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Diabetic retinopathy

 

Diabetic retinopathy –Diabetes mellitus is a fast growing health hazard throughout the world. According to a study Hyderabad has emerged as the Indian metro city with the highest incidence of diabetes. The study estimated 16.6% of Hyderabad populations have diabetes making it diabetic capital of India. A recent survey revealed only one third of the diabetic individuals know the evil effects of diabetes on the eye.
Diabetes is a metabolic disorder characterized mainly by high blood sugar. It can affect different parts of the body including blood vessels, heart, kidney, eye, foot and nerves.
Diabetic retinopathy is due to damage to the small blood vessels present in the retina (innermost light sensing tissue of the eye). Poorly maintained blood sugar levels and duration of diabetes are the risk factors for the progression of diabetic retinopathy.
Most diabetic patients are non insulin dependent (NIDDM or type 2 diabetics) and usually control their blood sugar with exercise and oral medication. The remaining are insulin dependent (IDDM or type 1 diabetics) and require insulin to regulate the sugar levels.
Diabetic retinopathy is seen in both type 1 and type2 diabetes. The risk is increased when hypertension, renal disease and pregnancy are added. Regular eye checkups (as diabetic retinopathy is asymptomatic unless the macula is involved) with added laser when necessary significantly stabilizes the progression of retinopathy.
Diabetic retinopathy is divided into 3 main categories
1.    Non proliferative diabetic retinopathy
2.    Proliferative diabetic retinopathy
3.    Diabetic maculopathy

Signs of diabetic retinopathy:
1.    Microaneurysums: These are deep red dots seen as first visible sign of diabetic retinopathy
2.    Vascular Permeability (Leaking vessels): Excelling leaking from small retinal blood vessels (capillaries) and micro aneurysms result in development of etinal edema especially in macular area where it is commonly called as macular edema. OCT is the diagnostic test used to assess the thickness of macula along with level and amount of fluid accumulation
3.    Macular edema is often accompanied by retinal hard exudates. Hard exudates are lipid deposits that are associated with leakage of vessels. Host patient with hard exudates have increased cholesterol levels. Good control of blood sugar levels and cholesterol decreases the chance of hard exudates formation
4.    Capillary closure: Obliteration of retinal capillaries (small blood vessels)


1.NPDR


2.PDR


3.Diabetic Maculopathy
Treatment of diabetic retinopathy
1.    Systemic disease control
Medical treatment of diabetes, hypertension and renal disease are important to slow the development and progression of diabetic retinopathy.
2.    Laser treatment
Laser treatment is indicated in maculopathy and proliferative diabetic retinopathy. It is an outpatient procedure and requires the pupil to be dilated to the full extent. Laser light is focused on the retina with the help of a contact lens, after anaesthetizing the eye with topical eye drops.
1.    Laser for macular oedema: The goal in treating macular oedema in diabetic retinopathy is not to improve the vision but to stabilize vision by attempting to stop damaged blood vessels from leaking fluid into the retina. Small discrete areas of vessel leakage re treated with focal lasers and diffuse leakage is treated with a grid pattern. Vision may get little worse following laser for a short period. Most of the patients who receive laser for macular oedema maintain better vision than those who had not received any treatment.
2.    Laser for proliferative diabetic retinopathy: PRP or pan retinal photocoagulation is done to treat the abnormal new vessels. Peripheral retina which is not receiving adequate blood flow is treated by laser to halt the new vessel formation. This process requires over 1000 laser applications and hence is divided into three or more separate sessions. The laser helps to prevent severe visual loss occurring due to complications of diabetic retinopathy, though it does not improve the lost vision.
3.Intraocular steroids and other medications:
Diffuse macular oedema and focal oedema not responding to laser treatment require intraocular injection of steroids or anti VEGF agents (bevacizumab/ranibizumab). Studies with anti VEGF agents showed promising results with excellent safety profile. The drug lasts for about 6 weeks in the eye after a single injection and may need to be repeated if the disease reactivates. Similarly, intravitreal long acting steroids have shown promising results in controlling diabetic macular edema, however they carry risk of increasing intraocular preassure and cataract progression.
4.Surgery:
 A person may have bleeding before the application of laser or rarely the diabetic retinopathy progresses even after laser treatment. Majority of vitreous hemorrhage clears by six weeks by absorption of the body. Vitrectomy surgery is indicated to remove vitreous hemorrhage if it is not absorbed within 6 weeks. The procedure is also done for treatment of tractional retinal detachment due to scar tissue formation.
Vitrectomy is performed in the operating room after anaesthetizing the eye with local anesthetics. It is one to two hours procedure and the patient can go home the same day.

Risk factors for progression of diabetic retinopathy:
-    Duration of diabetes
-    Glycemic control ( blood sugar control)
-    Hypertension
-    Hyper lipidemia ( increased blood cholesterol)
-    Pregnancy
-    Renal failure
-    Anaemia

 


 















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