Signs and symptoms

• Microaneurysms: In most cases, these are the earliest clinical abnormality detected. They appear as minute, discrete, circular, dark red spots near to but apparently separate from the retinal vessels [9].
• Hemorrhages: They characteristically occur in the deeper layers of the retina, are round and regular in shape, and are called 'blot' hemorrhages. In hypertensive patients, superficial flame-shaped hemorrhages may also occur.
• Hard exudates: These are characteristic of diabetic retinopathy [9]. They result from leakage of plasma from abnormal retinal capillaries and can vary in size from tiny specks to large patches.
• Cotton-wool spots: Most often seen in rapidly progressive retinopathy and hypertension, these spots represent arteriolar occlusions.
• Venous beading: Sausage-like dilatation and increased looping of veins indicate widespread capillary nonperfusion.

Presenting complaints

A patient may initially complain of blurred or fluctuating vision and difficulty in color perception. This may be more evident in one eye than in the other. The patient may then complain of empty or dark areas and floating spots or lines in his vision. In severe form of this condition, the patient may eventually suffer from complete loss of vision.

• Swelling

  Blurred vision may occur when the macula—the part of the retina that provides sharp central vision—swells from leaking fluid. This condition is called macular edema. [eyenm.com]

  Diabetic retinopathy is caused by elevated levels of sugar in the blood, often causing the blood vessels to leak and swell. [chestercountyeyecare.com]

  In some people with diabetic retinopathy, blood vessels may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina. The retina is the light-sensitive tissue at the back of the eye. [enhancedvision.com]

  Your retina specialist will examine your eye to determine if there is swelling in the macula that requires treatment (clinically significant macular edema). [avruc.com]

  In the non-proliferative form of diabetic retinopathy, the abnormal leakiness from the retinal vessels leads to macular edema or swelling, and this produces gradual loss of visual acuity. [weillcornelleye.org]

• Pain

  […] during light PRP compared with classic PRP with an imprecise estimate compatible with increased or decreased pain (RR 0.23, 95% CI 0.03 to 1.93, 65 eyes, 1 RCT).' [ncbi.nlm.nih.gov]

  Often there are no symptoms in the early stages of the disease, nor is there any pain. Don’t wait for symptoms. Be sure to have a comprehensive dilated eye exam at least once a year. [eyenm.com]

  According to the FDA, common side effects with Eylea included bleeding into the tissue that lines the inside of the eyelids and covers the white part of the eyes, eye pain, cataracts, floaters, increased pressure inside the eye, and separation of the [newsmax.com]

  Symptoms can include blurry or double vision rings, flashing lights or blank spots dark or floating spots pain or pressure in one or both of your eyes trouble seeing things out of the corners of your eyes if you have diabetes, you should have a complete [icd9data.com]

  Symptoms include pain, redness and decreased vision in the affected eye, coloured halos around lights, headache, nausea and vomiting. [bpac.org.nz]

• Weakness

  These new blood vessels are weak often causing them to break and bleed inside the eye. When bleeding occurs, it blocks the light entering the pupil towards the retina causing blurred vision. [associatedeyecare.com]

  This in turn, especially with more advanced disease, leads to formation of new but abnormally weak blood vessels which tend to cause big bleeds and scarring. Sometimes scarring can lead to a type of retinal detachment, called tractional detachment. [vimichigan.com]

  These new vessels are weak and can leak blood, blocking vision, which is a condition called vitreous hemorrhage. The new blood vessels can also cause scar tissue to grow. [diabetes.org]

  These new blood vessels are weak and can break easily, causing blood to leak and clouding vision. [chestercountyeyecare.com]

  In turn, these weak blood vessels leak fluid into your eye and blur your vision. Who Gets Diabetic Retinopathy? People with diabetes who do not keep their blood sugar under control are the most likely candidates to develop diabetic retinopathy. [vsp.com]

• Falling

  The incidence of diabetes is increasing, but that of diabetic retinopathy is falling, probably owing to better management of glucose levels, lipid abnormalities, and hypertension. [nejm.org]

  When I asked for an update from Cebix CEO Joel Martin, he replied, “Falling off the face of the Earth is pretty close!” Cebix, founded in 2008, was based on a promising hypothesis. [xconomy.com]

  Light ...in yellow... falls onto the retina. The retinal cells are rods (the long straight cells) and cones (the cells with the pointed end). [diabeticretinopathy.org.uk]

