Diabetic retinopathy diabetes management -
Developing diabetes when pregnant gestational diabetes or having diabetes before becoming pregnant can increase your risk of diabetic retinopathy. If you're pregnant, your eye doctor might recommend additional eye exams throughout your pregnancy.
Contact your eye doctor right away if your vision changes suddenly or becomes blurry, spotty or hazy. Over time, too much sugar in your blood can lead to the blockage of the tiny blood vessels that nourish the retina, cutting off its blood supply. As a result, the eye attempts to grow new blood vessels.
But these new blood vessels don't develop properly and can leak easily. Early diabetic retinopathy. In this more common form — called nonproliferative diabetic retinopathy NPDR — new blood vessels aren't growing proliferating.
When you have nonproliferative diabetic retinopathy NPDR , the walls of the blood vessels in your retina weaken. Tiny bulges protrude from the walls of the smaller vessels, sometimes leaking fluid and blood into the retina. Larger retinal vessels can begin to dilate and become irregular in diameter as well.
NPDR can progress from mild to severe as more blood vessels become blocked. Sometimes retinal blood vessel damage leads to a buildup of fluid edema in the center portion macula of the retina. If macular edema decreases vision, treatment is required to prevent permanent vision loss.
Advanced diabetic retinopathy. Diabetic retinopathy can progress to this more severe type, known as proliferative diabetic retinopathy. In this type, damaged blood vessels close off, causing the growth of new, abnormal blood vessels in the retina.
These new blood vessels are fragile and can leak into the clear, jellylike substance that fills the center of your eye vitreous. Eventually, scar tissue from the growth of new blood vessels can cause the retina to detach from the back of your eye. If the new blood vessels interfere with the normal flow of fluid out of the eye, pressure can build in the eyeball.
This buildup can damage the nerve that carries images from your eye to your brain optic nerve , resulting in glaucoma. In the early stages of diabetic retinopathy, the walls of the blood vessels in your retina weaken.
Tiny bulges protrude from the vessel walls, sometimes leaking or oozing fluid and blood into the retina. Tissues in the retina may swell, producing white spots in the retina. As diabetic retinopathy progresses, new blood vessels may grow and threaten your vision.
Anyone who has diabetes can develop diabetic retinopathy. The risk of developing the eye condition can increase as a result of:.
Diabetic retinopathy involves the growth of abnormal blood vessels in the retina. Complications can lead to serious vision problems:. Vitreous hemorrhage. The new blood vessels may bleed into the clear, jellylike substance that fills the center of your eye.
If the amount of bleeding is small, you might see only a few dark spots floaters. In more-severe cases, blood can fill the vitreous cavity and completely block your vision. Vitreous hemorrhage by itself usually doesn't cause permanent vision loss.
The blood often clears from the eye within a few weeks or months. Unless your retina is damaged, your vision will likely return to its previous clarity.
You can't always prevent diabetic retinopathy. However, regular eye exams, good control of your blood sugar and blood pressure, and early intervention for vision problems can help prevent severe vision loss.
Remember, diabetes doesn't necessarily lead to vision loss. Taking an active role in diabetes management can go a long way toward preventing complications. On this page. Risk factors. A Book: Mayo Clinic Guide to Better Vision. A Book: The Essential Diabetes Book. As the condition progresses, you might develop: Spots or dark strings floating in your vision floaters Blurred vision Fluctuating vision Dark or empty areas in your vision Vision loss.
When to see an eye doctor Careful management of your diabetes is the best way to prevent vision loss. More Information. Screening for diabetic macular edema: How often? Spotting symptoms of diabetic macular edema. Request an appointment. There are two types of diabetic retinopathy: Early diabetic retinopathy.
Diabetic retinopathy. Reducing your risks of diabetic macular edema. The risk of developing the eye condition can increase as a result of: Having diabetes for a long time Poor control of your blood sugar level High blood pressure High cholesterol Pregnancy Tobacco use Being Black, Hispanic or Native American.
Complications can lead to serious vision problems: Vitreous hemorrhage. Retinal detachment. The abnormal blood vessels associated with diabetic retinopathy stimulate the growth of scar tissue, which can pull the retina away from the back of the eye.
This can cause spots floating in your vision, flashes of light or severe vision loss. New blood vessels can grow in the front part of your eye iris and interfere with the normal flow of fluid out of the eye, causing pressure in the eye to build.
This pressure can damage the nerve that carries images from your eye to your brain optic nerve. Diabetic retinopathy, macular edema, glaucoma or a combination of these conditions can lead to complete vision loss, especially if the conditions are poorly managed.
If you have diabetes, reduce your risk of getting diabetic retinopathy by doing the following: Manage your diabetes. Make healthy eating and physical activity part of your daily routine.
Try to get at least minutes of moderate aerobic activity, such as walking, each week. Take oral diabetes medications or insulin as directed. Monitor your blood sugar level. You might need to check and record your blood sugar level several times a day — or more frequently if you're ill or under stress.
Ask your doctor how often you need to test your blood sugar. Ask your doctor about a glycosylated hemoglobin test. The glycosylated hemoglobin test, or hemoglobin A1C test, reflects your average blood sugar level for the two- to three-month period before the test.
Keep your blood pressure and cholesterol under control. Eating healthy foods, exercising regularly and losing excess weight can help. This test shows your average blood sugar level over the past 3 months. You can work with your doctor to set a personal A1C goal. Meeting your A1C goal can help prevent or manage diabetic retinopathy.
Having high blood pressure or high cholesterol along with diabetes increases your risk for diabetic retinopathy. So controlling your blood pressure and cholesterol can also help lower your risk for vision loss.
