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Retinal Problems With Diabetes

Melissa Flagg, COA, OSC, has worked in the medical field for over two decades as an ophthalmic technician and is certified by JCAHPO.

The most common disease treated by retinal specialists is damage caused by diabetes. Diabetes can be a devastating disease and is second only to cataracts as the leading cause of blindness in the United States.

The damage caused by diabetes is usually found first in the retina before it affects the rest of the body and most commonly takes the form of diabetic retinopathy.

What Is Diabetes?

Diabetes is a metabolic disorder in which the body is either intolerant of or cannot properly use insulin. Insulin is a hormone that essentially turns glucose into energy, or stores it as fat, and in a diabetic, this hormone is unable to keep blood sugar levels in the normal range either because the body cannot process it correctly or has built up a tolerance to it so that more insulin is needed to keep blood sugar levels stable.

Blood Vessels Deteriorate

Because of the inefficiency of insulin in diabetic patients, the blood sugar typically remains at a higher range and therefore causes damage to nerve fibers and blood vessels, among other things. The blood vessels in the retina are usually the first to show this type of damage. They become weakened and eventually break down and leak.

New Vessels Grow

To compensate for this leaking, the retina grows new blood vessels, which is called neovascularization. These new blood vessels are typically very weak and only cause more damage to the retina. Neovascularization can also cause swelling of the macula, called macular edema, as well as vitreous hemorrhage.

Diabetic Retinopathy

Diabetic retinopathy usually has no warning signs or symptoms and typically occurs in patients who have been diabetic for a few years, usually over ten. However, brittle diabetics, or diabetics who cannot control their blood sugar, may have retinopathy within just a few months or years.

There are two types of diabetic retinopathy:

  • Background diabetic retinopathy, or BDR
  • Proliferative diabetic retinopathy, or PDR

Background Diabetic Retinopathy

Background diabetic retinopathy is the beginning stage of the disease and is characterized by dot blot hemorrhages (see photo below), microaneurysms (small vascular buds), and lipoid exudates, or fat cells that leak from blood vessels under the macula. The lipoid exudates can cause the macula to swell, leading to cystoid macular edema or CME.

Proliferative Diabetic Retinopathy

Proliferative diabetic retinopathy is characterized by neovascularization, the growth of new blood vessels in the retina. These blood vessels grow from the optic disc or branch off from other blood vessels on the retina. They can also grow into the iris and cause what is known as neovascular glaucoma.

The blood vessels themselves can rupture and cause retinal or vitreous hemorrhages. They can also bundle up into a mass that can pull on the retina and separate it from the back wall of the eye, creating a retinal detachment.

Diagnosis of Retinal Issues

Diagnosing diabetic retinopathy is rather straightforward. Usually, most ophthalmologists will order a fluorescein angiogram to verify what was seen during their exam of the retina. A fluorescein angiogram is a series of photos taken with a special filter after injecting the patient with a vegetable-based dye known as fluorescein.

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This dye highlights leaking blood vessels and allows the ophthalmologist to pinpoint areas of the retina to be treated, as well as confirm the diagnosis. I’ve seen a number of patients actually get the diagnosis of diabetes from their eye doctor first because of damage found in their retina.

Treatment of Diabetic Retinal Problems

Once the diagnosis has been made, there are various treatment options depending on the needs of the patient.

Diabetic Retinopathy

Both types of diabetic retinopathy receive the same treatment: pan-retinal photocoagulation, or PRP. PRP uses an argon laser to seal leaking or weak blood vessels or prevent further neovascularization. Using this technique prevents further bleeding and consequently further damage to the retina.

In the case of neovascularization, the laser destroys the new, weak blood vessels preventing further growth and any possible leaking. Several thousand laser burns are usually required to complete the treatment, which usually requires two or more treatment sessions. Ongoing laser treatment may be required depending on the severity of diabetes.

Kenalog injections are often used to treat diabetic retinal problems.

Kenalog injections are often used to treat diabetic retinal problems.

Macular Edema

Focal laser photocoagulation is the treatment of choice for macular edema. The laser beam is focused to the accuracy of a pinpoint and is used to seal the microaneurysms that lie below the macula and cause the swelling. This has been shown it significantly improve the visual prognosis.

Intravitreal triamcinolone acetonide, also known by the brand name Kenalog, can also be used to treat macular edema. Kenalog is a corticosteroid that reduces inflammation and fluid build-up or edema. These treatments are very successful but have significant risks.

Since Kenalog is a steroid, it can cause cataracts as well as increased intraocular pressure, also called glaucoma. The treatment also needs to be repeated about every three months since the effects are not permanent. Kenalog is usually used in conjunction with laser therapy.

Anti-VEGF (vascular endothelial growth factor) drugs such as Avastin, Lucentis, and Macugen have been shown to improve the prognosis of macular edema. Usually used in conjunction with laser therapy, anti-VEGF drugs prevent the formation of neovascular blood vessels. These treatments, like Kenalog, are not permanent and need to be repeated about every three to six months. In my experience, this treatment was the most widely successful and limited the need for laser therapy.

Retinal and Vitreous Hemorrhages

Retinal hemorrhages are typically treated with laser to seal the leaking blood vessels, and sometimes anti-VEGF treatment to help the body reabsorb the blood. Some retinal hemorrhages involve the vitreous, the gel-like substance that gives the eye its rigidity and shape.

Vitreous hemorrhages almost always require a vitrectomy. Most physicians will observe the hemorrhage (to see if the body will reabsorb the blood) for about a month, sometimes more. If the hemorrhage does not show signs of resolving, however, a vitrectomy will be necessary.

