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Retinopathy is a
disease of the retina. The
retina is the nerve layer that lines the back of your
eye. It is the part of your eye that "takes pictures" and sends the images to
your brain. Many people with diabetes get retinopathy. This kind of retinopathy
diabetic retinopathy (retinal disease caused by
Diabetic retinopathy can lead to poor vision and even
blindness. Most of the time, it gets worse over many years. At first, the blood
vessels in the eye get weak. This can lead to blood and other liquid leaking
into the retina from the blood vessels. This is called nonproliferative retinopathy. And this is the most common retinopathy. If the fluid leaks into the center of your eye, you may have blurry vision. Most people with nonproliferative retinopathy have no symptoms.
If blood sugar levels stay high, diabetic retinopathy
will keep getting worse. New blood vessels grow on the retina. This may sound
good, but these new blood vessels are weak. They can break open very easily,
even while you are sleeping. If they break open, blood can leak into the middle
part of your eye in front of the retina and change your vision. This bleeding
can also cause scar tissue to form, which can pull on the retina and cause the
retina to move away from the wall of the eye (retinal detachment). This is called proliferative retinopathy. Sometimes people don't have symptoms until it is too late to treat them. This is why having eye exams regularly is so important.
Retinopathy can also cause swelling of the
macula of the eye. This is called
macular edema. The
macula is the middle of the retina, which lets you see
details. When it swells, it can make your vision much worse. It can even cause
If you are not able to keep your blood sugar
levels in a target range, it can cause damage to your blood vessels. Diabetic retinopathy
happens when high blood sugar damages the tiny blood vessels of the
When you have diabetic retinopathy, high blood pressure
can make it worse. High blood pressure can cause more damage to the weakened
vessels in your eye, leading to more leaking of fluid or blood and clouding more of your vision.
Most of the time, there
are no symptoms of diabetic retinopathy until it starts to change your vision.
When this happens, diabetic retinopathy is already severe. Having your eyes
checked regularly can find diabetic retinopathy early enough to treat
it and help prevent vision loss.
If you notice problems with your
vision, call an eye doctor (ophthalmologist) right away. Changes in
vision can be a sign of severe damage to your eye. These changes can include
floaters, pain in the eye, blurry vision, or new vision loss.
exam by an eye specialist (ophthalmologist or optometrist) is the only way to
detect diabetic retinopathy. Having a dilated eye exam regularly can help find
retinopathy before it changes your vision. On your own,
you may not notice symptoms until the disease becomes severe.
lower your chance of damaging small blood vessels in the eye by keeping your
blood sugar levels and blood pressure levels within a target range. If you
smoke, quit. All of this reduces the risk of damage to the retina. It can also
help slow down how quickly your retinopathy gets worse and can prevent future
If you have a dilated eye exam regularly, you and
your doctor can find diabetic retinopathy before it has a chance to get worse.
For most people, this will mean an eye exam every year. Finding retinopathy early gives you a better chance of avoiding vision loss and
Surgery, laser treatment, or
medicine may help slow the vision loss caused by diabetic retinopathy. You may
need to be treated more than once as the disease gets worse.
Learning about diabetic retinopathy:
Living with diabetic retinopathy:
Health Tools help you make wise health decisions or take action to improve your health.
Diabetes damages small blood vessels
throughout the body, leading to reduced blood flow. When these changes affect
the tiny blood vessels in the eyes,
diabetic retinopathy may occur.
early stage of diabetic retinopathy, tiny blood vessels in the eye weaken and
develop small bulges that may burst and leak into the
retina. Later, new fragile blood vessels grow on the
surface of the retina. These blood vessels may break and bleed into the eye,
clouding vision and causing scar tissue to form.
The scar tissue
may pull on the retina, leading to
retinal detachment. Retinal detachment occurs when the
retina separates from the wall of
the eye. This can lead to vision loss.
You may have
diabetic retinopathy for a long time without noticing
any symptoms. Typically, retinopathy does not cause noticeable symptoms until
significant damage has occurred and complications have developed.
Symptoms of diabetic retinopathy and its complications may
Diabetic retinopathy begins as a mild disease. During the early stage of the
disease, the small blood vessels in the
retina become weaker and develop small bulges called
microaneurysms. These microaneurysms are the earliest signs of retinopathy and
may appear a few years after the onset of diabetes. They may also burst and
cause tiny blood spots (hemorrhages) on the retina. But they do not usually
cause symptoms or affect vision. This is called nonproliferative retinopathy. At this stage, treatment is not required.