In the early stages of diabetic retinopathy, your eye doctor will probably just keep track of how your eyes are doing. Some people with diabetic retinopathy may need a comprehensive dilated eye exam as often as every 2 to 4 months.
Medicines called anti-VEGF drugs can slow down or reverse diabetic retinopathy. Other medicines, called corticosteroids, can also help. Learn more about injections. Laser treatment. To reduce swelling in your retina, eye doctors can use lasers to make the blood vessels shrink and stop leaking.
Learn more about laser treatment for diabetic retinopathy. Eye surgery. If your retina is bleeding a lot or you have a lot of scars in your eye, your eye doctor may recommend a type of surgery called a vitrectomy.
Learn more about vitrectomy. Scientists are studying better ways to find, treat, and prevent vision loss in people with diabetes. One NIH-funded research team is studying whether a cholesterol medicine called fenofibrate can stop diabetic retinopathy from getting worse. Last updated: November 15, National Eye Institute Research Today… Vision Tomorrow.
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Home Learn About Eye Health Eye Conditions and Diseases Diabetic Retinopathy. Print this Page. Diabetic Retinopathy. On this page:. At a glance: Diabetic Retinopathy Early Symptoms: None.
Later Symptoms: Blurry vision, floating spots in your vision, blindness. Diagnosis: Dilated eye exam. Treatment: Injections , laser treatment, surgery. What is diabetic retinopathy? Other types of diabetic eye disease Diabetic retinopathy is the most common cause of vision loss for people with diabetes.
But diabetes can also make you more likely to develop several other eye conditions: Cataracts. Having diabetes makes you 2 to 5 times more likely to develop cataracts.
It also makes you more likely to get them at a younger age. Learn more about cataracts. Open-angle glaucoma. Having diabetes nearly doubles your risk of developing a type of glaucoma called open-angle glaucoma. Learn more about glaucoma. What are the symptoms of diabetic retinopathy? What other problems can diabetic retinopathy cause?
Diabetic retinopathy can lead to other serious eye conditions: Diabetic macular edema DME. Over time, about 1 in 15 people with diabetes will develop DME. DME happens when blood vessels in the retina leak fluid into the macula a part of the retina needed for sharp, central vision.
This causes blurry vision. Neovascular glaucoma.
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If you do develop diabetic retinopathy, early treatment can stop the damage and prevent blindness. If your eye doctor thinks you may have severe diabetic retinopathy or DME, they may do a test called a fluorescein angiogram. This test lets the doctor see pictures of the blood vessels in your retina.
Managing your diabetes is the best way to lower your risk of diabetic retinopathy. That means keeping your blood sugar levels in a healthy range. This test shows your average blood sugar level over the past 3 months.
You can work with your doctor to set a personal A1C goal. Meeting your A1C goal can help prevent or manage diabetic retinopathy. Having high blood pressure or high cholesterol along with diabetes increases your risk for diabetic retinopathy.
So controlling your blood pressure and cholesterol can also help lower your risk for vision loss. In the early stages of diabetic retinopathy, your eye doctor will probably just keep track of how your eyes are doing.
Some people with diabetic retinopathy may need a comprehensive dilated eye exam as often as every 2 to 4 months. Medicines called anti-VEGF drugs can slow down or reverse diabetic retinopathy. Other medicines, called corticosteroids, can also help.
Learn more about injections. Laser treatment. To reduce swelling in your retina, eye doctors can use lasers to make the blood vessels shrink and stop leaking. Learn more about laser treatment for diabetic retinopathy. Eye surgery. If your retina is bleeding a lot or you have a lot of scars in your eye, your eye doctor may recommend a type of surgery called a vitrectomy.
Learn more about vitrectomy. Scientists are studying better ways to find, treat, and prevent vision loss in people with diabetes. One NIH-funded research team is studying whether a cholesterol medicine called fenofibrate can stop diabetic retinopathy from getting worse.
Last updated: November 15, National Eye Institute Research Today… Vision Tomorrow. English Español. Search the site. Learn About Eye Health Healthy Vision Eye Conditions and Diseases Eye Health Data and Statistics Campaigns Vision Rehabilitation NEI for Kids Outreach Resources Grants and Training How to Apply Funding Opportunities Training at NEI Funding for Training and Career Development Policies and Procedures Prior Approval Requests Resources for Researchers Contact Grants and Funding Staff Research at NEI Clinical Trials Research Labs and Branches Jobs and Training Opportunities at NEI NEI Research Seminars About NEI Diversity, Equity, Inclusion and Accessibility at NEI Strategic Planning News and Events Goals and Accomplishments NEI History NEI Leadership Budget and Congress Advisory Committees National Eye Health Education Program Donate to NEI.
Home Learn About Eye Health Eye Conditions and Diseases Diabetic Retinopathy. Print this Page. Diabetic Retinopathy. On this page:. At a glance: Diabetic Retinopathy Early Symptoms: None.
Later Symptoms: Blurry vision, floating spots in your vision, blindness. Diagnosis: Dilated eye exam. Treatment: Injectionslaser treatment, surgery. What is diabetic retinopathy? Other types of diabetic eye disease Diabetic retinopathy is the most common cause of vision loss for people with diabetes.
But diabetes can also make you more likely to develop several other eye conditions: Cataracts. Having diabetes makes you 2 to 5 times more likely to develop cataracts. It also makes you more likely to get them at a younger age.
Learn more about cataracts. Open-angle glaucoma. Having diabetes nearly doubles your risk of developing a type of glaucoma called open-angle glaucoma. Learn more about glaucoma. What are the symptoms of diabetic retinopathy?