A vitrectomy involves removing the vitreous from the eye through a probe, and inserting silicon-based oil in its place. Recovery time is lengthy, sometimes taking 6 months to 1 year, and there is further risk of retinal detachment, and another vitreous hemorrhage.

Preventing Diabetic Retinal Damage

Unfortunately, there is no true prevention for diabetic retinal disease except the prevention of diabetes itself. Keeping the blood sugar levels stable and incorporating an exercise program into the daily routine can delay the onset of such diseases. However, the longer the patient lives with diabetes, the more damage the disease causes. It’s only a matter of time before it takes its toll.

The Importance of Diet and Nutrition

Changing the diet has been shown to help control blood sugar. Switching to a vegetarian or vegan diet has been shown to reverse diabetes in some cases (including my own). If you are currently in the early stages of the disease or are “pre-diabetic,” changing your diet and losing weight can greatly reduce your risk of developing the full-blown disease. Taking vitamins such as vitamin C in large doses has been shown to improve the body’s ability to utilize insulin and decrease the risk factors for the disease.

This information is by no means conclusive and is not meant to replace a doctor’s expertise. It should give you a good idea of what to expect should you or someone you know have or develop diabetes. Always see your ophthalmologist right away if you have any visual disturbances or sudden loss of vision.

This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2012 Mel Flagg COA OSC


Mel Flagg COA OSC (author) from Rural Central Florida on August 30, 2012:

@tonymead60 Thank you for your comment! The 80-100 range is the desired range for a diabetic's blood sugar levels. We measure blood sugar differently here in the states. We use mg/dl I believe in Europe, the blood sugar readings you take are actually mmol/l. Blood sugar is checked the same way, by pricking the finger and putting blood on a strip, the reading is just a different number.

Tony Mead from Yorkshire on August 30, 2012:


very interesting article, well written and nicely presented in a logical way that helps the reader to follow it.

I have type 2 diabetes and as an artist I am very aware of the threat to my eyes. Fortunatly in England we have a free annual eye scan to try and spot problems early.

I don't understand your 80-100 range, what is that?

I test my sugar twice a day with a meter that reads blood from a pin prick thing. the reading should be about 5, but mine is much higher, despite a couple of tablets, well 7 actually and an injection Byetta twice a day.



Mel Flagg COA OSC (author) from Rural Central Florida on August 22, 2012:

@nicediabetes, I'm not entirely sure what your doctor is considering a "mild" retinal issue. In diabetics, retinal issues should never be considered mild since just one spike in blood sugar can cause a vitreous hemorrhage or exacerbate edema. Feel free to email me with the details and I'll try to answer your questions. The only thing I can recommend at this point without knowing your diagnosis is keeping tight control on your blood sugar. Most doctors recommend the 90-110 range, but new research has shown blood sugar levels in diabetics should be slightly lower than those of non-diabetics to prevent damage. So the 80-100 range is optimal.

Mel Flagg COA OSC (author) from Rural Central Florida on August 22, 2012:

@Mr. Happy, stress does affect the body's ability to utilize insulin, and the reason women are more affected by this is because when they become stressed they produce more cortisol than men do. Cortisol is a corticosteroid hormone, and steroids wreak havoc on the body's ability to regulate blood sugar, often sending it out of control.

Relaxing is definitely a key element to the prevention of Diabetes, vitamin C is the other. Vitamin C is essentially the antidote to cortisol and adrenaline and prevents the damage caused by these hormones when taken in megadoses.

Mel Flagg COA OSC (author) from Rural Central Florida on August 22, 2012:

Thank you Mr. Happy! Indeed, many patients who suffer with diabetes lose their vision before the end. It's very sad because with the loss of vision goes a lot of their quality of life. Unfortunately, there is no prevention except keeping the blood sugar in normal range which is very difficult for most diabetics.

Mel Flagg COA OSC (author) from Rural Central Florida on August 22, 2012:

Indeed billybuc, I've been so distracted with my hubby's surgery and the apprenticeship that I haven't had a chance to do much reading lately. Never fear, I have bookmarked all the hubs published recently and I do intend to read them! lol

Thank you for your kind comment, and it's good to hear from you again. I'll try to do better at keeping in touch, I really feel bad that I haven't had a chance to read many of my favorite hubbers recent publications! Life can get in the way sometimes lol

nicediabetes from Australia on August 21, 2012:

As a diabetic, this is the one area that scares the bejesus out of me so thanks for the tips on how to try to prevent/stop further damage.

I have very mild retinal issues, in the words of a Dr no worse than a non diabetic so any further tips would be great

Mr. Happy from Toronto, Canada on August 21, 2012:

May be a little coincidence but as I was just watching the news, there was a report about a study done which concluded that for women, the stress related to their job/place of employment, does in many cases increase the chances of developing diabetes.

They said men are usually not so worried with losing a job, therefore there is not so much stress for them. I agree with the fact that job or no job, I try not to indulge in stress much. No point, in my opinion - it doesn't help.

So, a hint for the ladies: keep away from work-related stress! : )

Mr. Happy from Toronto, Canada on August 21, 2012:

Very indepth information here. I knew diabetes eventually results in blindness because the mother of a good friend of mine died from it and in the last little part of her life, she could no longer see. I did not know all the details though ... It's a tough battle to lose this one ...

Thank You for putting this piece of writing together. I am sure many people will find it helpful.

All the best! : )

Bill Holland from Olympia, WA on August 21, 2012:

I seem to have lost contact with you my friend. I'm sorry that happened; I always enjoyed your hubs and hearing from you. Anyway, this was quite informative and you did a great job of explaining complicated material in a way all of us could understand.

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