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Diabetic Eye Diseases

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Diabetic Retinopathy:
Diabetes is the leading cause of blindness in the United States in patients ranging from 20 to 74 years of age. There are approximately 16 million diabetic patients in the U.S. Some reports indicate that 50% of the population does not know they have diabetes. With the increasing prevalence of obesity developing in the county, the increase of individuals with diabetes will mushroom. With this, there will be an increase in diabetic retinopathy, cataracts, kidney disease, coronary artery and other diseases. Arkansas has one of the highest numbers of diabetes patients in the U.S. Blindness occurs 25 times more often in patients with diabetes than in patients without the disease. There are two types of diabetes. Type I is insulin dependent and Type II, which can usually be treated initially with oral medications and/or diet and weight loss in conjunction with regular exercise. Eventually, insulin therapy will be required as well.

Medical conditions that make diabetic retinopathy progress faster and become more severe in nature are hypertensive cardiovascular disease (high blood pressure) and elevated triglycerides and cholesterols. Other risk factors in the development of this disease are the duration of the diabetes, the degree or severity of the retinopathy, rate of control of blood sugars, kidney disease, pregnancy, and even cataract surgery. The longer the duration of diabetes, the more likely diabetic retinopathy will develop.

In patients with Type I diabetes, 25% will develop diabetic retinopathy within five years of onset of diabetes; 60% at ten years; 80% at fifteen years. Unfortunately, 25% of these patients will develop the proliferative stage of diabetic retinopathy, that is the formation and growth of abnormal blood vessels that leak fluid, causing hemorrhaging within the eye and eventual blindness if not treated.

Diabetic retinopathy will develop in 40% of patients with Type II diabetes in five years of onset, 84% in ten years. With these percentages, it becomes quite apparent that strict control of an individual’s blood sugars, strict dietary control, exercise and treatment of other conditions is critical in maintaining not only the health of the eye but the body as a whole.

Intensive treatment of diabetes can decrease the degree of diabetic retinopathy by 50%. Patients with diabetes should see their medical doctor regularly to monitor their blood sugar levels as well as become knowledgeable about the HgbA 1C blood test. This test denotes an average of the blood sugar over a three month period of time and correlates very strongly with diabetes control. The values ranging from 6 to 7 signify control of diabetes. Values between 7 and 9 signify that additional medication or better adherence to diet and exercise is in order. Values over 9 reflect a diabetic state that is totally out of control.

We at Moulton Eye Clinic try to stress to our diabetic patients that a HgbA 1C level between 6 and 7 will help immensely in regard to their whole body health, not just the eyes. We also stress the importance of controlling their trigyceride and cholesterol levels as well as blood pressure.

Non-proliferative background diabetic retinopathy (NPBDR):
This form of retinopathy is basically the development of changes in the capillaries of the retinal vasculature that result in the leaking of fluid and even blood into the retinal tissues themselves. These small capillaries can also become occluded over time, producing areas of ischemia and preventing oxygen and nutrients from reaching the retina. NPBDR is the primary cause for loss of useful central visual acuity in the diabetic patient.

Most patients with diabetic retinopathy will have moderate vision loss due to macular edema. Diabetic macular edema from NPBDR changes is very common among working age adults with diabetes. The only proven and effective treatment for diabetic macular edema has been laser photocoagulation, but not all patients can be treated successfully with laser. Strict control of blood sugar and HgbA 1C levels are still a must. Laser photocoagulation is a safe procedure done in our clinic. It is relatively effective in maintaining visual acuity, although it does not consistently improve the vision. This is true especially in patients who present with moderate to severe diabetic retinopathy and diabetic macular edema. When utilizing laser treatment for NPBDR for macular edema, the laser beams are used in a scattered grid form to reduce the leakage of blood vessels and prevent further visual loss. Even though it is uncommon for patients who have blurred vision from the macular edema to recover normal vision, some patients do experience a good return of visual function. Obviously, the sooner the condition is diagnosed and treated, the better off the patient will be long-term.

In conjunction with laser photocoagulation for this condition, we use several forms of pharmacological agents or medications that help reduce the swelling of the retina from the diabetic retinopathy by stabilizing the leakage from the blood vessels as well as preventing and even produce regression of the abnormal new blood vessels that bleed and fill the eye with blood. The agents that we currently use are in the form of Kenalog and Avastin injections.