What other problems can diabetic retinopathy cause? Diabetic retinopathy can lead to other serious eye conditions: Diabetic macular edema DME. Over time, about 1 in 15 people with diabetes will develop DME. DME happens when blood vessels in the retina leak fluid into the macula a part of the retina needed for sharp, central vision.
This causes blurry vision. Neovascular glaucoma. Diabetic retinopathy can cause abnormal blood vessels to grow out of the retina and block fluid from draining out of the eye.
This causes a type of glaucoma a group of eye diseases that can cause vision loss and blindness. Learn more about types of glaucoma. Retinal detachment. Diabetic retinopathy can cause scars to form in the back of your eye. Learn more about types of retinal detachment.
Am I at risk for diabetic retinopathy? What causes diabetic retinopathy? How will my eye doctor check for diabetic retinopathy? Learn what to expect from a dilated eye exam. What can I do to prevent diabetic retinopathy? Learn more about the A1c test. What is the latest research on diabetic retinopathy and DME?
Get the latest news on NEI-supported diabetic eye disease research. Diabetic Eye Disease Resources Find statistics and data on diabetic retinopathy in the United States Check out our library of diabetic eye disease videos See our materials for community health educators Get flyers, booklets, and other resources about diabetic eye disease.
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: Diabetic retinopathy diabetes management| At a glance: Diabetic Retinopathy | However, the prevalence rate increases sharply after 5 years' duration of diabetes in postpubertal individuals with type 1 diabetes The Diabetic Retinopathy Study Research Group. International Business Collaborations. Presented at: American Diabetes Association 66th Scientific Sessions; June , ; Washington, DC. Two trials of fenofibrate have been conducted to reduce the levels of serum triglycerides in an effort to reduce cardiovascular risk 9 , Guidelines for the frequency of dilated eye examinations have been largely based on the severity of the retinopathy 1 , 4. |
| Diabetic retinopathy | AOA | Trans Managemfnt Diabetic retinopathy diabetes management U K. Managemfnt NPDR, the blood vessels in the retina are weakened. You may not notice symptoms in the early stage. There are many new interventions, but the evidence to support their use is uncertain. Goldstein DE, Blinder KJ, Ide CH, et al. |
| What is diabetic retinopathy? | Pregnancy and puberty can accelerate these changes 12 , The lack of efficacy in this study may be related to poorer glycemic control, shorter follow-up, and lower blood pressure levels at baseline as compared with the UKPDS. At first, diabetic retinopathy might cause no symptoms or only mild vision problems. Xu et al. The effect of fenofibrate was not evident after the drug was stopped in the clinical trial of ACCORD. |
Diabetic retinopathy diabetes management -
Sharon D. Solomon , Emily Chew , Elia J. Duh , Lucia Sobrin , Jennifer K. Sun , Brian L. VanderBeek , Charles C.
Wykoff , Thomas W. Gardner; Diabetic Retinopathy: A Position Statement by the American Diabetes Association. Diabetes Care 1 March ; 40 3 : — Diabetic retinopathy diagnostic assessment and treatment options have improved dramatically since the American Diabetes Association Position Statement 1.
These improvements include the widespread adoption of optical coherence tomography to assess retinal thickness and intraretinal pathology and wide-field fundus photography to reveal clinically silent microvascular lesions.
Treatment of diabetic macular edema is now achieved by intravitreous injection of anti—vascular endothelial growth factor agents, and the same drugs are now used for proliferative diabetic retinopathy. Improvements in medications and devices for the systemic therapy of diabetes have also improved the ability of patients to optimize their metabolic control.
This Position Statement incorporates these recent developments for the use of physicians and patients. Diabetic retinopathy is a highly specific neurovascular complication of both type 1 and type 2 diabetes, the prevalence of which strongly correlates to both the duration of diabetes and level of glycemic control.
A pooled meta-analysis involving 35 studies conducted worldwide from to estimated global prevalence of any diabetic retinopathy and proliferative diabetic retinopathy PDR among patients to be Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20—74 years in developed countries.
Glaucoma, cataracts, and other disorders of the eye occur earlier and more frequently in people with diabetes. In addition to diabetes duration, factors that increase the risk of or are associated with retinopathy include chronic hyperglycemia 3 , 4 , nephropathy 5 , hypertension 6 , and dyslipidemia 7.
In patients with dyslipidemia, retinopathy progression may be slowed by the addition of fenofibrate, particularly with very mild nonproliferative diabetic retinopathy NPDR at baseline 7. Several case series and a controlled prospective study suggest that pregnancy in patients with type 1 diabetes may aggravate retinopathy and threaten vision, especially when glycemic control is poor at the time of conception 11 , Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy.
Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy. In general, retinopathy advances from mild nonproliferative abnormalities, characterized by increased numbers of microaneurysms that may wax and wane.
With increasing severity, there is increased vascular permeability and occlusion and progression from moderate and severe NPDR to PDR, characterized by the growth of new blood vessels on the retina and posterior surface of the vitreous see Table 1 for definitions of diabetic retinopathy stages.
Pregnancy and puberty can accelerate these changes 12 , Cataract surgery has not been definitely demonstrated by recent studies to accelerate the progression of diabetic retinopathy, especially in the more recent era of treating both diabetic macular edema DME and PDR with the use of anti—vascular endothelial growth factor anti-VEGF agents Vision loss due to diabetic retinopathy results from several mechanisms.
Second, the new blood vessels of PDR and contraction of the accompanying fibrous tissue can distort the retina and lead to tractional retinal detachment, producing severe and often irreversible vision loss. Third, the new blood vessels may bleed, adding the further complication of preretinal or vitreous hemorrhage.
