DIABETES

First of all, what is diabetes?  Diabetes is a metabolic disease that affects the vascular system, particularly the smaller blood vessels in the body.  The body depends on hemaglobin in red blood cells to carry oxygen to all the tissues and organs in order to sustain life.  When the body cannot produce or properly use insulin, it cannot convert glucose (sugars), starches, and other food sources into energy.  This results in too much glucose in the blood, and not enough oxygen. Chronic elevation of blood glucose levels lead to damage of blood vessels.  Some of the smallest and most capillary rich vessels in the body are found in the hands and feet, and most especially the eyes.

CAUSES

Several factors are involved in the cause of diabetes.  Suffice it to say that environmental factors such as obesity, lack of exercise and proper nutrition, as well as genetics can all play a role.

When diabetes starts to damage the vessels in the eye, it is called Diabetic Retinopathy. Diabetic Retinopathy is a common eye disease.  When the smaller blood vessels in the eye are damaged, it will result in areas where the vessels will bulge, leak, or actually rupture.  If the underlying cause (diabetes) goes uncontrolled or untreated, it can lead to reduced vision and ultimately blindness.  Diabetic retinopathy is one of the most common causes of blindness for adults in the United States.

TYPES

There are two main categories of diabetic retinopathy: nonproliferative and proliferative.

Nonproliferative diabetic retinopathy (NPDR): this is the initial stage of retinopathy.  It is virtually unnoticeable for the patient in this stage; however, the doctor can see the damage in the eye with the aid of ocular instruments.  The damage that will be present in the back of the eye consists of any combination of: tiny retinal hemorrhages, areas of oxygen deprivation, abnormal vessels, lipid deposits, or fluid leakage (swelling) at the macula.  Some of this damage may cause blurry vision. The signs that are present will determine if the retinopathy is mild, moderate, or severe.  With each progression of severity in retinopathy, the risk for reduced vision increases.  

Proliferative diabetic retinopathy (PDR): this condition is usually present in the advanced stages of retinopathy.  The classic signs are the growth of new, unwanted blood vessels that are very fragile.  If these vessels rupture it can lead to severe bleeding in the eye which results in vision loss.  If left untreated or uncontrolled, NPDR can turn into PDR.  All of the same signs that are found in NPDR may be present in PDR as well.

TREATMENT

There is no cure for diabetic retinopathy; however, several treatment options have been shown to be effective in delaying or reducing vision loss.  The treatments may vary for each patient depending on the severity or location of the retinopathy.  

No Treatment: Most of the time, diabetic retinopathy requires only monitoring on a regular basis if in the mild, moderate, or even severe categories.  If the patient is in the high risk severe category, or has proliferative, then other surgical options are considered.

Focal or Grid Laser: This is for those patients who have fluid leaking on or around the fovea (clinically significant macular edema or CSME). Several laser burns are placed surrounding the fovea to slow or stop the leakage.  

Injection: This is another option for patients that have CSME. Triamcinolone acetonide (steroid) or an Anti-VEGF agent can be injected into the vitreous of the eye, and has been commonly used in combination with Focal Laser treatment.

Panretinal Laser Photogoagulation (PRP): This is done by the doctor placing several hundred laser burns on the peripheral areas of the retina.  This helps to shrink the new abnormal blood vessels that have started to grow.  It is most effective if those new vessels have NOT started to bleed yet, but is still successful if they have ruptured.

Vitrectomy: This is indicated if the abnormal vessels have ruptured and are bleeding into the vitreous.  This causes the vitreous to be cloudy and results in reduced vision.  The blood may not clear up on its own, which is why the vitreous may need to be removed and replaced with a clear salt solution.  This procedure is fairly common, and the patient can usually go home the same day as surgery.

FOLLOW-UP

·    Diabetes without retinopathy – annual dilated examinations.
·    Mild NPDR – dilated examination every 6 to 9 months.
·    Moderate to Severe NPDR – dilated examination every 4 to 6 months.
·    PDR (non high-risk) – dilated examination every 2 to 3 months.
·    Post surgery – as doctor recommends.

WHAT CAN I DO?

• First and foremost, educate yourself about your condition - know what diabetes is and how it affects your body.
• Have regular exams with your primary care provider (general practitioner) to monitor and care for your condition.
• Take control of your diet! Consider meeting with a dietician to find out what foods you should or should not consume.
• Excercise!  Even if you can only walk, that is better than nothing.  The more you excercise, the better off you will be.
• Take daily (or as your doctor recommends) measurements of your blood/sugar levels, and keep them under control.
• Know what your Hb_A1C levels are.  This is basically an average percentage of sugar that is in your hemaglobin over a 3 month time period.  The normal level is considered 4.5 to 6.  6 to 7 is considered high.  And >7 is considered out of control.  For someone with diabetes, less than 7 is the goal.  Studies have shown that Diabetic Retinopathy is not likely to happen if your Hb_A1C is less than 7.