Diabetic retinopathy is a pathology of the organs of vision that occurs as a result of long-existing hyperglycemia. The pathogenesis of this disease is based on disorders of the microvasculature (microaneurysms, hemorrhages, exudates, newly formed vessels), which arise due to hypoxic conditions, which, in turn, are caused by a hyperglycemic state. The initial stage of the lesion without special studies is difficult to identify, because symptomatically it does not make itself felt. Decreased visual acuity (or blindness) are signs of a disease that has already gone far, which cannot be eliminated.
To avoid such serious visual impairment, people with diabetes need to visit an ophthalmologist at least once a year and strictly follow all his recommendations. Of course, that the main therapy is aimed at reducing blood sugar, diet and motor activity. Nevertheless, there is a need for the use of drugs that affect the state of the organs of vision. One of such preventive medicines is eye drops according to Filatov, which contain biologically active substances that help preserve eye health.
Particular attention is paid to the intake of B vitamins (their doctor can prescribe both parenterally and for oral administration), as well as C, P and E, which have angioprotective properties. Periodically, you need to take drugs that have a more pronounced effect on the vessel wall: prodectin, dicinone, etc.
A more radical measure - laser coagulation of the retina - a point effect on the retina of the eye, preventing the excessive formation of blood vessels on it. This procedure sometimes leads to complications (for example, hemorrhage in the vitreous body), which require additional interventions in the form of vitrectomy - removal of the vitreous body and replacing it with a special sterile solution.
A relatively new method of treating retinopathy also appeared - injection of an inhibitor of endothelial vascular growth factor (ranibizumab) into the cavity of the eye.
The patient, drawing conclusions from the above information, must understand that such difficult medical measures can be avoided if you follow the banal rules of a healthy lifestyle: do not overeat, eat healthy foods, avoid harmful foods and maintain physical activity at a good level.
How retinopathy develops
With diabetes, the vessels of the retina gradually change. Over time, the delicate tissues of the visual organ receive less and less oxygen. Diabetic retinopathy develops gradually, the stages are directly proportional to the "experience" of diabetics. Also important is the age of the patient.
In people under the age of 30, the likelihood of developing retinopathy increases to 50% after 10 years from the onset of endocrine disease. After 20 years of illness, the risk of anomalies in vision is 75%.
Sugar gradually damages the walls of blood vessels. Their permeability rises to an abnormal level. Because of this, the liquid part of the blood can freely seep into the space between the arteries and capillaries. The retina swells, lipid complexes (solid exudates) are deposited in the tissues, or simply speaking fats, which are not properly absorbed due to a metabolic failure. Similar changes are characteristic of the early stages of diabetic retinopathy. It is also called background or non-proliferative, that is, not complicated.
Over time, the processes of destruction become more pronounced. At the stage of preproliferative changes, some parts of the retina are completely disconnected from the bloodstream. Here cotton-like foci begin to form. They indicate a myocardial retinal tissue. In other areas, local hemorrhages may occur. Sites that fall out of visual work become blind.
Proliferative diabetic retinopathy is considered the latest stage in the complication of diabetes. Circulatory problems are becoming increasingly serious. Abnormal vessels begin to grow on the surface of the retina. They are also sources of constant point bleeding. Because of this, the vitreous body suffers, and vision also gradually begins to decline.
Neoplasms, bleeding, and other destructive phenomena lead to the appearance of scar tissue on the surface. Similar structures are not typical for this organ. Cicatricial conglomerates begin to contract the retina, causing it to exfoliate and lose vision.
Forms of pathology
Classification of diabetic retinopathy involves the separation of this type of complications of diabetes into two forms. They were mentioned earlier, considering the pathogenesis of the disease. More details below.
- Retinal Background Retinopathy
This form of the pathological condition is characterized by abnormal changes that occur in the retina, but cannot be seen at the very initial stages. This form is inherent in “diabetics with experience”, usually occurs at a fairly advanced age. The disease is characterized by a sluggish anomaly of vision
- Proliferative retinopathy
Due to an increase in oxygen deficiency in tissues, the background handicap of retinopathy can at any time transform into proliferative pathology. In adolescence, destructive changes leading to severe visual impairment occur in a matter of months. Subsequent retinal detachment leads to complete retinal detachment. It is proliferative retinopathy that is considered one of the main causes of vision loss in a young working population.