These clinically evident vascular changes are accompanied by damage to retinal neurons 15 , the final common pathway for vision loss. Several epidemiological studies have described the progression rates for diabetic retinopathy. The cohort with the longest follow-up is the Wisconsin Epidemiologic Study of Diabetic Retinopathy WESDR , which reported the year progression of diabetic retinopathy in patients with type 1 diabetes However, the WESDR started recruitment in when options for glycemic, blood pressure, and lipid control were markedly limited compared with the options available today.
The risk factors identified in WESDR—longer duration of diabetes, greater hyperglycemia, increased blood pressure, and dyslipidemia—remain relevant while the progression rates in more recent studies may differ markedly.
Table 2 shows the odds ratios associated with the most consistently associated retinopathy risk factors in studies performed in the modern era of expanded options for glucose, lipid, and blood pressure control.
The WESDR found a relationship between onset of retinopathy and duration of diabetes. It established that progression of retinopathy was a function of baseline retinopathy. More severe baseline retinopathy led to a greater frequency of progression to vision-threatening retinopathy.
The WESDR epidemiological data were limited primarily to white Northern European extraction populations and may not be applicable to African American, Hispanic American, or Asian American populations or to others with a high prevalence of diabetes and retinopathy.
After duration of diabetes, hyperglycemia has been the most consistently associated risk factor for retinopathy. A large and consistent set of observational studies and clinical trials document the association of poor glucose control and retinopathy.
In addition, the DCCT demonstrated a definitive relationship between hyperglycemia and diabetic microvascular complications, including retinopathy Early treatment with intensive therapy was most effective. In addition, intensive therapy had a substantial beneficial effect over the entire range of retinopathy.
The UK Prospective Diabetes Study UKPDS of patients newly diagnosed with type 2 diabetes conclusively demonstrated that improved blood glucose control in those patients reduced the risk of developing retinopathy and nephropathy and possibly reduced the risk for neuropathy 8.
Epidemiological analysis of the UKPDS data showed a continuous relationship between the risk of microvascular complications and glycemia, such that every percentage point decrease in HbA 1c e. More recently, the ACCORD trial of medical therapies demonstrated that intensive glycemic control reduced the risk of progression of diabetic retinopathy in people with type 2 diabetes of 10 years duration 9.
This study included 2, ACCORD participants who were enrolled into the ACCORD Eye Study and followed for 4 years. The results of the DCCT, UKPDS, and ACCORD Eye Study showed that while intensive therapy does not prevent retinopathy completely, it reduces the risk of the development and progression of diabetic retinopathy.
This can be translated clinically to a higher likelihood of preserving sight and to a reduced need for treatment. Furthermore, all three studies demonstrated that years after the initial clinical trial ended, the treatment effect of intensive glycemic control persisted, despite the fact that both treatment groups had similar levels of HbA 1c.
In fact, 25 years after the cessation of the DCCT, ocular surgery rates were reduced in those who had been assigned to intensive glycemic control In the DCCT, at varying intervals, the beneficial effects of intensive glycemic control persisted but declined over time. This persistent beneficial effect beyond the clinical trial was true for people with type 1 and type 2 diabetes.
Blood pressure control has also been studied in several observational and clinical trials, including the UKPDS. However, the more recent ACCORD Eye Study did not show either a harmful or a beneficial effect when comparing systolic pressure of mmHg vs.
Several observational studies have suggested that dyslipidemia may play a role in the progression of diabetic retinopathy.
Dyslipidemia is associated with retinal hard exudate and visual loss. Two trials of fenofibrate have been conducted to reduce the levels of serum triglycerides in an effort to reduce cardiovascular risk 9 , Although fenofibrate does not have an effect on cardiovascular risk, both studies showed an effect on the progression of diabetic retinopathy.
The Fenofibrate Intervention and Event Lowering in Diabetes FIELD study demonstrated the beneficial effects of fenofibrate mg daily versus placebo in reducing the need for laser photocoagulation hazard ratio 0.
A substudy of the FIELD participants with fundus photographs showed the beneficial effect on the Early Treatment Diabetic Retinopathy Study ETDRS scale, especially in those with retinopathy at baseline and also on the development of macular edema hazard ratio 0. The ACCORD Study also compared fenofibrate mg daily with simvastatin versus placebo with simvastatin and found that the risk of progression of diabetic retinopathy was reduced by one-third.
The effect was particularly demonstrated in those with preexisting diabetic retinopathy. The effect of fenofibrate was not evident after the drug was stopped in the clinical trial of ACCORD.
This suggests that the treatment with fenofibrate therapy may indeed be real. The results of these two large randomized trials, ACCORD Eye Study and FIELD, suggest that fenofibrate may be a potential therapy for people with diabetic retinopathy.
These results were not subgroup analyses, and these beneficial effects were supported by two large randomized controlled clinical trials. Because of the lack of beneficial effects on cardiovascular disease, medical physicians have been reluctant to prescribe fenofibrate for people with diabetic retinopathy.
There are sufficient data to suggest developing collaboration between the ophthalmologists eye care providers and the medical physician to consider this treatment for people affected with diabetic retinopathy.
Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes.
Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis.
If there is no evidence of retinopathy for one or more annual eye exams, then exams every 2 years may be considered.
If any level of diabetic retinopathy is present, subsequent dilated retinal examinations for patients with type 1 or type 2 diabetes should be repeated at least annually by an ophthalmologist or optometrist.
If retinopathy is progressing or sight-threatening, then examinations will be required more frequently. Eye examinations should occur before pregnancy or in the first trimester in patients with preexisting type 1 or type 2 diabetes, and then these patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy.
