Diabetic retinopathy
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| Diabetic retinopathy | |
| ICD-10 | H36 (E10.3 E11.3 E12.3 E13.3 E14.3) |
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| ICD-9 | 250.5 |
| DiseasesDB | 29372 |
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Diabetic retinopathy Microchapters |
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Diabetic retinopathy On the Web |
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American Roentgen Ray Society Images of Diabetic retinopathy |
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Diabetes mellitus Main page |
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Patient Information |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]
Overview
Historical Perspective
Pathophysiology
Risk Factors
Screening
Epidemiology and demographics
Natural history, Complications, and Prognosis
Classification
Causes
Differentiating Type page name here from other Disorders
Diagnosis
History and Symptoms | Physical Examination | Laboratory Tests | Electrocardiogram | Chest X Ray | MRI | CT | Echocardiography | Other Imaging Findings | Other Diagnostic Studies
Treatment
Medical: Medical Therapy
Surgical: Surgery
Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies|Social issues
See also
References
Risk factors
All people with diabetes mellitus are at risk – those with Type I diabetes (juvenile onset) and those with Type II diabetes (adult onset). The longer a person has diabetes, the higher the risk of developing some ocular problem. Between 40 to 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy. [1] After 20 years of diabetes, nearly all patients with type 1 diabetes and >60% of patients with type 2 diabetes have some degree of retinopathy.[2]
During pregnancy, diabetic retinopathy may also be a problem for women with diabetes. It is recommended that all pregnant women with diabetes have dilated eye examinations each trimester to protect their vision.
Diagnosis
Diabetic retinopathy is detected during an eye examination that includes:
- Visual acuity test: This test uses an eye chart to measure how well a person sees at various distances (i.e., visual acuity).
- Pupil dilation: The eye care professional places drops into the eye to widen the pupil. This allows him or her to see more of the retina and look for signs of diabetic retinopathy. After the examination, close-up vision may remain blurred for several hours.
- Ophthalmoscopy: This is an examination of the retina in which the eye care professional: (1) looks through a device with a special magnifying lens that provides a narrow view of the retina, or (2) wearing a headset with a bright light, looks through a special magnifying glass and gains a wide view of the retina. Note that hand-held ophthalmoscopy is insufficient to rule out significant and treatable diabetic retinopathy.
- Ocular Coherence Tomography or OCT: This is a scan similar to an ultrasound which is used to measure the thickness of the retina. It produces a cross section of the retina and can determine if there is any swelling or leakage.
- Tonometry: A standard test that determines the fluid pressure (intraocular pressure) inside the eye. Elevated pressure is a possible sign of glaucoma, another common eye problem in people with diabetes.
- Digital Retinal Screening Programs: Systematic programs for the early detection of eye disease including diabetic retinopathy are becoming more common, such as in the UK, where all people with diabetes mellitus are offered retinal screening at least annually. This involves digital image capture and transmission of the images to a digital reading center for evaluation and treatment referral. See Vanderbilt Ophthalmic Imaging Center [4] and the English National Screening Programme for Diabetic Retinopathy [5]
- Slit Lamp Biomicroscopy Retinal Screening Programs: Systematic programs for the early detection of diabetic retinopathy using slit-lamp biomicroscopy. These exist either as a standalone scheme or as part of the Digital program (above) where the digital photograph was considered to lack enough clarity for detection and/or diagnosis of any retinal abnormality.
Of the 18 million to 20 million diabetics in the United States, only about half receive annual eye examinations for retinopathy risk. In an effort to increase diabetic patient’s compliance for regular eye exams, Digital Healthcare, a Wake Forest, NC company specializing in retinal risk assessment, has announced the introduction of Retasure, a new retinal imaging risk assessment solution that connects primary care physicians with ophthalmic specialists to perform retinal imaging.
Retasure allows primary care physicians to capture digital images of diabetic patients’ retinas in a non-invasive procedure that takes just a few minutes. The images are then transmitted over a secure, HIPPA compliant network to a board certified ophthalmologist at an accredited reading center for examination. Results are returned to the primary care physician within 72 hours.
Retasure has been available throughout Europe, and more than one million people have benefited from the system annually.
The eye care professional will look at the retina for early signs of the disease, such as:
- leaking blood vessels,
- retinal swelling, such as macular edema,
- pale, fatty deposits on the retina (exudates) – signs of leaking blood vessels,
- damaged nerve tissue (neuropathy), and
- any changes in the blood vessels.
Additionally;
- Should the doctor suspect macular edema, he or she may perform a test called fluorescein angiography.
- In this test, a special dye is injected into the arm.
- Pictures are then taken as the dye passes through the blood vessels in the retina.
- This test allows the doctor to find the leaking blood vessels.
Management
There are three major treatments for diabetic retinopathy, which are very effective in reducing vision loss from this disease. In fact, even people with advanced retinopathy have a 90 percent chance of keeping their vision when they get treatment before the retina is severely damaged. Still, the best way of addressing diabetic retinopathy is to monitor it vigilantly and ensure that it does not happen in the first place by careful blood glucose control and limitation of dietary fructose.