Stages of the development of the disease
There are three stages of diabetic retinopathy:
- First stage. Non-proliferative changes do not require treatment as such. The patient is observed by the doctor on an ongoing basis. Vision changes are not observed. Isolated cases of blockage of small vessels of the retina,
- Second stage. Preproliferative retinopathy is characterized by more severe changes in the fundus. The vessels are very permeable, and constant hemorrhage leads to a gradual deterioration of visual functions,
- Third stage. The most dangerous and advanced proliferative retinopathy is the result of the patient’s careless attitude to his own health, as well as the incompetence of the doctor who supervised the diabetic. The vessels are totally clogged, the vast areas of the retina are “dead”. Pathological vessels against the background of a clear "starvation" of the retina grow at an abnormal rate. The end result is retinal detachment and blindness.
Symptoms of Diabetic Retinopathy
Diabetic retinopathy is a “silent” disease, symptoms occur in the very last stages when the changes become irreversible. The obvious manifestations of diabetic retinopathy include:
- Flies and spots that seem to “float” before your eyes. These are blood clots that enter the vitreous body. When the patient looks at any light source, they interfere with visual perception,
- Sweating visual acuity for no apparent reason. A diabetic may have difficulty reading the text while working with small items. This is a clear symptom indicating increasing retinal edema,
- A sharp veil before the eyes is a sign that a hemorrhage has just occurred.
Treatment of retinopathy in diabetes, first of all, requires appropriate diagnostic measures. In order to refute or confirm the diagnosis, a number of important diagnostic measures will be required:
- The study of visual fields (perimetry) allows you to fully assess the condition of the retina on the periphery,
- An electrophysiological study will study the nerve cells of the retina, as well as the optic nerve itself,
- Ultrasound examination of eye tissues,
- Ophthalmoscopy (fundus examination).
All people who are diagnosed with diabetes should remember that there is always a risk of all kinds of complications. Avoiding vision problems is always easier than starting treatment for diabetic retinopathy. All patients with diabetes are recommended to visit an ophthalmologist at least once every 6 months for the purpose of preventive examinations. The doctor will be able to notice possible adverse changes and take the necessary measures.
Treating Diabetes Complications
According to statistics, in more than 80% of all cases of ophthalmic problems in diabetics, it is possible to prevent the occurrence of blindness. It is important to understand that the risk of retinal damage is associated not only with the patient’s age and the duration of the illness itself. A significant role is played by fluctuations in blood sugar and blood pressure.
Patients with severe retinopathy must visit the office of the laser surgeon. The specialist will be able to identify key problems in time and eliminate them, using modern developments in laser surgery.
One of the surgical methods of treatment is laser coagulation (laser cauterization). Such treatment for diabetic retinopathy is available to all categories of patients and allows you to stop local bleeding.
The essence of laser coagulation (cauterization)
The procedure is performed on an outpatient basis under local anesthesia. Using a laser beam aimed at pathological vascular formations, the surgeon cauterizes the necessary areas. This allows you to prevent intraocular hemorrhage in the future and to avoid loss of vision. The recovery period is minimal - no more than 1 week.
Vitrectomy - a last resort
In the presence of serious deviations from the norm, the patient is indicated for vitrectomy. Intervention is considered the only way out in the presence of extensive hemophthalmus (if a large hematoma occurs in the tissues).
Surgically remove the damaged fragments of the vitreous body, clean the membrane from the surface of the retina. Also, treatment of neoplasms of the vascular tissue of the retina is carried out. The surgeon, if possible, restores the optimal anatomical position of the retina.
If retinopathy is accompanied by damage to the central segment of the retina, drug treatment of the organ is indicated. For this, intravitreal injections are practiced - special medicinal formulations are introduced into the tissues, which the doctor selects.
