreoretinal surgery.
Why is laser treatment performed in diabetic retinopathy, what are its aims?
Although diabetic retinopathy itself cannot be prevented, its complications leading to blindness can be reduced. In macular edema, it is tried to restore the inner and outer blood-retina barrier to health with focal or grid style laser treatment. In PDR, on the other hand, by destroying the ischemic regions with laser, the emergence of angiogenic factors released from these regions is prevented, thus the neovascularization stimulus is inhibited.
When is surgical treatment required in the treatment of diabetic retinopathy?
Vitreo-retinal surgical techniques are applied in the following situations:
• Vitreous hemorrhage
• Pre-retinal hemorrhage
• Tractional macular detachment
• Tractional + rhegmatogenous retinal detachment
• Chronic macular edema (due to traction)
• Active non-regressive proliferative diabetic retinopathy
• Rubeosis iridis (with iris vascularization) In the presence of media opacity that prevents laser treatment
If vitreous hemorrhages in type I diabetic cases do not recede within 1-2 months, vitrectomy is performed in the early period. On the other hand, if there is no macular or retinal detachment in type II cases, if the other eyes of the patients can be seen, 6 or even 12 months can be waited for the bleeding to stop. In conclusion, diabetic retinopathy is one of the most common complications of diabetes, which can cause severe vision loss if not treated, and whose adverse effects can be kept to a minimum with proper metabolic control, follow-up, and treatment.
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