These three treatments are laser surgery, injection of triamcinolone into the eye and vitrectomy. It is important to note that although these treatments are very successful, they do not cure diabetic retinopathy. Caution should be exercised in treatment with laser surgery since it causes a loss of retinal tissue. It is often more prudent to inject triamcinolone. In some patients it results in a marked increase of vision, especially if there is an edema of the macula.
Avoiding tobacco use and correction of associated hypertension are important therapeutic measures in the management of diabetic retinopathy. [3]
Laser surgery
A type of laser surgery called panretinal photocoagulation, or PRP, is used to treat severe macular edema and proliferative retinopathy. The goal is to create 1 000 - 2 000 burns in the retina with the hope of reducing the retina's oxygen demand, and hence the possibility of ischemia. In treating advanced diabetic retinopathy, the burns are used to destroy the abnormal blood vessels that form at the back of the eye.
Before the surgery, the ophthalmologist dilates the pupil and applies anesthetic drops to numb the eye. In some cases, the doctor also may numb the area behind the eye to prevent any discomfort. The lights in the office are also dimmed to aid in dilating the pupil. The patient sits facing the laser machine while the doctor holds a special lens to the eye. The physician can use a single spot laser or a pattern scan laser for two dimensional patterns such as squares, rings and arcs. During the procedure, the patient may see flashes of light. These flashes may eventually create an uncomfortable stinging sensation for the patient. After the laser treatment, patients should be advised not to drive for a few hours while the pupils are still dilated. Vision may remain a little blurry for the rest of the day, though there should not be much pain in the eye.
Scatter laser treatment
Template:Diabetes Rather than focus the light on a single spot, the eye care professional may make hundreds of small laser burns away from the center of the retina, a procedure called scatter laser treatment or panretinal photocoagulation. The treatment shrinks the abnormal blood vessels. Patients may lose some of their peripheral vision after this surgery, but the procedure saves the rest of the patient's sight. Laser surgery may also slightly reduce colour and night vision.
A person with proliferative retinopathy will always be at risk for new bleeding as well as glaucoma, a complication from the new blood vessels. This means that multiple treatments may be required to protect vision.
Vitrectomy
Instead of laser surgery, some people need an eye operation called a vitrectomy to restore vision. A vitrectomy is performed when there is a lot of blood in the vitreous. It involves removing the cloudy vitreous and replacing it with a saline solution made up of salt and water. Because the vitreous is mostly water, there should be no change between the saline solution and the normal vitreous.
Studies show that people who have a vitrectomy soon after a large hemorrhage are more likely to protect their vision than someone who waits to have the operation. Early vitrectomy is especially effective in people with insulin-dependent diabetes, who may be at greater risk of blindness from a hemorrhage into the eye.
Vitrectomy is often done under local anesthesia. The doctor makes a tiny incision in the sclera, or white of the eye. Next, a small instrument is placed into the eye to remove the vitreous and insert the saline solution into the eye.
Patients may be able to return home soon after the vitrectomy, or may be asked to stay in the hospital overnight. After the operation, the eye will be red and sensitive, and patients usually need to wear an eyepatch for a few days or weeks to protect the eye. Medicated eye drops are also prescribed to protect against infection.
References
- ↑ "NIHSeniorHealth: Diabetic Retinopathy - Causes and Risk Factors". Diabetic Retinopathy. NIHSenior Health. 2005.
- ↑ "Screening for Diabetic Retinopathy". Diabetic Retinopathy. American Diabetes Association. 2002.
- ↑ "Diabetes Ocular complications". Chronic Complications of Diabetes. Armenian Medical Network. 2006. Text " Umesh Masharani, MB, BS, MRCP " ignored (help)
Additional Resources
- The original text of this document was taken from the public domain resource document "Facts About Diabetic Retinopathy", at http://www.nei.nih.gov/health/diabetic/retinopathy.asp See the copyright statement at http://www.nei.nih.gov/order/index.htm, which says "Our publications are not copyrighted and may be reproduced without permission. However, we do ask that credit be given to the National Eye Institute, National Institutes of Health."
- Basic ophthalmology for medical students and primary care residents, 7th edition
- Kawasaki T, Ogata N, Akanuma H, Sakai T, Watanabe H, Ichiyanagi K, Yamanouchi T. Postprandial plasma fructose level is associated with retinopathy in patients with type 2 diabetes. Metabolism 2004;53:583-8. Fulltext. PMID 15131761.
- Eye Care for Diabetics
External links
- Diabetic Retinopathy Resource Guide from the National Eye Institute (NEI).
- National Diabetes Information Clearinghouse
- Lions Eye Institute, Perth, Australia
- Educational website on Diabetic Retinopathy
- English National Screening Programme for Diabetic Retinopathy
Template:SIB cs:Diabetická retinopatie de:Diabetische Retinopathie nl:Diabetische retinopathie fi:Diabeettinen retinopatia