Diabetes is a chronic disease that you can live with but not cure. Adhering to all the rules and recommendations of the attending physician, you can live a long and full life without clouding your life with the unpleasant consequences of the disease. Patients should regularly monitor their blood glucose and blood pressure in general. Another important point is regular preventive examinations. Taking care of your own health will help to avoid the formidable complications of diabetes, including diabetic retinopathy.
What is diabetic retinopathy?
Diabetic retinopathy is one of the biggest complications of diabetes. In this disease, the retina of the eye suffers, which is responsible for the conversion of light flows into nerve impulses.
Damage begins at the level of small blood vessels, capillaries, supplying the retina with nutrients, as a result of which photosensitive cells die “from hunger”.
Diabetic retinopathy can occur with both type 1 diabetes and type 2 diabetes.
Mechanisms for the development of diabetic retinopathy
The appearance of diabetic retinopathy is caused by a change in the wall of the capillaries of the retina, that is, those small blood vessels that carry blood to the retina.
In particular, it happens:
- Cell loss: i.e. vascular endothelial cells and the cells that surround endothelial cells.
- Thickening of the capillaries: the basement membrane of the capillaries, which leads to narrowing of the artery and limiting blood flow.
- Changes in the connections between cells: the loss or destruction of bonds between endothelial cells causes a weakening of the vascular wall with the subsequent formation of edema at the level of the retina.
Risk factors and consequences of diabetic retinopathy
All diabetics run the risk of diabetic retinopathy. However, there are certain risk factors that increase the likelihood of this pathology.
Among the risk factors we have:
- Duration of a diabetic disease: it is assumed that when diagnosing diabetes in a 30-year-old person, after five years he has a 20% chance of developing retinopathy, after ten years this probability increases to 40-50%, and after 15 - more than 90%. Therefore, the longer the duration of the disease, the higher the risk of developing retinopathy.
- Poorly controlled diabetes: this means that sugar levels often reach limit values. This occurs when the patient does not apply adequate therapy or does not want to change his lifestyle.
- The presence of other risk factors: the simultaneous presence of risk factors such as smoking, alcohol, hypertension and a high-fat diet increase the likelihood of diabetic retinopathy, as these elements damage the walls of arterial vessels.
Stages of retinopathy: proliferative and non-proliferative
Diabetic retinopathy can be divided into stages of progression, which go foot to foot with an increase in the severity of the pathology.
There are two main stages:
Nonproliferative retinopathy: also called a simple and less severe form of retinopathy. It is characterized by the formation of microaneurysms, that is, the expansion of the walls of the vessels, which leads to their weakening and the possible formation of hemorrhages at the level of the retina and macular edema.
Exudate also appears, therefore this form is called exudative, caused by leakage of fluid from the vessels due to non-functional disorders in the wall. Such exudate at the first stage is of a rigid type, that is, it consists of fats and proteins, such as fibrin.
Proliferative retinopathy: this is the most advanced and most severe stage, which is characterized by the presence of additional blood vessels that form to block the damaged ones.
The exudate at this stage has a mild type, resembles pieces of cotton wool, and is formed during ischemia in various areas of the retinal fibers and the accumulation of endoplasmic material flowing through the damaged endothelium.
New vessels, which are formed for blood supply to the areas of ischemia, have very fragile walls and easily break, which leads to the formation of hemorrhages. Also, scar tissue forms on the retina due to the constant ruptures of these vessels, this can determine retinal wrinkling and its detachment.
Medicines for diabetic retinopathy
Among the new drug therapies used to treat diabetic retinopathy, intravitreal injections should be noted. With this therapy, the drug is injected into the vitreous space with a needle, which reduces the formation of new blood vessels.
Of the drugs most often used:
- Anti-VEGF preparations: Avastin and Lucentis belong to this category.
- Corticosteroids: triamcinolone and dexamethasone. They are used because of their powerful anti-inflammatory effect, which reduces the formation of edema.
To improve vision, you can use glasses and lenses that filter light and improve lighting conditions.