  In the United Kingdom Prospective Diabetes Study Group a 10 mm Hg fall in systolic blood pressure and a 5 mm Hg fall in diastolic blood pressure was associated with a 47% reduction in risk of doubling of visual angle at 9 years [25, 26]. [go.galegroup.com]

• Short Stature

  All of the cases had short stature which was non-familial and all had other microvascular complications (nephropathy and neuropathy). [ncbi.nlm.nih.gov]

• Nausea

  People who have more severe and long-term (chronic) kidney disease may have symptoms such as: Fatigue most of the time General ill feeling Headache Irregular heartbeat Nausea and vomiting Poor appetite Swelling of the legs Shortness of breath Itchy skin [nlm.nih.gov]

  The most common non-eye-related side effects are nose and throat infections, headache, lung/airway infections, and nausea. Patients may report side effects to the FDA at (800) FDA-1088 or http:// www.fda.gov/medwatch. [gene.com]

  Symptoms include pain, redness and decreased vision in the affected eye, coloured halos around lights, headache, nausea and vomiting. [bpac.org.nz]

• Macula

  Ideally the retinal detachment should be repaired prior to the involvement of the macula. If the macula becomes detached, the vision is unlikely to be as good as it was prior to the retinal detachment even with successful surgical re-attachment. [avruc.com]

  These damaged blood vessels can cause vision loss: Fluid can leak into the macula, the area of the retina responsible for clear central vision. Although small, the macula is the part of the retina that allows us to see colors and fine detail. [aoa.org]

  Your doctor places 1,000 to 2,000 laser burns in the areas of the retina away from the macula, causing the abnormal blood vessels to shrink. [eyenm.com]

  Dilated Eye Exam Dilation drops allow your doctor to get a better look at your retina, optic nerve, and macula. [dukemedicine.org]

  […] at the center of the macula—opting for the term “center-involving diabetic macula edema” when it is centrally located, and “non-center involving edema” when the center of the macula is spared. [reviewofoptometry.com]

• Blurred Vision

  This changes the curvature of the lens, leading to blurred vision. However, once blood sugar levels are controlled, blurred distance vision will improve. [aoa.org]

  If you diabetic and experience blurred vision, you should visit an eye specialist immediately. [moorfields.nhs.uk]

  Both the microaneurysms and the new blood vessels may rupture causing the leakage of blood into the retina and blurred vision. [news-medical.net]

  Blurred vision happens for two reasons: with diabetic macular edema, leaky blood vessels cause swelling of the macula, which can lead to blurred vision. with proliferative diabetic retinopathy, fragile new blood vessels on the retina cause bleeding in [diabetes.ie]

  Blurred vision may occur when the macula—the part of the retina that provides sharp central vision—swells from leaking fluid. This condition is called macular edema. [eyenm.com]

• Visual Impairment

  With good screening and care, visual impairment due to diabetes can be avoided for the vast majority of patients. Two studies have prospectively assessed the effect of fenofibrate on microvascular disease, principally retinopathy. [racgp.org.au]

  […] for VTDR, 2% for BCVA CONCLUSION: These data show relatively low cumulative incidences of DR, VTDR and visual impairment. [ncbi.nlm.nih.gov]

• Background Retinopathy

  The categories of retinopathy are: Background retinopathy Background retinopathy occurs in the early stages and damage is limited to tiny bulges (microaneurysms) in the blood vessel walls. [diabeticretinascreen.ie]

  One patient had mild background retinopathy on both eyes, with visual acuity of 1.0 and 0.7 after cataract extraction plus intravitreal triamcinolone injection. [ncbi.nlm.nih.gov]

• Cotton Wool Spots

  Cotton-wool spots are areas of microinfarction of the retinal nerve fiber layer that lead to retinal opacification; they are fuzzy-edged and white and obscure underlying vessels. [merckmanuals.com]

  Screening for retinopathy is undertaken using conventional color fundus photography and relies on the identification of hemorrhages, vascular abnormalities, exudates, and cotton-wool spots. These can sometimes be difficult to identify. [ncbi.nlm.nih.gov]

  Diabetic retinopathy - Three main categories exist: background, or "simple," retinopathy, consisting of microaneurysms, hemorrhages, exudates, and retinal edema; preproliferative retinopathy with arteriolar ischemia manifested as cotton-wool spots (small [health.am]