While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional. Screening strategies depend on the rates of appearance and progression of diabetic retinopathy and on risk factors that alter these rates.
While population-based studies often are the best source for evaluating the rates of progression, data from other studies, including observational studies and clinical trials, have provided important information as well.
A summary of screening recommendations is in Table 3. With regard to retinopathy onset, vision-threatening retinopathy rarely appears in type 1 diabetes patients in the first 3—5 years of diabetes or before puberty 22 , Because retinopathy takes at least 5 years to develop after the onset of hyperglycemia, adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the diagnosis of diabetes.
Up to one-fifth of patients with type 2 diabetes have retinopathy at the time of first diagnosis of diabetes 24 , Patients with type 2 diabetes who may have had years of undiagnosed diabetes and have a significant risk of diabetic retinopathy at the time of diagnosis should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of diagnosis.
Subsequent examinations for patients with type 1 or type 2 diabetes are generally repeated annually for patients with minimal to no retinopathy. Exams every 2 years may be cost-effective after one or more normal eye exams and, in a population with well-controlled type 2 diabetes, there was essentially no risk of development of significant retinopathy with a 3-year interval after a normal examination Examinations will be required more frequently by the ophthalmologist if retinopathy is progressing.
Pregnancy can be associated with rapid progression of diabetic retinopathy in the setting of type 1 and type 2 diabetes Women who develop gestational diabetes mellitus do not require an eye examination during pregnancy and do not appear to be at increased risk of developing diabetic retinopathy during pregnancy Women with preexisting type 1 or type 2 diabetes who plan to become pregnant should have an ophthalmic examination prior to pregnancy and receive counseling about the risk of development and progression of diabetic retinopathy.
When pregnant, an eye examination should be performed during the first trimester with follow-up visits scheduled depending on retinopathy severity 12 , Rapid implementation of tight glycemic control in the setting of retinopathy can be associated with worsening of retinopathy The preventive effects of therapy and the fact that patients with PDR or macular edema may be asymptomatic provide strong support for screening to detect diabetic retinopathy.
An ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing diabetic retinopathy should perform the examinations. If diabetic retinopathy is present, prompt referral to an ophthalmologist is recommended. Comprehensive evaluation by an ophthalmologist will include dilated slit-lamp examination including biomicroscopy with a hand-held lens 90 or 78 diopter , indirect ophthalmoscopy, and testing as appropriate that may include optical coherence tomography and fluorescein angiography.
Retinal photography, with remote reading by experts, has great potential to provide screening services in areas where qualified eye care professionals are not readily available High-quality fundus photographs can detect most clinically significant diabetic retinopathy.
Interpretation of the images should be performed by a trained eye care provider. Retinal photography can also enhance efficiency and reduce costs when the expertise of ophthalmologists can be used for more complex examinations and for therapy In-person exams are still necessary when the retinal photos are unacceptable and for follow-up if abnormalities are detected.
Retinal photos are not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional.
Results of eye examinations should be documented and transmitted to the referring health care professional. Over time, more than half of people with diabetes will develop diabetic retinopathy.
The good news is that you can lower your risk of developing diabetic retinopathy by controlling your diabetes. Women with diabetes who become pregnant — or women who develop gestational diabetes — are at high risk for getting diabetic retinopathy. If you have diabetes and are pregnant, have a comprehensive dilated eye exam as soon as possible.
Diabetic retinopathy is caused by high blood sugar due to diabetes. Over time, having too much sugar in your blood can damage your retina — the part of your eye that detects light and sends signals to your brain through a nerve in the back of your eye optic nerve.
Diabetes damages blood vessels all over the body. The damage to your eyes starts when sugar blocks the tiny blood vessels that go to your retina, causing them to leak fluid or bleed.
These new blood vessels can leak or bleed easily. Eye doctors can check for diabetic retinopathy as part of a dilated eye exam. The exam is simple and painless — your doctor will give you some eye drops to dilate widen your pupil and then check your eyes for diabetic retinopathy and other eye problems.
If you do develop diabetic retinopathy, early treatment can stop the damage and prevent blindness. If your eye doctor thinks you may have severe diabetic retinopathy or DME, they may do a test called a fluorescein angiogram. This test lets the doctor see pictures of the blood vessels in your retina.
Managing your diabetes is the best way to lower your risk of diabetic retinopathy. That means keeping your blood sugar levels in a healthy range. This test shows your average blood sugar level over the past 3 months. You can work with your doctor to set a personal A1C goal.
Meeting your A1C goal can help prevent or manage diabetic retinopathy. Having high blood pressure or high cholesterol along with diabetes increases your risk for diabetic retinopathy.
So controlling your blood pressure and cholesterol can also help lower your risk for vision loss. In the early stages of diabetic retinopathy, your eye doctor will probably just keep track of how your eyes are doing.
Some people with diabetic retinopathy may need a comprehensive dilated eye exam as often as every 2 to 4 months. Medicines called anti-VEGF drugs can slow down or reverse diabetic retinopathy.
Other medicines, called corticosteroids, can also help. Learn more about injections. Laser treatment. To reduce swelling in your retina, eye doctors can use lasers to make the blood vessels shrink and stop leaking. Learn more about laser treatment for diabetic retinopathy.
Eye surgery. If your retina is bleeding a lot or you have a lot of scars in your eye, your eye doctor may recommend a type of surgery called a vitrectomy. The Liverpool Diabetic Eye Study reported the 1-year cumulative incidence of sight-threatening diabetic retinopathy in individuals with type 1 or type 2 diabetes who, at baseline, had no diabetic retinopathy, had background retinopathy or had mild preproliferative retinopathy.