As retinopathy progresses, fluid
and protein leak from the damaged blood vessels and cause the retina to swell.
This may cause mild to severe vision loss, depending on which parts of the
retina are affected. If the center of the retina (macula) is affected, vision loss can be severe.
Swelling and distortion of the macula (macular edema), which results from a
buildup of fluid, is the most common complication of retinopathy. Macular edema treatment usually works to stop and sometimes reverse your loss of vision.
In some people, retinopathy gets worse over the course of several years and progresses to proliferative retinopathy.
In these cases, reduced blood flow to the retina stimulates the growth
(proliferation) of fragile new blood vessels on the surface of the retina. As the new blood vessels
multiply, one or more complications may develop and damage the person's vision.
These complications can include:
Any of these later complications may cause severe,
permanent vision loss.
Your risk for diabetic retinopathy depends largely on two things:
how long you have had diabetes and whether or not you have kept good control of
your blood sugar.
You can control some risk factors, which are things that may
increase your risk for diabetic retinopathy and its complications. Risk factors
that you can control include:
If you have type 2 diabetes and use the medicine
rosiglitazone (Avandia, Avandamet, Avandaryl) to treat your diabetes, you may
have a higher risk for problems with the center of the retina (the macula). The
U.S. Food and Drug Administration (FDA) and the makers of the drug have warned
that taking this medicine could cause swelling in the macula, which is called
Call your doctor immediately if you have
diabetes and notice:
Watchful waiting is not an option if you have
diabetes and notice changes in your vision.
If you have type 2 diabetes,
even if you do not have any symptoms of eye disease, you still need to have
your eyes and vision checked regularly by an eye specialist (ophthalmologist
or optometrist). If you wait until you have symptoms, it is more likely that
complications and severe damage to the
retina will have already developed. These may be harder to treat and may result in permanent vision loss.
If you have type 1 diabetes, are age 10 or older, and were diagnosed 5 or more years ago, you should have your eyes checked even if you don't have symptoms. If you wait until you have symptoms, it is more likely that complications and severe damage to the retina will have happened. These may be harder to treat. And the damage may be permanent.
Watchful waiting is not an option if you already
have diabetic retinopathy but do not have symptoms or vision loss. You will
need to return to your ophthalmologist for frequent evaluations (every few
months in some cases) so that your doctor can closely monitor changes in your
eyes. There is no cure for the disease. But treatment can slow its progression.
Your ophthalmologist can tell you how often you need to be evaluated.
People who have diabetes need to see a doctor who
specializes in eye care for their eye evaluations.
If you have
diabetic retinopathy and need laser treatment or
surgery, you need to consult an ophthalmologist who specializes in treating the
retina and has special training in the care of eye
disease caused by diabetes.
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Diabetic retinopathy can be detected during a dilated eye exam by an
optometrist. An exam by your primary doctor, during
which your eyes are not dilated, is not an adequate substitute for a full exam
done by an ophthalmologist. Eye exams for people with
diabetes can include:
Your doctor may also do a test called
an optical coherence tomography (OCT) to check for fluid in your retina. Sometimes a fluorescein angiogram is done to check for and locate leaking
blood vessels in the retina, especially if you have symptoms, such as blurred
or distorted vision, that suggest damage to or swelling of the retina.
Fundus photography can track changes in the eye over time in people who
have diabetic retinopathy and especially in those who have been treated for it.
Fundus photography produces accurate pictures of the back of the eye (the
fundus). An eye doctor can compare photographs taken at different times to
watch the progression of the disease and find out how well
treatment is working. But the photos do not take the place of a full eye exam.
Early detection and treatment of diabetic retinopathy can help prevent vision loss. For people in whom
diabetic retinopathy has not been diagnosed, the American Diabetes Association
recommends that screening be done based on the following guidelines:1
Note: Pregnant women who develop
gestational diabetes are not at risk for diabetic
retinopathy and do not need to be screened for it. (But women who develop
gestational diabetes during pregnancy have a greater chance of developing type
2 diabetes later in life, which can put them at increased risk for retinopathy
and other eye problems.)