Depending on the stage of the disease, the nature of the pathological changes in the vessels, as well as the tissues of the eye, the following classification is adopted:
- non-proliferative diabetic retinopathy,
- preproliferative diabetic retinopathy,
- proliferative diabetic retinopathy.
The main source of energy for the full functioning of the body is glucose. Under the influence of insulin, the hormone of the pancreas, glucose penetrates into the cells where it is being processed. In diabetes mellitus, for some reason, a violation of insulin secretion occurs. Non-processed sugar accumulates in the blood, as a result of which metabolic processes in the body are disturbed. It leads to blockage, damage to blood vessels of various organs, including the organs of vision. If the correction of the increased glucose content in patients with diabetes mellitus is not started in time, then diabetic retinopathy begins to develop.
Causes of occurrence
The main cause of the pathology is an increase in blood sugar (glucose) for a rather long time.
Normally, blood sugar levels should not rise above 5.5 mmol / L on an empty stomach and 8.9 mmol / L after eating.
In addition, the presence of concomitant factors in patients with diabetes affects the occurrence of retinopathy. They can not only provoke the formation of such a complication, but also accelerate its course.
- increased blood sugar
- persistent hypertension (increased blood pressure),
- various pathologies and diseases of the kidneys,
- age-related changes in the cardiovascular system,
- genetically determined predisposition.
People with this disease should adhere to proper nutrition, which is one of the main methods of complex therapy used.
From the diet exclude:
- sugar, replacing it with substitutes (xylitol, sorbitol),
- baking and puff pastry,
- premium and first grade bread,
- fatty meat, fish,
- sweet curd desserts and curds, cream,
- smoked meats
- pasta, semolina, rice,
- concentrated fatty broths, soups cooked in milk with cereals, noodles,
- hot seasonings, sauces, spices,
- sweet carbonated and non-carbonated drinks, juices, including grape,
- honey, ice cream, jam
- gray, best rye, as well as bran bread,
- low-fat types of meat, poultry, fish - boiled and aspic,
- buckwheat, oat, or pearl barley (due to bread restriction),
- a day you need to eat no more than two soft-boiled eggs or an omelet,
- cheese, sour cream only in limited quantities,
- berries, such as cranberries, blackcurrants or stewed fruit, unsweetened apples, but not more than 200 grams per day,
- tomato and other unsweetened fruit and berry juices,
- coffee needs to be replaced with chicory.
Of particular importance is the phytodiet. In patients with diabetes mellitus, acidification occurs in the body, which is why the use of vegetables with an alkalizing effect is recommended:
Drink birch sap in half a glass up to three times a day, fifteen minutes before eating.
In drug treatment, the main place is occupied by:
- blood cholesterol lowering drugs
- anabolic steroid,
- biogenic stimulants,
- desensitizing drugs
- coenzymes and others.
- Hypocholesterolemic drugs:
These drugs are recommended for use in diabetic retinopathy, which occurs in combination with general atherosclerosis.
- sore throat
- Dicinone "or" Etamsylate,
- For the treatment of the preproliferative stage of the pathology, the drug “Phosphaden” is used, which improves eye hemodynamics, the general condition of the fundus and stimulates metabolic processes
- The immunomodulating effect in the early stages of the disease is achieved by the use of the tablet drug Levomezil, and the injections Tactivin and Prodigiosan.
- Vitamins of group B, C, E, R.
- Restoring and improving metabolism in the eye tissues: preparations "Taufon", "Emoksipin".
- Intraocular administration of the enzyme preparations "Lidaza", "Gemaza" is used in the presence of pronounced hemorrhages.
To achieve a high result in treatment, you can use the Sidorenko Glasses, a physiotherapeutic device that is convenient for use at home, and improves blood circulation.
Unfortunately, drug treatment can only be effective in the initial stages of this type of retinopathy. In later periods of its development, laser therapy is used.
Laser coagulation allows you to slow down or even stop the proliferation of newly formed vessels, strengthens their walls and minimizes permeability. The probability of retinal rejection is reduced.
With the advanced form of diabetic retinopathy, surgery is required - vitrectomy.