In people with type 1 diabetes, the incidence in these groups was 0. Although the incidence of sight-threatening diabetic retinopathy in the group without baseline diabetic retinopathy is low 14,15,23,24 , there have been no studies comparing various screening intervals in their effectiveness to reduce the risk of vision loss Telemedicine programs relying on fundus photography are widely used in Canada and internationally for the identification and triage of people with diabetic retinopathy This has been greatly facilitated by the advent of high-resolution ultra-wide field imaging UWFI.
The Joslin Vision Network, an ocular telehealth program at the Joslin Diabetes Center, demonstrated that UWFI employed by trained certified imagers adhering to defined imaging and grading protocols, accurately evaluated images for the presence of diabetic retinopathy or diabetic retinopathy that required referral for prompt ophthalmic care, with a sensitivity and negative predictive value approaching 1.
Furthermore, UWFI technology has permitted the identification of peripheral diabetic retinal lesions, missed by standard 7-field fundus photography, that more accurately identifies the severity level of diabetic retinopathy and the risk of retinopathy progression over 4 years Risk factors for the development or progression of diabetic retinopathy are longer duration of diabetes, elevated A1C, increased blood pressure BP , dyslipidemia, anemia, pregnancy with type 1 diabetes , proteinuria and severe retinopathy itself 1,16—19,21,29—34 see Diabetes and Pregnancy chapter, p.
In the Action to Control Cardiovascular Risk in Diabetes ACCORD Eye study, intensive glycemic control was associated with a lower rate of retinopathy progression than standard therapy 40,41 , while in the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation ADVANCE Retinal Measurements study AdRem , intensive glycemic control did not significantly reduce development or progression of retinopathy In type 1 diabetes, rapid improvement of glycemia may be associated with transient early worsening of retinopathy, but this effect is offset by long-term benefits BP control is an important component of risk factor modification in diabetes and reduces the risk of retinopathy progression see Treatment of Hypertension chapter, p.
The ACCORD and ADVANCE studies examined more aggressive BP lowering in people with established type 2 diabetes. standard therapy. However, in the ADVANCE study data set, analysis of visit-to-visit variability of systolic BP and maximum systolic BP were predictive of diabetic retinopathy complications independent of mean BP In contrast, in type 1 diabetes, the DCCT trial did not show variability of BP as a risk factor for diabetic retinopathy Although a number of clinical trials have examined the effect s of renin angiotensin aldosterone system RAAS blockade on retinopathy progression or development among normotensive people with diabetes, the results have generally been conflicting or inconclusive.
In the Renin-Angiotensin System Study RASS , involving normotensive, normoalbuminuric participants with type 1 diabetes, neither the angiotensin-converting enzyme ACE inhibitor, enalapril, or the angiotensin receptor blocker ARB , losartan, reduced retinopathy progression independent of BP change The DIRECT studies did not meet their primary endpoints, although there was an overall change toward less severe retinopathy with candesartan 48, In view of the conflicting data, a systematic review and meta-analysis was carried out to evaluate the effect s of RAAS inhibition on diabetic retinopathy, and to compare between ACE inhibitors and ARBs The study included 21 randomized controlled clinical trials and 13, participants.
Results of these analyses suggest that RAAS inhibition was associated with reduced risk of incidence and progression of diabetic retinopathy, and that ACE inhibitors were better than ARBs at reducing these risks. However, the study did not evaluate the effect s of RAAS inhibition in participants with multiple medical comorbidities the subgroup of participants that are more likely to benefit from RAAS blockade , or the optimal dosage and duration of specific RAAS inhibitors.
Thus, while BP lowering including use of RAAS blockers reduces retinopathy rates and is an important component of cardiovascular CV protection see Cardiovascular Protection in People with Diabetes chapter, p.
S , there is insufficient evidence to recommend specific routes of RAAS blockade as primary prevention for retinopathy for all normotensive people with diabetes.
Dyslipidemia is an independent risk factor for retinal hard exudates and CSME in type 1 diabetes 24, While statin-based lipid-lowering therapies are an integral part of CV protection in diabetes, the role of these agents in preventing the development or progression of retinopathy has not been established 37, The role of the peroxisome proliferator-activated receptor-alpha agonist fenofibrate has been assessed in 2 large-scale randomized controlled trials.
From the study's control and event rates, the number of people needed to treat with combination statin and fenofibrate therapy to prevent 1 retinopathy progression event is estimated at 27 over the 4-year period.
The mechanism for any beneficial effect of fenofibrate in diabetic retinopathy has not been established. Active treatment with fenofibrate was associated with an increase in high-density lipoprotein cholesterol HDL-C and decrease in serum triglycerides in ACCORD Eye 40,41 ; however, in the FIELD study, any beneficial effect of fenofibrate was independent of plasma lipid concentrations Thus, the addition of fenofibrate to statin therapy could be considered in people with type 2 diabetes to slow the progression of established retinopathy.
Systematic review suggests that acetylsalicylic acid ASA therapy neither decreases or increases the incidence or progression of diabetic retinopathy Correspondingly, ASA use does not appear to be associated with an increase in risk of vitreous hemorrhage or DME 55, Treatment modalities for diabetic retinopathy include retinal photocoagulation, intraocular injection of pharmacological agents and vitreoretinal surgery.
Long-term follow-up studies to the original laser photocoagulation trials confirm its benefit over several decades The cytokine, vascular endothelial growth factor VEGF , is a potent vascular permeability and angiogenic factor.