Avastin is a pharmacological agent that inhibits the development and progression of new abnormal blood vessels that develop in the proliferative stage of diabetic retinopathy. It is the proliferative vessels that cause bleeding within the eye and total obstruction in the vision. If not treated early and aggressively, this condition can lead to blindness.

Proliferative diabetic retinopathy (PDR):
This condition entails the development of abnormal new blood vessels or neovascularization. These blood vessels start growing on the surface of the retina or the optic nerve. Over time, these vessels attach to the jelly material called vitreous that fills the eye and leak fluid, causing inflammation in the vitreous. The inflammation will cause the vitreous to contract, thereby pulling and popping these abnormal blood vessels that then bleed within the eye and fill the eye with blood. The result is more inflammation on the vitreous and the cycle repeats itself. These abnormal new blood vessels develop in response to a widespread closure of retinal blood vessels, preventing adequate blood flow and thereby not delivering the necessary nutrients and oxygen supply to the highly active metabolic retinal tissue.

PDR may also produce a traction detachment of the retina, that part of the eye that is like the film in a camera. These new abnormal blood vessels can form scar tissue, thereby shrinking and wrinkling. When this occurs, the retina can detach.

Neovascular glaucoma can be produced as a result of PDR and in some severe cases of NPBDR. New abnormal blood vessels grow on the outflow channels of the eye, thereby blocking fluid from flowing out of the eye. This results in a back-up of fluid and elevated intraocular pressure, producing glaucoma and often damaging the optic nerve to the extent that blindness occurs.

PDR is commonly treated with laser photocoagulation. The laser is focused on the entire retina except the central macula. The treatment causes abnormal new blood vessels to shrink and often prevents their growth in the future, thus resolving the problem. By doing this, the chance of the eye filling with blood and loss of vision is reduced.

Another treatment used for PDR is a surgical procedure called a Vitrectomy. This is a microsurgical procedure performed in the hospital whereby the blood filled jelly-like vitreous is removed from the eye and replaced with a clear solution. Within about five days, this clear solution is naturally replaced with the eye’s own clear fluid produced in the front of the eye. A Vitrectomy often prevents further bleeding by removing the abnormal vessels that caused the bleeding. If areas of the retina have detached from traction, repair can be done during the Vitrectomy. If traction detachment of the macula is present, surgery must be performed as soon as possible. Otherwise, this traction will cause permanent visual loss. The longer the macula is distorted by traction detachment, the more serious the vision loss will become.

If you have diabetes, it is important to know that with improved methods of diagnosis and treatment only a small percentage of patients who develop retinopathy have serious visual problems. The key is early detection and treatment.

At Moulton Eye Clinic, we treat many patients with diabetic retinopathy. Examinations are usually scheduled every three to four months, depending on the stage of retinopathy and treatment response, the more serious the problem, the more frequent the exams. Patients who have diabetes without retinopathy should be examined at least once a year. Pregnant women with diabetes should be examined within the first trimester, because retinopathy can progress quickly during the pregnancy. Diabetic patients who want a prescription for new glasses should know that their blood sugars should be under consistent control prior to the appointment. Rapid changes in blood sugars will cause fluctuation in vision and an accurate prescription will not be possible.

Patients 30 years of age or younger with Type I diabetes should have their initial eye exam within five years of diagnosis. Patients over 30 years of age with Type II diabetes or needing insulin along with oral medication should have an eye exam within a week to a month following diagnosis.

In addition to retinal and macular edema in patients with diabetes, we also offer treatment for occlusion of the central retinal vein, or the main venous drainage blood flow from the eye and branch occlusion of one of the veins. Both of these conditions lead to swelling of the macula, much like that in diabetic macular edema. Treatment options for branch vein occlusion are much the same as for diabetic macular edema patients. Laser photocoagulation would be performed as well as pharmacological agent injections. For central retinal vein occlusion, laser therapy has not proven to be beneficial. However, the pharmacological agent injections have shown great promise.

We at Moulton Eye Clinic have been offering these surgical treatments for diabetes, macular edema, abnormal blood vessel growth, hemorrhage and retinal detachment since 1979 in Fort Smith at both St. Edward Mercy Medical Center and Sparks Regional Medical Center. Both ambulatory surgery centers have the necessary equipment to perform these surgeries.

Occasionally, when the problem is too extensive, we will recommend further treatment to the patient, usually in Little Rock.