Exclusion of risk factors: stabilization of body weight, treatment of hypertension, refusal of alcohol and smoking helps to restore metabolic processes, increases the result of treatment.
What is retinopathy?
The pathogenesis of the development of such a serious complication is very confusing and multifaceted.
The following factors play a major role in the progression of visual impairment:
- Microangiopathy. Chronic hyperglycemia provokes sclerosis of arterioles and venules, as a result of which their sclerosis occurs and blood circulation in the visual analyzer worsens. The retina does not receive enough blood. The body compensatory increases the flow of fluid, which mechanically damages the microvessels and leads to their injury.
- Increased penetration of capillary membranes. In this case, a large number of substances that could not get into the eye before are actively transported there. This also applies to toxins with other undesirable compounds.
- Permanent damage to the structure of the blood supply makes the neovascularization process activate - the formation of new arterioles. They are much weaker than usual, therefore, episodes of hemorrhage become more frequent.
Ultimately, in the absence of adequate drug therapy, retinopathy in diabetes progresses to complete loss of vision.
Diabetic retinopathy is a highly specific late complication of diabetes mellitus, both insulin-dependent and non-insulin-dependent. In ophthalmology, diabetic retinopathy causes vision impairment in patients with diabetes in 80-90% of cases. In people with diabetes, blindness develops 25 times more often than in other representatives of the general population. Along with diabetic retinopathy, people with diabetes have an increased risk of coronary heart disease, diabetic nephropathy and polyneuropathy, cataracts, glaucoma, occlusion of the central nervous system and central nervous system, diabetic foot and gangrene of the extremities. Therefore, the treatment of diabetes requires a multidisciplinary approach, including the participation of specialists from endocrinologists (diabetologists), ophthalmologists, cardiologists, podologists.
Causes and Risk Factors
The mechanism of development of diabetic retinopathy is associated with damage to retinal vessels (blood vessels of the retina): their increased permeability, occlusion of capillaries, the appearance of newly formed vessels and the development of proliferative (scar) tissue.
Most patients with a prolonged course of diabetes mellitus have some or other signs of damage to the fundus. With a duration of diabetes up to 2 years, diabetic retinopathy is detected to one degree or another in 15% of patients, up to 5 years - in 28% of patients, up to 10-15 years - in 44-50%, about 20-30 years - in 90-100%.
The main risk factors affecting the frequency and progression of diabetic retinopathy include the duration of diabetes mellitus, the level of hyperglycemia, arterial hypertension, chronic renal failure, dyslipidemia, metabolic syndrome, and obesity. The development and progression of retinopathy can contribute to puberty, pregnancy, a genetic predisposition, and smoking.
Given the changes developing in the fundus, non-proliferative, preproliferative and proliferative diabetic retinopathy are distinguished.
Elevated, poorly controlled levels of blood sugar lead to damage to blood vessels of various organs, including the retina. In the non-proliferative stage of diabetic retinopathy, the walls of the retinal vessels become permeable and brittle, which leads to point hemorrhages, the formation of microaneurysms - local saccular dilatation of the arteries. A liquid fraction of blood seeps through the semipermeable walls from the vessels into the retina, leading to retinal edema. In the case of involvement in the process of the central zone of the retina, macular edema develops, which can lead to decreased vision.
In the preproliferative stage, progressive retinal ischemia develops due to occlusion of arterioles, hemorrhagic heart attacks, venous disorders.
Preproliferative diabetic retinopathy precedes the next proliferative stage, which is diagnosed in 5-10% of patients with diabetes mellitus. Contributing factors in the development of proliferative diabetic retinopathy include high myopia, occlusion of the carotid arteries, posterior vitreous detachment, optic atrophy. At this stage, due to oxygen deficiency experienced by the retina, new vessels begin to form in it to maintain an adequate level of oxygen. The process of neovascularization of the retina leads to repeated preretinal and retrovitreal hemorrhages.
