DIABETIC RETINOPATHY

REPORTED ON AUGUST 5, 2010

BY

MARK MANALO

CHRISTOPHER MEJIA

STEPHANIE ONG

VINCENT PEJI

ROCHELLE JOY T. RAMOS

 INTRODUCTION

Diabetic retinopathy is a damage to the retina caused by complications of diabetes mellitus

affecting the blood vessels in the retina, which can eventually lead to blindness. It is an ocular
manifestation of systemic disease which affects up to 80% of all patients who have had diabetes
for 10 years or more. Despite these intimidating statistics, research indicates that at least 90% of
these new cases could be reduced if there was proper and vigilant treatment and monitoring of
the eyes. If diagnosed and treated promptly, blindness is usually preventable. It begins without
any noticeable change in vision. But even then there are often are extensive changes in the retina
visible to a ophthalmologist.

In some people with diabetic retinopathy, blood vessels may swell and leak fluid. In other
people, abnormal new blood vessels grow on the surface of the retina. The retina is the light-
sensitive tissue at the back of the eye. A healthy retina is necessary for good vision. At first, a
person with diabetic retinopathy may not notice changes to your vision. But over time, diabetic
retinopathy can get worse and cause vision loss. Diabetic retinopathy usually affects both eyes.

Diabetic retinopathy often has no early warning signs. Even macular edema, which may
cause vision loss more rapidly, may not have any warning signs for some time. In general,
however, a person with macular edema is likely to have blurred vision, making it hard to do
things like read or drive. In some cases, the vision will get better or worse during the day.

As new blood vessels form at the back of the eye as a part of proliferative diabetic
retinopathy (PDR), they can bleed (ocular hemorrhage) and blur vision. The first time this
happens, it may not be very severe. In most cases, it will leave just a few specks of blood, or
spots, floating in a person's visual field, though the spots often go away after a few hours.

These spots are often followed within a few days or weeks by a much greater leakage of
blood, which blurs vision. In extreme cases, a person will only be able to tell light from dark in
that eye. It may take the blood anywhere from a few days to months or even years to clear from
the inside of the eye, and in some cases the blood will not clear. These types of large
hemorrhages tend to happen more than once, often during sleep.

On funduscopic exam, a doctor will see cotton wool spots, flame hemorrhages (similar
leisons are also caused by the alpha-toxin of Clostridium novyi), and dot-blot hemorrhages.
Elevation of blood-glucose levels can also cause edema (swelling) of the crystalline lens
(hyperphacosorbitomyopicosis) as a result of sorbitol (sugar alcohol) accumulating in the lens.
This edema often causes temporary myopia (nearsightedness). A common sign of
hyperphacosorbitomyopicosis is blurring of distance vision while near vision remains adequate.

Stages of Diabetic Retinopathy

There are two basic types the Non-proliferative Diabetic Retinopathy (NPDR) and
Proliferative Diabetic Retinopathy (PDR). Non-proliferative Diabetic Retinopathy is seen in the
retina as red dots and blots of hemorrhages or as yellow dots which are lipid (fatty) leakages. If
the macula of the retina is affected, swelling can occur which would cause blurring of vision that
cannot be fully corrected with eyeglass prescriptions.
 These retinal changes increase in number and cover a wider area the longer the patient
has diabetes. The retinopathy will progress even though the blood sugar is well controlled. The
speed with which the retinopathy deteriorates will, however, be slower if there is strict control of
the patient’s blood sugar.

Proliferative Diabetic Retinopathy is the more advanced stage where abnormal, new
blood vessels begin to grow on the surface of the retina. A simple analogy is to think of the roots
of a tree which continually branch and grow looking for sources of nutrients. These abnormal
blood vessels continue to branch and multiply. Because their vessel walls are weaker, they may
rupture and or leak causing hemorrhage and swelling which could result in severe blurring of
vision or blindness.

In the earlier stages of the proliferation, the blood vessels grow on the surface of the
retina. If one thinks of the coconut, the blood vessels are creeping along the surface of the “white
coconut meat”. Later, however, these blood vessels begin to extend upwards and grow into the
fluid of the eye called the vitreous. This would be like having blood vessels grow out of the
“white coconut meat” into the fluid compartment. If these blood vessels bleed, the extent of
hemorrhage could be severe, replacing the fluid with blood.

PATHOPHYSIOLOGY

Blood vessels damaged from diabetic retinopathy can cause vision loss in two ways.
First, fragile, abnormal blood vessels can develop and leak blood into the center of the eye,
blurring vision. This is proliferative retinopathy and is the fourth and most advanced stage of the
disease. Then it can be that a fluid can leak into the center of the macula, the part of the eye
where sharp, straight-ahead vision occurs. The fluid makes the macula swell, blurring vision.
This condition is called macular edema. It can occur at any stage of diabetic retinopathy,
although it is more likely to occur as the disease progresses. About half of the people with
proliferative retinopathy also have macular edema.

All people with diabetes both type 1 and type 2 are at risk. That's why everyone with
diabetes should get a comprehensive dilated eye exam at least once a year. The longer someone
has diabetes, the more likely he or she will get diabetic retinopathy. Between 40 to 45 percent of
Americans diagnosed with diabetes have some stage of diabetic retinopathy. If you have diabetic
retinopathy, your doctor can recommend treatment to help prevent its progression.