Increased VEGF expression has been demonstrated to play a pivotal role in the development of diabetic retinopathy and, in particular, DME. Treatment of centre-involving DME with intravitreal anti-VEGF agents has been associated with improved vision and reduction of macular edema thickening , unlike focal macular laser where the effect is to reduce the probability of further vision loss.
Thus, anti-VEGF drugs have become first-line therapy in the management of centre-involving DME, and focal macular laser continues to be used when central vision is not involved.
Three anti-VEGF agents are available, namely, ranibizumab, aflibercept and off-label use of bevacizumab. Two masked, phase III, randomized clinical trials, A Study of Ranibizumab Injection in Subjects With Clinically Significant Macular Edema ME With Center Involvement Secondary to Diabetes Mellitus RISE and A Study of Ranibizumab Injection in Subjects With Clinically Significant Macular Edema ME With Center Involvement Secondary to Diabetes Mellitus RIDE , using monthly ranibizumab, a humanized recombinant anti-VEGF antibody fragment, with or without prompt laser, improved visual acuity compared against sham over the 2 years of study RISE and RIDE open-label extension trials showed visual acuity gains and safety profiles were maintained with a marked reduction in subsequent treatment frequency Furthermore, 1-year results of a phase III clinical trial, Ranibizumab Monotherapy or Combined with Laser versus Laser Monotherapy for Diabetic Macular Edema RESTORE , using an initial loading dose of 3 monthly injections of 0.
In all studies, the effect s of ranibizumab were consistent when used as monotherapy or in conjunction with macular photocoagulation. Three-year extension results maintained similar outcomes Similar positive results were obtained by the Diabetic Retinopathy Clinical Research Network DRCR.
net Protocol I - 5-year results using flexible ranibizumab plus prompt or deferred laser treatment algorithms 62, Aflibercept is a recombinant fusion protein comprised of the highest-affinity binding site from VEGF receptor 1 and 2, fused to the constant region Fc of immunoglobulin G1, and binds or traps VEGF and PlGF Placental Growth Factor.
Two masked phase III randomized clinical trials, Study of Intravitreal Aflibercept Injection in Patients With Diabetic Macular Edema VISTA DME and Intravitreal Aflibercept Injection in Vision Impairment Due to DME VIVID-DME , evaluated aflibercept at 2 different dosing intervals 2q4 and 2q8 vs.
macular laser photocoagulation. The week visual and anatomic superiority of aflibercept over laser control was sustained through week , with similar efficacy in the 2q4 and 2q8 groups. Mean BCVA gain from baseline to week with aflibercept 2q4, 2q8 and laser control was A similar outcome was noted when comparing intraocular injection of bevacizumab a full-length antibody against VEGF to macular laser.
However, unlike ranibizumab and aflibercept, intraocular injection of bevacizumab in diabetic retinopathy constitutes off-label use of the drug in Canada.
A head-to-head randomized clinical trial, Diabetic Retinopathy Clinical Research Network Protocol T study, was carried out comparing the 3 anti-VEGF agents—aflibercept, bevacizumab and ranibizumab—in the treatment of centre-involving DME.
All 3 agents demonstrated improvement of visual acuity and reduction in central macular thickness both at year 1 66 and year 2. Superiority of aflibercept was noted in the group of participants with worse baseline visual acuity.
This superiority of aflibercept at year 2 with gains of Steroids are an alternate class of drug utilized in the management of DME.
Injectable agents include triamcinolone, dexamethasone and fluocinolone. Intravitreal injection of triamcinolone combined with prompt macular laser was as effective as ranibizumab in a single subgroup of people characterized by previous cataract surgery The Macular Edema: Assessment of Implantable Dexamethasone in Diabetes MEAD study group showed positive visual results with the dexamethasone DEX implant over a 3-year follow-up period.
The fluocinolone implant for DME has been studied 68,69 and more recently was studied vs. sham in the Fluocinolone Acetonide for Macular Edema FAME study, a phase III clinical trial consisting of 2 3-year pivotal trials.
The percentage of participants with improvement from baseline letter score of 15 or more at month 24 was However, treatments with intraocular steroids are associated with increased rates of glaucoma and cataract formation.
Randomized-controlled trials evaluating anti-VEGF therapy for the treatment of centre-involving DME have noted improved diabetic retinopathy severity scale DRSS.
Progression of DRSS severity has been associated with an increased risk of development of proliferative diabetic retinopathy and DME Thus, future randomized controlled trials may further evaluate DRSS as a primary endpoint in the prevention or regression of diabetic retinopathy.
Similarly, early vitrectomy was associated with higher chance of visual recovery in people with either type 1 or 2 diabetes with very severe proliferative diabetic retinopathy More recent surgical advances and instrumentation in vitrectomy since the DRVS trials have demonstrated reduced side effects with more consistent favourable visual outcomes, thus supporting vitrectomy in advanced proliferative diabetic retinopathy Furthermore, these advances have expanded surgical indications to include earlier vitrectomy for diffuse macular edema, particularly with vitreomacular traction It is worth noting that the use of perioperative ASA 77—79 and warfarin therapy 80 for persons undergoing ophthalmic surgery does not appear to raise the risk of hemorrhagic complications.
Overall, the last few years have seen significant advances in systemic, local and surgical treatments of diabetic eye disease, with significantly improved visual outcome. Most notably, long-term follow up to early laser studies confirm their sustained efficacy in preserving vision Pharmacologic therapies, especially VEGF and steroid agents, demonstrate both preservation and recovery of vision in persons with DME.