In most cases, minor hemorrhages in the layers of the retina and vitreous body resolve independently. However, with massive hemorrhages in the eye cavity (hemophthalmus), irreversible fibrous proliferation in the vitreous body occurs, characterized by fibrovascular fusion and scarring, which ultimately leads to tractional retinal detachment. When blocking the outflow pathway of the HPV, secondary neovascular glaucoma develops.
Diabetic Retinopathy Treatment
Along with the general principles of treatment of retinopathies, therapy includes the correction of metabolic disorders, optimization of control over the level of glycemia, blood pressure, lipid metabolism. Therefore, at this stage, the main therapy is prescribed by the endocrinologist-diabetologist and cardiologist.
Careful monitoring of the level of glycemia and glucosuria, the selection of adequate insulin therapy for diabetes mellitus is carried out, angioprotectors, antihypertensive drugs, antiplatelet agents, etc. are administered. Intravitreal injections of steroids are performed to treat macular edema.
Patients with advanced diabetic retinopathy are indicated for laser retinal coagulation. Laser coagulation allows you to suppress the process of neovascularization, to achieve obliteration of blood vessels with increased fragility and permeability, to prevent the risk of retinal detachment.
Laser retina surgery for diabetic retinopathy uses several basic methods. Barrier laser coagulation of the retina involves the application of paramacular coagulates of the “lattice” type, in several rows, and is indicated for the non-proliferative form of retinopathy with macular edema. Focal laser coagulation is used to cauterize microaneurysms, exudates, and small hemorrhages revealed during angiography. In the process of panretinal laser coagulation, coagulates are applied throughout the retina, with the exception of the macular region, this method is mainly used at the preproliferative stage to prevent its further progression.
With opacification of the optical media of the eye, an alternative to laser coagulation is transscleral cryoretinopexy, based on cold destruction of pathological parts of the retina.
In the case of severe proliferative diabetic retinopathy complicated by hemophthalmus, macular traction or retinal detachment, they resort to vitrectomy, during which the blood, the vitreous body itself is removed, the connective tissue strands are cut, bleeding vessels are burned.
Stage Diabetic Retinopathy
Diabetic retinopathy consists of several stages. The initial stage of retinopathy is called non-proliferative, and is characterized by the appearance of microaneurysms that expand the arteries, point hemorrhages in the eye in the form of round dark spots or dashed stripes, the appearance of ischemic zones of the retina, retinal edema in the macular region, as well as increased permeability and fragility of the vessel walls. In this case, through the thinned vessels, the liquid part of the blood enters the retina, leading to the formation of edema. And if the central part of the retina is involved in this process, then a decrease in vision is observed.
It should be noted that this form of diabetes can occur at any stage of the disease, and represents the initial stage of retinopathy. If it is not treated, then a transition to the second stage of the disease occurs.
The second stage of retinopathy is proliferative, which is accompanied by circulatory disorders in the retina, which leads to a deficiency of oxygen in the retina (oxygen starvation, ischemia). To restore oxygen levels, the body creates new blood vessels (this process is called neovascularization). The newly formed vessels are damaged and begin to bleed, as a result of which the blood enters the Vitreous humor, the layers of the retina. As a result of this, floating opacities appear in the eyes against the background of decreased vision.
In the late stages of retinopathy with continued growth of new vessels and scar tissue, it can lead to retinal detachment and the development of glaucoma.
The main reason for the development of diabetic retinopathy is insufficient insulin, which leads to the accumulation of fructose and sorbitol, which increase pressure, thicken the walls of the capillaries and narrow their gaps.
Diabetic Retinopathy Prevention
Prevention of retinopathy is to maintain normal blood sugar levels in diabetics, optimal compensation for carbohydrate metabolism, control of blood pressure, and correction of lipid metabolism. This allows you to reduce possible eye complications.
Proper nutrition and regular physical activity positively affect the general condition of patients with diabetes. It is also important to undergo regular examinations by an ophthalmologist. The timely prevention of diabetic retinopathy and eye damage in diabetes is very important. Since in the later stages of the disease, treatment is not effective.However, due to the fact that at the initial stages of retinopathy, visual disturbances are not observed, patients seek help when extensive hemorrhages and changes in the central zone of the retina are already occurring.