Affection of retina because of diabetes is called Diabetic retinopathy. It can cause vision loss
and blindness in people who have diabetes.
a) Duration of diabetes — the longer you have diabetes, the greater your risk of
developing diabetic retinopathy.
b) Poor control of your blood sugar level.
c) High blood pressure.
d) High cholesterol.
e) Kidney disease
g) Tobacco use.
a) The involvement of central part of retina i.e. macula is called Diabetic
maculopathy ( Diabetic macular edema)
b) When rest of the retina get affected it is called diabetic retinopathy.
c) Usually , maculopathy & diabetic retinopathy go hand in hand.
There are 2 stages of Diabetic retinopathy
- NPDR : Mild / Moderate / Severe
- PDR : Early / Advanced
Leakage of fluid or accumulation of hard exudates under macula is called as macular edema.
The early stages of diabetic retinopathy usually don’t have any symptoms. Some people notice changes in their vision, like trouble reading ( distortion / metamorphopsia ) or seeing faraway objects. These changes may come and go.
In later stages of the disease, blood vessels in the retina start to bleed into the vitreous (gel-like fluid in the centre of the eye). If this happens, you may see dark, floating spots or streaks that look like cobwebs. Sometimes, the spots clear up on their own — but it’s important to get treatment right away. Without treatment, the bleeding can happen again, get worse, or cause scarring.
- During initial stages of diabetic retinopathy, usually no treatment is needed, unless you have macular edema.
- Late stages need treatment to prevent further damage.
- To prevent progression of diabetic retinopathy, people with diabetes should strictly control their levels of blood sugar, blood pressure, blood cholesterol & other systemic disorders.
You should see your retina specialist as soon you are detected with Diabetes Mellitus.
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 3 to 4 months.
In later stages, it’s important to start treatment right away ( as suggested by your doctor) depending upon the involvement of your retina
- You need to consult your physician / diabetologist for complete evaluation & treatment ( if needed) for your systemic diseases
- Following investigations may be needed :
Fundus fluorescein angiography
Optical coherence tomography
B-Scan ( Ultra-sonography)
- A) Intra-vitreal Injections : For macular edema . After initial treatment, few patients might need few more injections in coming 1-2 years to preserve your vision.
There are various options of injections. Multiple factors decide which injection you will be recommended.
I: Intra-vitreal injections of Anti-VEGF drugs : First drug of choice.
Types of anti-VEGF :
- a) Avastin : Bevacizumab
Not FDA approved
Primarily used in treatment of colon cancer
Used world wide for retinal disorders.
- b) Accenterix : Ranibizumab
World wide studies have been done regarding its safety & efficacy
- c) Razumab : Accenterix
Biosimilar : A biopharmaceutical drug designed to have active properties similar to one that has previously been licensed & approved.
DCGI approved in 2015
Phase 3 trial in Indian patients only
No world wide trials
- d) Eylea : Aflibercept
Multicentric trials done
II: Intra-vitreal injections of Corticosteroids : Other option . There is risk of increase in eye pressure in 30% patients after this injection, but, that increase in eye pressure can be managed by drops.
Options of corticosteroid injections are :
- a) Triamcinolone acetate : Stays in eye for around 6 weeks
After injection , your vision becomes cloudy because of milky consistency of injection. So, you will be advised to rest with 2 pillows for early settling down of injection. With this molecule there are more chances of increase in ocular pressure.
- b) Ozurdex / Dexamaethasone implant : It is a bio-degradable cylindrical implant injected into your eye. It slowly release drug over a period of 3-3.5 months. Initially you may see a cylinder in your visual field, which gradually reduces in size & finally disappears.
a) Laser treatment : to make leaking blood vessels shrink.
- Focal laser : In “focal” CSME, a focal laser pattern is used to treat leaking microaneurysms identified on FFA that contribute to retinal edema.
- Pan-retinal photocoagulation : Laser treatment is done to cover the whole of the retina, but it treats the peripheral (outside) and middle portions of your retina. It does not treat the central or macular region. Treatment usually consists of approximately 1,500-2,000 spots of laser per eye. This is done in 3 sessions. Your vision will be poor immediately after the treatment, but will recover to the pre-treatment level over time. You can resume your daily activities from next day , but have to refrain from strenuous activities for weeks to months ( depending upon the severity of disease)
The goal of pan-retinal photocoagulation is to prevent the development of new vessels over the retina and elsewhere and not to regain the lost vision. There is no improvement in vision after the laser treatment. Vision may decrease due to edema/swelling of the retina, after the laser treatment for 1-2 weeks. This procedure sacrifices peripheral vision in order to save as much of the central vision as possible and to save the eye itself. Night vision will be diminished. Recurrences of proliferative retinopathy may occur even after an initial satisfactory response to treatment & it all correlates with your systemic control of disease.
Serious complications with pan-retinal photocoagulation are extremely rare, but like any surgical procedure, it does have risks. These risks can be minimized by going to a specialist experienced in pan-retinal photocoagulation.
Surgery : Vitreous surgery (Vitrectomy )
If the bleeding is severe or you develop traction , you may need a surgical procedure called a vitrectomy. During vitrectomy, vitreous gel, which is pulling on the retina, is removed from the eye and replaced with a gas bubble or oil to keep the retina in place. Your body’s own fluids will gradually replace a gas bubble. An oil bubble will need to be removed from the eye at a later date with another surgical procedure. After surgery, your ophthalmologist will recommend that you keep your head in special positions for a time.
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