During pregnancy, diabetic retinopathy may be a problem for women with diabetes. To protect
vision, every pregnant woman with diabetes should have a comprehensive dilated eye exam as
soon as possible.
 Chronic elevations in blood glucose levels

Glycoprotein cell wall deposits

Small vessel disease

Increase in retinal capillary permeability

Vein dilation

Micro aneurysm formation

Interretinal haemorrhage

macular edema

hard exudates

Ischemia

Neovaculation and fibrous tissue formation

retinal detachment

DIAGNOSTIC TESTS

To detect Diabetic Retinopathy, an eye exam is performed by a retina specialist which would
include testing the vision, checking for cataracts and glaucoma and doing a retina screening. A
visual acuity test is done which uses an eye chart to measure how well a person sees at various
distances. In the 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. A retina screening
involves dilating the pupil in order to be able to see the retina adequately via Indirect
Ophthalmoscopy. Ophthalmoscopy: This is an examination of the retina in which the eye care
professional looks through a device with a special magnifying lens that provides a narrow view
of the retina, or 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.

Digital Retinal Screening Programs is a 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. Another one is Slit Lamp Biomicroscopy Retinal Screening Programs is a
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.

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.

If Diabetic Retinopathy is noted, color photographs and/or Fluorescein Angiography are

recommended. Fluorescein Angiography (FA) is a special technique performed which allows
detailed analysis of the blood vessels of the retina and helps determine the seriousness of the
retinopathy to plan for the mode of management. Optical Coherence Tomography (OCT) may
also be recommended. This exam evaluates the severity of the macular edema. This is an optical
imaging modality based upon interference, and analogous to ultrasound. It produces cross-
sectional images of the retina (B-scans) which can be used to measure the thickness of the retina
and to resolve its major layers, allowing the observation of swelling and or leakage.

Medical and Surgical 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. These three treatments are laser surgery, injection of triamcinolone into the eye, and
vitrectomy. Although these treatments are very successful (in slowing or stopping further vision
loss), 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. The best way of addressing diabetic
retinopathy is to monitor it vigilantly and achieve euglycemia.

Laser photocoagulation can be used in two scenarios for the treatment of diabetic
retinopathy. It is widely used for early stages of proliferative retinopathy. Panretinal
photocoagulation, or PRP (also called scatter laser treatment), is used to treat proliferative
diabetic retinopathy (PDR). 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 in the retina. This has been shown to reduce the risk of severe vision loss
for eyes at risk by 50%. Before using the laser, 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 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.

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.

Triamcinolone is a long acting steroid preparation. When injected in the vitreous cavity,
it decreases the macular edema (thickening of the retina at the macula) caused due to diabetic
maculopathy, and results in an increase in visual acuity. The effect of triamcinolone is transient,
lasting up to three months, which necessitates repeated injections for maintaining the beneficial
effect. Complications of intravitreal injection of triamcinolone include cataract, steroid-induced
glaucoma and endophthalmitis.

Instead of laser surgery, some people require 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. 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.

Nursing Management

Implementing individual care and providing patient education are the focus of nursing
management in patients with diabetic retinopathy. The focus of educating the patient is on
prevention through regular ophthalmologic examinations, blood glucose control and self-
management of eye care regimens. The emphasis of the teaching is the effectiveness of early
diagnosis and prompt treatment. In the event that the loss of vision occurs, nursing management
must also address the patient’s adjustment to impaired vision and use of adaptive devices for
diabetes self-care as well as the activities of daily living.

Patient Teachings
• Retinopathy may appear after many years of diabetes and its appearance does not
necessarily means that the condition is on a downhill course.
 • Especially with the adequate control of glucose levels and blood pressure, the odds for
maintaining vision are in the patient’s favor.
• The best way to preserve vision is prevention, by frequent eye examinations, because it
allows detection and prompt treatment of retinopathy.

Continuing Care
• Careful diabetes management is important to slow progression of visual changes. If eye
changes are progressive and persistent, the patient should be prepared for inevitable loss
of vision. Consideration is given to making referrals for teaching the patient Braille and
training him or her with guide dogs. Referral to state agencies should be made to ensure
that the patient receives services for the blind. Family members are taught how to assist
the patient to remain as independent as possible despite decreasing visual acuity.
• Referral for home care may be indicated for some patients, such as those who live alone,
those who are not coping well, and those who have health problems or complications of
diabetes that may interfere their ability to perform self-care. During home visits, the
nurse could assess the home environment and the patient’s ability to manage diabetes
despite visual impairments.

The nurse should keep in mind the following points when a patient with diabetes has some
type of visual impairment.
• Visual impairment can be a shock. A patient’s response to the vision loss depends on
personality, self-concept, and coping mechanisms.
• As with any loss, acceptance of blindness occurs in stages. Some patients may accept
blindness in a short period; some might take a long time or could never accept the
condition.
• Although retinopathy occurs in both eyes, the severity may differ.
• Many of the chronic complications of diabetes appear at the same time.
• The need for glycemic control still persists despite retinopathy, to prevent other
complications.