Despite these successes, it is important to encourage people with even moderate visual loss to seek assistance from community services that provide spectacle correction, enhanced magnification, vision aids and measures to encourage independence and ongoing quality of life 81, A1C, glycated hemoglobin ; ACE; angiotensin-converting enzyme ; ARB; angiotensin receptor blocker ; BP , blood pressure; CV , cardiovascular; CVD , cardiovascular disease; CSME ; clinically significant macular edema; DHC , diabetes health-care; DME , diabetic macular edema; DRSS , diabetic retinopathy severity scale; HDL-C ; high-density lipoprotein cholesterol; OCT ; optical coherence tomography; PlGF ; placental growth factor; PRP , panretinal photocoagulation; RAAS ; renin angiotensin aldosterone system; VEGF ; vascular endothelial growth factor.
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group P referred R eporting I tems for S ystematic Reviews and M eta- A nalyses: The PRISMA Statement.
PLoS Med 6 6 : e pmed For more information, visit www. Altomare has nothing to disclose. Lovshin reports grants from Sanofi Canada and Merck Canada; personal fees from Novo Nordisk, AstraZenca, and Eli Lilly, outside the submitted work.
All content on guidelines. ca, CPG Apps and in our online store remains exactly the same. For questions, contact communications diabetes. Become a Member Order Resources Home About Contact DONATE. Next Previous. Key Messages Recommendations Figures Full Text References. Chapter Headings Introduction Definition and Pathogenesis Screening Delay of Onset and Progression Treatment Other Relevant Guidelines Author Disclosures.
Key Messages Regular screening is important for early detection of treatable diabetic retinopathy. Screening intervals for diabetic retinopathy vary according to the individual's age and type of diabetes.
Optimal glycemic control reduces the onset and progression of sight-threatening diabetic retinopathy. Local intraocular pharmacological therapies have the potential to improve vision and reduce the level of retinopathy.
Key Messages for People with Diabetes Diabetic retinopathy involves changes to retinal blood vessels that can cause them to bleed or leak fluid, distorting vision. With good glycemic control, regular eye exams and early treatment, the risk of vision loss is reduced.
Diabetic retinopathy often goes unnoticed until vision loss occurs; therefore, people with diabetes should get a comprehensive dilated eye exam regularly.
Discuss the recommended frequency with your diabetes healthcare team and experienced vision care professionals optometrists or ophthalmologists.
Diabetic retinopathy can be treated with several therapies used alone or in combination. Introduction Diabetic retinopathy is the most common cause of incident blindness legal in people of working age 1.
Definition and Pathogenesis Diabetic retinopathy is clinically defined, diagnosed and treated based on the extent of retinal vascular disease detected by ophthalmoscopy.
Delay of Onset and Progression Risk factors for the development or progression of diabetic retinopathy are longer duration of diabetes, elevated A1C, increased blood pressure BP , dyslipidemia, anemia, pregnancy with type 1 diabetes , proteinuria and severe retinopathy itself 1,16—19,21,29—34 see Diabetes and Pregnancy chapter, p.
BP control BP control is an important component of risk factor modification in diabetes and reduces the risk of retinopathy progression see Treatment of Hypertension chapter, p. Lipid-lowering therapy Dyslipidemia is an independent risk factor for retinal hard exudates and CSME in type 1 diabetes 24, Antiplatelet therapy Systematic review suggests that acetylsalicylic acid ASA therapy neither decreases or increases the incidence or progression of diabetic retinopathy Treatment Treatment modalities for diabetic retinopathy include retinal photocoagulation, intraocular injection of pharmacological agents and vitreoretinal surgery.
Local intraocular pharmacological intervention The cytokine, vascular endothelial growth factor VEGF , is a potent vascular permeability and angiogenic factor.
S; for screening recommendations for pregnant women, see Diabetes and Pregnancy chapter, p. In individuals with type 2 diabetes, screening and evaluation for diabetic retinopathy should be performed by an experienced vision care professional optometrist or ophthalmologist at the time of diagnosis of diabetes [Grade A, Level 1 17,20 ].
The interval for follow-up assessments should be tailored to the severity of the retinopathy [Grade D, Consensus]. In those with no or minimal retinopathy, the recommended interval is 1—2 years [Grade A, Level 1 17,20 ] for screening recommendations for children and adolescents with type 2 diabetes, see Type 2 Diabetes in Children and Adolescents chapter, p.
Screening for diabetic retinopathy should be performed by an experienced vision care professional optometrist or ophthalmologist , either in person or through interpretation of retinal photographs taken through dilated pupils [Grade A, Level 1 13 ] or undilated pupils with high-resolution ultra-wide field imaging [Grade D, Consensus].
Results of eye examinations and the follow-up interval and plan should be clearly communicated to all members of the diabetes health-care team to promote optimal care [Grade D, Consensus]. To prevent the onset and delay the progression of diabetic retinopathy, people with diabetes should be treated to achieve optimal control of BG [Grade A, Level 1A 35,38 for type 1 diabetes; Grade A, Level 1A 36,40,41 for type 2 diabetes] and BP [Grade A, Level 1A 36,44 for type 2 diabetes; Grade D, Consensus for type 1 diabetes].
Diabetic retinopathy managmeent the most common cause Diabetfs incident retiopathy legal in Anti-cancer awareness and education of working age 1. The Eye Refinopathy Prevalence Research Group determined the crude prevalence Diabetic retinopathy diabetes management of retinopathy in maagement adult population with diabetes of the United States to be Higher prevalence rates have been noted in Indigenous populations in Canada 4,5. Visual loss is associated with significant morbidity, including increased falls, hip fracture and a 4-fold increase in mortality 6. Among individuals with type 1 diabetes, limb amputation and visual loss due to diabetic retinopathy are independent predictors of early death 7.
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