People who have diabetes are also at
increased risk for other eye diseases, including
cataracts. Regular dilated eye exams can help detect these
diseases early and prevent or delay vision loss.
There is no cure for
diabetic retinopathy. But
laser treatment (photocoagulation) is usually very
effective at preventing vision loss if it is done before the
retina has been severely damaged. Surgical removal of
vitreous gel (vitrectomy) may also help improve vision
if the retina has not been severely damaged. Sometimes injections of an anti-VEGF (vascular endothelial growth factor) medicine or an anti-inflammatory medicine help to shrink new blood vessels in proliferative diabetic retinopathy. Because symptoms may not develop
until the disease becomes severe, early detection through regular screening is
important. The earlier retinopathy is detected, the easier it is to treat and
the more likely vision will be preserved.
You may not need
treatment for diabetic retinopathy unless it has affected the center (macula) of the retina or, in rare cases, if your side
(peripheral) vision has been severely damaged. But you do need to have your
vision checked regularly.
If the macula has been damaged by
macular edema, you may need laser treatment. For more
severe retinopathy, you may need either laser treatment or vitrectomy. These
procedures can help prevent, stabilize, or slow vision loss when they are done
before the retina has been severely damaged. Newer treatment includes medicines like anti-VEGF medicine or steroids that are injected into the eye.
Surgical removal of
the vitreous gel (vitrectomy) is done when there is bleeding (vitreous
retinal detachment, which are rare in people with
early-stage retinopathy. Vitrectomy is also done when severe scar tissue has
Treatment for diabetic retinopathy is often very effective
in preventing, delaying, or reducing vision loss. But it is not a cure for the
disease. People who have been treated for diabetic retinopathy need to be
monitored frequently by an eye doctor to check for new changes in their eyes.
Many people with diabetic retinopathy need to be treated more than once as the
condition gets worse.
Also, controlling your blood sugar levels is
always important. This is true even if you have been treated for diabetic
retinopathy and your eyes are better. In fact, good blood sugar control is
especially important in this case so that you can help keep your retinopathy
from getting worse.
Ideally, laser treatment should be done early
in the course of the disease to prevent serious vision loss rather than to try
to treat serious vision loss after it has already developed.
People with diabetes who have any signs of retinopathy need to be
examined as soon as possible by an
There are steps you can take to reduce your
chance of vision loss from
diabetic retinopathy and its complications:
The risk for severe retinopathy and vision loss
may be even less if you:
Surgical treatment for diabetic retinopathy is removal of the
vitreous gel (vitrectomy). Vitrectomy does not cure the disease. But it may improve vision in people who
have developed bleeding into the vitreous gel (vitreous hemorrhage),
retinal detachment, or severe scar tissue formation.
Unfortunately, by the time some people are diagnosed with
retinopathy (especially late-stage retinopathy), it is often too late for
vitrectomy to provide much benefit. Even with treatment,
vision may continue to decline.
Early detection of retinopathy
through dilated eye exams can help you decide to have surgery when it is most
After a person has had most of the vitreous gel removed by vitrectomy,
surgery to remove scar tissue or to repair a new retinal detachment may be
Vitrectomy may require an overnight hospital stay. But it is sometimes done
as outpatient surgery. Your eye doctor will determine if the surgery can be done with
local or general anesthesia.
(photocoagulation) can be an effective treatment for
diabetic retinopathy. But it does not cure the
disease. It can prevent, delay, and sometimes reverse vision loss. Without
either laser treatment or surgery, vision loss caused by diabetic retinopathy
and its complications may get worse until blindness occurs. So early treatment
is vital to slowing vision loss, which can happen quickly.
diabetic retinopathy causes bleeding (hemorrhage) into the
vitreous gel, extensive scar tissue formation, or
retinal detachment, surgical removal of the vitreous
gel (vitrectomy) may be needed before laser treatment is considered.
Unfortunately, by the time some people are diagnosed with diabetic
retinopathy, it is often too late for treatment to provide much benefit. Even
with treatment, vision will continue to decline.
of retinopathy through dilated eye exams can provide the opportunity to have
laser treatment when it is most effective.
Laser photocoagulation uses the heat
from a laser to seal or destroy abnormal, leaking blood vessels in the
retina. It can cause the abnormal, weak blood vessels to shrink.