• Retinal Hemorrhage

  We present the case of an early stage diabetic retinopathy patient presented with retinal hemorrhages in the superior temporal area and disc hemorrhages of disc nasal area. The patient was diagnosed with mild NPDR on fundus examinations. [ncbi.nlm.nih.gov]

  These symptoms are typically caused by vitreous hemorrhage or traction retinal detachment. [merckmanuals.com]

  Any NVD with vitreous hemorrhage 3. NVE ≥ ½ disc area with vitreous hemorrhage High-risk PDR was also defined as three or more of the following high-risk characteristics (HRC’s): 1. Presence of vitreous hemorrhage or pre-retinal hemorrhage 2. [bu.edu]

• Stroke

  Complications of diabetes made worse by smoking include retinopathy, heart disease, stroke, vascular disease, kidney disease, nerve damage, foot problems and many others. [health.ny.gov]

  Most people who are diagnosed with diabetes are not told of the dangers related to the eyes, but instead are told about other problems like strokes, heart attacks and kidney disease. [thomaseye.com]

  […] endproducts (AGEs), receptors for AGEs (RAGE), carotid artery intima-media thickness, markers of antioxidant stress, and related candidate genes and their relationships to diabetic retinopathy, diabetic nephropathy, diabetic neuropathy, myocardial infarction, stroke [epi.ophth.wisc.edu]

  Uncommonly, Lucentis patients have had serious, sometimes fatal problems related to blood clots, such as heart attacks or strokes. [gene.com]

  Do not smoke – this causes strokes, heart attacks and poor circulation in the legs which may result in amputation. [healthnavigator.org.nz]

• Mydriasis

  PurposeTo ascertain the risk of angle closure glaucoma associated with mydriasis in the Northern Ireland Diabetic Retinopathy Screening Programme.MethodsA retrospective case note review was carried out, cross referencing hospital records with those of [ncbi.nlm.nih.gov]

  We review the current evidence on the critical features and characteristics of ocular telehealth programs for DR in the following categories: image gradability, mydriasis, sensitivity and specificity, cost-effectiveness, long-term effectiveness, patient [doi.org]

  Photocoagulation therapy was performed with a semiconductor diode Laser, after a full mydriasis. Anaesthetic drops (Amethocaine 0.5%) were first instilled on the cornea. [bmcophthalmol.biomedcentral.com]

  […] underwent complete ophthalmological examination: distance visual acuity testing using Snellen method, intraocular pressure (IOP) measurement with applanation tonometry, slit lamp examination of anterior and posterior segment of the eye in artificial mydriasis [go.galegroup.com]

• Kidney Failure

  However, there are other critical steps that can be taken by diabetics to prevent vision loss, kidney failure and peripheral neuropathy. These include: 1. Refraining from smoking. [news-medical.net]

  The magnitude of the improvements Kempner got was surprising; reversal of end stage heart and kidney failure, simply beyond belief. [nutritionfacts.org]

  Information for People with Diabetes Diabetes is a very serious disease that can cause problems like blindness, heart disease, kidney failure, and amputations. [masseyeandear.org]

  The self-reported prevalence of diabetes is two to three times higher among Pacific, Māori and Indo-Asian people. 1 Diabetes is a leading cause of blindness, end stage kidney failure and complications leading to lower limb amputation. [bpac.org.nz]

Workup includes a complete history and physical examination. The following tests should be conducted:

Laboratory tests

• Complete blood count
• Resting blood sugar
• Fasting blood sugar
• HbA1c levels
• Liver function tests

Imaging

• Fluorescein angiography: This is a test in which pupils are dilated and photographs of the vessels are taken. Then a radiocontrast dye is injected and photographs are taken again once the dye has perfused to all eye vessels.
• Optical Coherence Tomography (OCT): OCT provides us with cross-sectional images of the retina which help in both identifying retinal thickening if any, as well as monitoring the progress of treatment.
• B-scan Ultrasonography may also be done.

• Hypercholesterolemia

  We investigated the incidence of CV events with intensive or standard lipid-lowering therapy in patients with hypercholesterolemia, diabetic retinopathy, and no history of coronary artery disease (treat-to-target approach). [ncbi.nlm.nih.gov]

Medications

Multiple doses of intravitreal injections of anti-VEGF drugs such as bevacizumab show good results [10]. Similar drugs like Ranibizumab and a corticosteroid Triamcinolone may also be given.

