Chronically high blood sugar from diabetes is associated with damage to the tiny blood vessels in the retina, leading to diabetic retinopathy. The retina detects light and converts it to signals sent through the optic nerve to the brain. Diabetic retinopathy can cause blood vessels in the retina to leak fluid or hemorrhage (bleed), distorting vision. In its most advanced stage, new abnormal blood vessels proliferate (increase in number) on the surface of the retina, which can lead to scarring and cell loss in the retina.
Diabetic retinopathy may progress through four stages:
- Mild nonproliferative retinopathy. Small areas of balloon-like swelling in the retina’s tiny blood vessels, called microaneurysms, occur at this earliest stage of the disease. These microaneurysms may leak fluid into the retina.
- Moderate nonproliferative retinopathy. As the disease progresses, blood vessels that nourish the retina may swell and distort. They may also lose their ability to transport blood. Both conditions cause characteristic changes to the appearance of the retina and may contribute to DME.
- Severe nonproliferative retinopathy. Many more blood vessels are blocked, depriving blood supply to areas of the retina. These areas secrete growth factors that signal the retina to grow new blood vessels.
- Proliferative diabetic retinopathy (PDR). At this advanced stage, growth factors secreted by the retina trigger the proliferation of new blood vessels, which grow along the inside surface of the retina and into the vitreous gel, the fluid that fills the eye. The new blood vessels are fragile, which makes them more likely to leak and bleed. Accompanying scar tissue can contract and cause retinal detachment—the pulling away of the retina from underlying tissue, like wallpaper peeling away from a wall. Retinal detachment can lead to permanent vision loss.
Who is at risk for diabetic retinopathy?
People with all types of diabetes (type 1, type 2, and gestational) are at risk for diabetic retinopathy. Risk increases the longer a person has diabetes. Between 40 and 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy, although only about half are aware of it. Women who develop or have diabetes during pregnancy may have rapid onset or worsening of diabetic retinopathy.
Symptoms and Detection
What are the symptoms of diabetic retinopathy and DME?
The same scene as viewed by a
person with normal vision (Top)
and with (Center) advanced
diabetic retinopathy. The
floating spots are hemorrhages
that require prompt treatment.
The early stages of diabetic retinopathy usually have no symptoms. The disease often progresses unnoticed until it affects vision. Bleeding from abnormal retinal blood vessels can cause the appearance of “floating” spots. These spots sometimes clear on their own. But without prompt treatment, bleeding often recurs, increasing the risk of permanent vision loss. If DME occurs, it can cause blurred vision.
How are diabetic retinopathy and DME detected?
Diabetic retinopathy and DME are detected during a comprehensive dilated eye exam that includes:
- Visual acuity testing. This eye chart test measures a person’s ability to see at various distances.
- Tonometry. This test measures pressure inside the eye.
- Pupil dilation. Drops placed on the eye’s surface dilate (widen) the pupil, allowing a physician to examine the retina and optic nerve.
- Optical coherence tomography (OCT). This technique is similar to ultrasound but uses light waves instead of sound waves to capture images of tissues inside the body. OCT provides detailed images of tissues that can be penetrated by light, such as the eye.
A comprehensive dilated eye exam allows the doctor to check the retina for:
- Changes to blood vessels
- Leaking blood vessels or warning signs of leaky blood vessels, such as fatty deposits
- Swelling of the macula (DME)
- Changes in the lens
- Damage to nerve tissue
If DME or severe diabetic retinopathy is suspected, a fluorescein angiogram may be used to look for damaged or leaky blood vessels. In this test, a fluorescent dye is injected into the bloodstream, often into an arm vein. Pictures of the retinal blood vessels are taken as the dye reaches the eye.
How can people with diabetes protect their vision?
Vision lost to diabetic retinopathy is sometimes irreversible. However, early detection and treatment can reduce the risk of blindness by 95 percent. Because diabetic retinopathy often lacks early symptoms, people with diabetes should get a comprehensive dilated eye exam at least once a year. People with diabetic retinopathy may need eye exams more frequently. Women with diabetes who become pregnant should have a comprehensive dilated eye exam as soon as possible. Additional exams during pregnancy may be needed.
Studies such as the Diabetes Control and Complications Trial (DCCT) have shown that controlling diabetes slows the onset and worsening of diabetic retinopathy. DCCT study participants who kept their blood glucose level as close to normal as possible were significantly less likely than those without optimal glucose control to develop diabetic retinopathy, as well as kidney and nerve diseases. Other trials have shown that controlling elevated blood pressure and cholesterol can reduce the risk of vision loss among people with diabetes.
Treatment for diabetic retinopathy is often delayed until it starts to progress to PDR, or when DME occurs. Comprehensive dilated eye exams are needed more frequently as diabetic retinopathy becomes more severe. People with severe nonproliferative diabetic retinopathy have a high risk of developing PDR and may need a comprehensive dilated eye exam as often as every 2 to 4 months.
How is proliferative diabetic retinopathy (PDR) treated?
For decades, PDR has been treated with scatter laser surgery, sometimes called panretinal laser surgery or panretinal photocoagulation. Treatment involves making 1,000 to 2,000 tiny laser burns in areas of the retina away from the macula. These laser burns are intended to cause abnormal blood vessels to shrink. Although treatment can be completed in one session, two or more sessions are sometimes required. While it can preserve central vision, scatter laser surgery may cause some loss of side (peripheral), color, and night vision. Scatter laser surgery works best before new, fragile blood vessels have started to bleed. Recent studies have shown that anti-VEGF treatment not only is effective for treating DME, but is also effective for slowing progression of diabetic retinopathy, including PDR, so anti-VEGF is increasingly used as a first-line treatment for PDR.
What is a vitrectomy?
A vitrectomy is the surgical removal of the vitreous gel in the center of the eye. The procedure is used to treat severe bleeding into the vitreous, and is performed under local or general anesthesia. Ports (temporary water-tight openings) are placed in the eye to allow the surgeon to insert and remove instruments, such as a tiny light or a small vacuum called a vitrector. A clear salt solution is gently pumped into the eye through one of the ports to maintain eye pressure during surgery and to replace the removed vitreous. The same instruments used during vitrectomy also may be used to remove scar tissue or to repair a detached retina.
Vitrectomy may be performed as an outpatient procedure or as an inpatient procedure, usually requiring a single overnight stay in the hospital. After treatment, the eye may be covered with a patch for days to weeks and may be red and sore. Drops may be applied to the eye to reduce inflammation and the risk of infection. If both eyes require vitrectomy, the second eye usually will be treated after the first eye has recovered.
What if treatment doesn’t improve vision?
An eye care professional can help locate and make referrals to low vision and rehabilitation services and suggest devices that may help make the most of remaining vision. Many community organizations and agencies offer information about low vision counseling, training, and other special services for people with visual impairment. A nearby school of medicine or optometry also may provide low vision and rehabilitation services.