Some anti-VEGF (vascular endothelial growth factor) medicines, such as ranibizumab (Lucentis), can help treat macular edema from diabetic retinopathy.
laser treatment is used to treat several spots on the retina during one or,
most often, two sessions. It reduces the risk of serious bleeding and the
progression of severe proliferative retinopathy.
Laser photocoagulation can result in some loss of vision,
because it destroys some of the nerve cells in the retina and can cause the abnormal blood vessels to go away. With pan-retinal
photocoagulation, this most often affects the outside (peripheral) vision,
because the laser is directed at that area. Your vision may be worse right
after treatment. But vision loss caused by laser treatment is mild compared
with the vision loss that may be caused by untreated retinopathy.
The American Academy of Ophthalmology (AAO) is an association of
medical eye doctors. It provides general information and brochures on eye
conditions and diseases and low-vision resources and services. The AAO is not
able to answer questions about specific medical problems or conditions.
The American Diabetes Association (ADA) is a national organization
for health professionals and consumers. Almost every state has a local office.
ADA sets the standards for the care of people with diabetes. Its focus is on
research for the prevention and treatment of all types of diabetes. ADA
provides patient and professional education mainly through its publications,
which include the monthly magazine Diabetes Forecast,
books, brochures, cookbooks and meal planning guides, and pamphlets. ADA also
provides information for parents about caring for a child with diabetes.
EyeCare America is a public service program of the
Foundation of the American Academy of Ophthalmology. This site aims to raise awareness about
eye diseases and eye care. It has information about eye conditions, treatments, and general eye health. You can check to see if you qualify for a free eye exam.
As part of the U.S. National Institutes of Health, the National Eye
Institute provides information on eye diseases and vision research.
Publications are available to the public at no charge. The Web site includes
links to various information resources.
The National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK) provides information and conducts research on a wide
variety of diseases as well as issues such as weight control and
The National Library Service has a free service for Americans whose low vision, blindness, or physical handicap makes it hard to read a standard printed page. Audio books, braille books and magazines, and similar materials can be mailed postage-free to people who are eligible for
American Diabetes Association (2013). Standards of medical care in diabetes—2013. Diabetes Care, 36(Suppl 1): S11–S66.
Other Works Consulted
American Diabetes Association (2013). Standards of medical care in diabetes—2013. Diabetes Care, 36(Suppl 1): S11–S66.
Brownlee M, et al. (2011). Complications of diabetes mellitus. In S Melmed et al., eds., Williams Textbook of Endocrinology, 12th ed., pp. 1462–1551. Philadelphia: Saunders.
Cavallerano JD, Stanton RM (2010). MIcrovascular complications. In RS Beaser, ed., Joslin's Diabetes Deskbook: A Guide for Primary Care Providers, 2nd ed., pp. 445–473. Boston: Joslin Diabetes Center.
Dagogo-Jack S (2010). Complications of diabetes mellitus. In EG Nabel, ed., ACP Medicine, section 9, chap. 3. Hamilton, ON: BC Decker.
Fletcher EC, et al. (2011). Retina and retinal disorders. In P
Riordan-Eva, JP Whitcher, eds., Vaughan and Asbury's General Ophthalmology, 18th ed., pp. 190–221. New York: McGraw-Hill.
Gebel E (2010). Aids for insulin users. Diabetes Forecast, 63(1). Available online: http://forecast.diabetes.org/magazine/features/aids-insulin-users.
Hammes HP, et al. (2010). Diabetic retinopathy: Targeting vasoregression. Diabetes, 60(1): 9–16. Available online: http://diabetes.diabetesjournals.org/content/60/1/9.full.
Massin P, et al. (2010). Safety and efficacy of ranibizumab in diabetic macular edema (RESOLVE study*). Diabetes Care, 33(11): 2399–2405. Available online: http://care.diabetesjournals.org/content/33/11/2399.full.pdf.
Mohamed QA, et al. (2011). Diabetic retinopathy (treatment), search date June 2010. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.
Nicholson BP, Schachat AP (2010). A review of clinical trials of anti-VEGF agents for diabetic retinopathy. Graefe's Archive of Clinical and Experimental Ophthalmology, 248(7): 915–930.
February 27, 2013
Adam Husney, MD - Family Medicine & Carol L. Karp, MD - Ophthalmology
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