Clinica Oftalmologica Dr. Munteanu

Diabetic Retinopathy - complication of diabetes

Retinopatia diabetică, o afecțiune oculară progresivă, poate afecta grav persoanele cu diabet zaharat. Este esențial să înțelegem stadiile și simptomele retinopatiei diabetice pentru a interveni cât mai devreme. Retinopatia diabetică evoluează în patru stadii distincte, de la modificări minore ale vaselor de sânge până la dezvoltarea neovascularizației. Simptomele inițiale pot include vedere încețoșată sau distorsionată, pete întunecate sau pierderea vederii centrale. O intervenție promptă și un tratament adecvat, cum ar fi terapia laser sau injecțiile intravitreene, pot încetini progresia retinopatiei diabetice și pot preveni complicații grave.

1. What is diabetic retinopathy?

Diabetic retinopathy is a complication of diabetes, caused by high blood sugar levels affecting the retina (the receptor for vision).

Can cause blindness unless is diagnosed and treated. 

2. If I am diabetic, do I also have diabetic retinopathy?

Worldwide, diabetic retinopathy is the leading cause of blindness among working-age adults.

387 million people with diabetes worldwide, estimated to rise to 592 million people in 2035.

The worldwide prevalence of diabetic retinopathy in patients with type 1 diabetes is 77.3% and with type 2 is 25.1%.

Among patients aged 25 to 74, diabetic retinopathy is the leading cause of vision loss worldwide. By 2030, it is estimated that 191.0 million people globally will have diabetic retinopathy and approximately 56.3 million will have sight-threatening diabetic retinopathy.

3. How do I prevent diabetic retinopathy?

  • Studies have shown that the most important factor in preventing The most common complication of ocular and general diabetes is blood glucose control. Blood pressure control also plays a key role. 
  • Each 1% reduction in mean HbA1c (glycosylated hemoglobin) was associated with a 21% risk reduction for any diabetes-related complication, 21% for diabetes-related deaths, 14% for myocardial infarction and 37% for microvascular complications (this includes diabetic retinopathy).

4. Risk factors

  1. Duration of diabetes: 
  • In type 1 diabetes, 25% of patients will develop diabetic retinopathy after 5 years, 60% after 10 years and 80% after 15 years
  • In type 2 diabetes, proliferative diabetic retinopathy will develop in 2% of patients if disease duration is 25 years

     2. Glycemic control

  • Recommendation: Hb A1c 7% or 6.5% in selected cases

    3. Increased blood pressureă

    4. Hypercholesterolemia, hypertriglyceridemia

    5. Pregnancy - only if there are previous retinopathy lesions

    6. Kidney failure

    7. Age

    8. Blood clotting problems

    9. Physical inactivity 

5. How do I feel if I have diabetic retinopathy?

  • You may be asymptomatic
  • Vision loss, vision variations
  • Floating flakes
  • Metamorphopsii
Retinopatia diabetica este o complicatie a diabetului, oftalmologie

6. Are there several types of diabetic retinopathy?

The classification of diabetic retinopathy divides it into a non-proliferative and a proliferative form. The non-proliferative form of the disease starts with minimal lesions, whose negative evolution leads to the appearance of retinal haemorrhages and exudates and areas of ischaemia, i.e. non-functional areas of the retina. Proliferative stages are characterised by the appearance of bad (neovascular) blood vessels that invade the fundus and may include the anterior part of the eye, complicated by vitreous haemorrhages and retinal detachment. 

As the disease progresses, diabetic macular edema may develop.

7. What investigations should be performed to diagnose and classify diabetic retinopathy?

In addition to the clinical-ocular examination using the biomicroscope to assess the appearance of the retina, there are two investigations considered "gold-standard" for the diagnosis and staging of diabetic retinopathy:

  • Fluorescein angiography can be used to determine the degree of ischemia or the presence of retinal vascular abnormalities, the presence of retinal edema and neoplasms. 
  • Optical coherence tomography is useful for determining the presence and location of intraretinal and/or subretinal fluid and for measuring retinal thickness. Tomography is essential in monitoring and evaluating response to treatment. 

And the lab tests are important in the evaluation of diabetes and therefore diabetic retinopathy.

Haemoglobin A1c determines the blood glucose value of the last 3 months. A target of 5.5 % - 6.0 % is ideal, although difficult to achieve in some patients. In general, the target is HbA1c ≤ 7. Sometimes, for older patients (≥70 years), diabetologists aim for a slightly higher HbA1C, as levels below 7 have been associated with increased morbidity.

8. What is the treatment for this disease?

  • The most important factor in the medical management of diabetic retinopathy is good glycemic control
  • Adequate control of hypertension
  • Different types of treatment are effective in 90% of cases to prevent severe vision loss.
  • Increasing physical activity
  • Treatment options
    • Laser therapy
    • Anti-VEGF drugs (bevacizumab, ranibizumab, aflibercept) and corticosteroids
    • Surgical intervention

9. How does the laser work in diabetic retinopathy?

Laser treatment for retinopathy, called laser photocoagulation, works in part by creating tiny, painless retinal burns that seal blood vessels and reduce edema. The number of laser spots we apply and the number of treatments you need depend on the type and extent of your retinopathy and how well you respond to treatment. You may have to wait a few months to find out if this treatment is effective for your eye.

10. Role of intravitreal injections with anti-VEGF agents and corticosteroids in diabetic retinopathy

Vascular endothelial growth factor (VEGF) is secreted by the ischemic retina. VEGF leads to a) increased vascular permeability resulting in retinal oedema and b) angiogenesis or the formation of new blood vessels (neovessels). Due to this pathophysiological mechanism one of the treatment options is the injection of anti-VEGF substances. 

In the last few years, anti-vascular endothelial growth factor (anti-VEGF) inhibitors have become first-line therapy in diabetic macular oedema. 

Injections are performed in the operating room, following strict hygiene and disinfection measures. The drug is injected intraocularly through a very thin 30 Ga needle. The procedure takes a few seconds and is painless. In most cases patients require several intraocular injections, depending on the response to treatment, assessed by coherence tomography. optics. Risks of the procedure occur extremely rarely, but range from intraocular infections to heart disease. 

11. Surgical intervention in patients with diabetic retinopathy

In case of diabetic retinopathy complications, vitreous hemorrhage, retinal detachment, the only treatment is posterior vitrectomy surgery. In these cases the postoperative visual prognosis is reserved. 

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Dr. Munteanu