Photocoagulation

In cases of nonproliferative DR, laser photocoagulation may be used to treat macular edema due to vascular leakage.
In patients with proliferative diabetic retinopathy, pan-retinal photocoagulation is used to spare the macular area and treat the entire diseased retina.

Vitrectomy

This procedure may be used in some patients with proliferative diabetic retinopathy.

Cryotherapy

This procedure may be used when the patient already suffers from other eye diseases like cataracts, etc.

Blood sugar level control

This is the primary mode of controlling the progression of retinopathy. By bringing blood glucose to normal levels, edema and other such conditions involved in diabetic retinopathy can be lessened.

The longer a person has diabetes, the higher his chances of developing diabetic retinopathy [8]. If a person has been diagnosed early, he would have well-defined leakage and good perifoveal perfusion. His vision loss would be mild and exudates would be minimal. In such cases, the prognosis is favorable as with the right control and treatment, the progression of the disease may be halted.

If on the other hand, a patient with diabetic retinopathy also has hypertension and/or kidney disease, and has already suffered from irreversible macular ischemia and edema, the prognosis is bad.

Complications

Complications include all the factors that may worsen the ischemic state of the eye such as:

• Hypertension
• Smoking
• Hyperlipidemia
• Renal diseases
• Cataract formation
• Glaucoma

As the name indicates, the primary cause of diabetic retinopathy is diabetes. In type I diabetes mellitus, the chances of developing this condition are comparatively less. In patients with type II diabetes mellitus, however, the incidence of this condition is directly proportional to disease duration.

Other causes include hypertension and hyperlipidemia which may exacerbate preexisting diabetes and increase the risk of developing diabetic retinopathy. Studies reveal that pregnant women that have this condition have a 4-5% chance of progression to a more severe stage.

Diabetes is responsible for approximately 8000 eyes becoming blinded each year, meaning diabetes is responsible for 12% of blindness [2].

A recent estimate of the prevalence of diabetic retinopathy in the US showed a high prevalence of 28.5% among those with diabetes aged 40 years or older [3]. Clearly the longer a person has diabetes, i.e the older a person is, the more likely he is of developing retinopathy.

The retinal vasculopathy of diabetes mellitus can be classified into the background (pre-profilerative) diabetic retinopathy and proliferative diabetic retinopathy [4].

Pre-proliferative diabetic retinopathy

Hyperglycaemia induced intramural pericyte death and thickening of the basement membrane leads to vascular wall incompetence. These damages change the formation of the blood-retinal barrier and also make the retinal blood vessels more permeable [5]. Smaller vessels may occlude and the weakened walls of the larger vessels may dilate. As a result, microaneurysms and macular edema occur.

Proliferative diabetic retinopathy

Retinal ischemia can result in the up-regulation of pro-angiogenesis factors such as VEGF and lead to retinal angiogenesis [6]. Retinal neovascularization may be accompanied by the development of a neovascular membrane on the iris surface, presumable secondary to increased levels of VEGF in the aqueous humor [7]. Gradually, scar tissue develops which may cause retinal detachment and/or build up of intraorbital pressure leading to glaucoma and optic nerve damage.

Preventing diabetic retinopathy Strategies for preventing diabetic retinopathy include: Effective diabetes management – including better control of blood sugar levels, blood pressure and cholesterol. [betterhealth.vic.gov.au]

Prevention of diabetic retinopathy is the most important step to take for anyone with diabetes. [fightingblindness.ie]

Although good control of your blood sugar and blood pressure can help prevent diabetic eye disease, significant problems can still occur. [eyecenteroftexas.com]

Early detection is the best way to prevent vision loss. [retinagroupflorida.com]

Strict control of blood sugar and blood pressure levels can greatly reduce or prevent diabetic retinopathy. [umkelloggeye.org]

Diabetes mellitus is a metabolic disorder that results in excess glucose in the blood. This excess amount of glucose causes widespread complications.

The most common and potentially most blinding of these complications, however, is diabetic retinopathy (DR) [1]. In this condition, a person's retinal vessels suffer ischemia and damage due to high blood glucose levels resulting in visual loss and in the worst case - blindness.

Diabetic retinopathy is a complication of long-standing, and often uncontrolled, diabetes mellitus. It is caused due to raised glucose levels in the blood which damage the blood vessels of the eyes, leading to first blurred vision and finally blindness. If you are diabetic and feel that your visual power has decreased, you should schedule a consultation with an eye specialist immediately.