28.03.2024

Diabetic retinopathy – eye disease in diabetes

Diabetes is insidious not only in itself. It causes a number of complications that significantly reduce quality of life. One of these complications – eye disease. Diabetes blurred vision occurs due to destruction of the retina. It is irreversible, and requires long hard treatment, and in severe cases leads to blindness.

Diabetic retinopathy – what is it?

Diabetic retinopathy is among the “top three” diseases, which most ophthalmologists have attended. When the disease affects the blood vessels of the retina of the eyeball.

Their anatomical and physiological disorders caused by elevated levels of sugar in the blood. If ten years ago diabetic retinopathy in most cases, the tormented older patients (50 years and older), now it is rapidly “younger”, and the doctors were not surprised by the cases of vascular lesions of eyes in diabetes mellitus patients at the age of 23-28 years.

The longer hurts people with diabetes, the greater the percentage of probability that it will combat diabetic retinopathy. Patients whose diabetes was diagnosed for 5-7-10 years, diabetic retinal changes of various degrees of severity are observed with a frequency from 45% to 80% of clinical cases and more than 15 years – from 87% to 99%. Just diabetic retinopathy is exposed according to various sources, 85-90% of patients with diabetes, regardless of duration of illness.

Complaints of vision loss in this disease in the majority of cases appear after its prolonged course.

It’s kind of a clue in the diagnosis of loss of visual acuity in the early stages of diabetes (diabetes mellitus) says:

  • comorbidity, which is doubly should alert the ophthalmologist, as this disease will also progress due to diabetes;
  • less – on rapidly developing in the tissues of diabetic changes, provoking the deterioration of the eyes depends on correction treatment.

If you do not deal with a patient, inevitably deteriorating eyesight, diabetes sooner or later leads to blindness, which is actually a synonym for disability. Vision loss in patients with diabetes occurs 25 times more often than in cases of blindness, caused by other reasons. According to various sources, complete loss of vision suffering from 2% to 5% suffering from diabetic retinopathy. The majority of you people in the street in dark glasses, tapping a stick is blind because of the “sweet” of the disease.

The reasons for the development of retinopathy

The proximate cause of diabetic retinopathy is hyperglycemia (high blood sugar). It leads to destructive changes of the vessel wall with circulating blood. The first and main attack takes on the endothelium – the inner membrane of the vessels.

Factors contributing to vascular lesions of the retina in diabetes:

  • high blood pressure, especially in ill “with experience”;
  • Smoking (even Smoking 1 cigarette a day, but regularly);
  • kidney disease;
  • pregnancy (regardless of duration);
  • age ranging from 40 years. In the last 7-10 years the risk of developing retinopathy has spread to younger age – prevalence and 20 years of age. Statistics of the destruction of young people is slowly but steadily increasing – this can lead to the fact that age is a risk factor, clinicians will set starting at 25 years of age.

Not the last role in the occurrence of diabetic retinopathy plays an inherited feature of the structure of the vascular wall. If it is suffered by someone in one of the generations, the chances of Contracting the descendants in two or more times higher than those who are the first in the family got sick with diabetes.

The most dangerous combination of factors leading to diabetic retinopathy is simultaneously observed hyperglycemia and high blood pressure.

Pathogenesis

The pathogenesis (development) of diabetic vascular lesions of the retina difficult. It is based on the disruption of the microcirculation, that is, the “cooperation” of the smallest vessels and tissues that the vessels supply the blood with oxygen and nutrients. As a result – come the metabolic (metabolic) changes in the retinal cells.

Mainly affects the following structures of the retina:

  • arterioles (small arteries, which anatomically are not capillaries) – often they are deformed due to multiple sclerosis (excessive formation of connective tissue); most commonly affects their precapillary segments in the rear area of the fundus;
  • Vienna – there is enlargement and deformity (curvature);
  • capillaries – often there is dilatation (expansion, “loosening” of some of the local sites), significantly increases the permeability. In diabetic the defeat of the retinal capillaries is able to swell, it can lead to complete blockage and the cessation of inflow-outflow of blood on them, with all the attendant metabolic consequences. Also in diabetic retinopathy retinal capillaries in severe affected by proliferation of endothelium and formation of microscopic aneurysms.

“Sweet” blood works in two ways on the wall of the vessel – that may:

  • shrink and deform;
  • thicken and deform.

In both cases, morphological changes lead to disruption of blood flow. This, in turn, entails:

  • oxygen starvation of tissues of the retina of the eye;
  • violation of receipt of proteins, fats, carbohydrates, mineral substances in the tissue;
  • violation of output of waste products from the cells.

Hyperglycemia also causes the attack on the blood-retinal barrier. It consists of:

  • the endothelium (cells lining inside the blood vessels of the retina);
  • pigment epithelium of eye retina.

Normal blood-retinal barrier does not allow for too large molecules to get from the blood vessels into the tissues of the retina of the eye, thereby protecting the retina from their destructive actions. When diabetes affects the endothelial cells, their ranks are thinning, the blood-retinal barrier becomes more discerning and are no longer able to withstand the onslaught of large molecules, and risk of life retina.

The mesh membrane of the eye is formed by nerve cells. All the nervous structures are characterized by enhanced sensitivity to negative factors and can not be restored. That’s why if you have started the process of destructive changes due to starvation, it cannot be reversed – except to stop in order to conserve the remaining viable cells. This clearly explains the danger of diabetic retinopathy – can I prevent diabetic eye damage at some stage, but it is impossible to renew the lost vision. You should also consider that the retina uses more oxygen per unit area than other tissues of the human body. Therefore, even minimal but constant oxygen starvation can be critical: the ischemia mortify very quickly, developing so-called cotton-like areas – the local foci of infarction of the retina.

Diabetes affects not only vessels of eye retina. But diabetic retinopathy is the most common of all the diabetic lesions of small blood vessels (microvascular complications).

The General scheme of development of pathological changes in diabetic retinopathy the following:

  • due to poor blood flow through the modified vessels of the retina they at first are dilatatie (extension) that leads to transient compensatory increase in blood flow;
  • the endothelium is exposed to even greater effect of high blood sugar;
  • capillaries swell more and more;
  • because of the impaired blood flow through the capillaries the blood is looking for new ways forward – which results in the formation of arteriovenous shunts (abnormal connection between the arterioles and venules, which directly resets the blood) and aneurysmal enlargement of small blood vessels. Begins neovascularization – unusual germination retinal new vessels;
  • new vessels, like the affected “colleagues”, not different strength, degenerative changes in their walls leading to their destruction and hemorrhage;
  • as a result of such changes, focal changes occur in the retina of the eye, if mass – retina degenerates completely, it is blind.
Classification

Ophthalmologists are guided by several classifications of diabetic retinopathy.

The most common is the classification that was proposed in 1992 by doctors E. Kohner and M. Porta and adopted by the world health organization. According to her, there are three forms of the disease:

  • nonproliferative retinopathy (diabetic retinopathy I);
  • preproliferative retinopathy (diabetic retinopathy II);
  • proliferative retinopathy (diabetic retinopathy III).

When nonproliferative retinopathy in the retina are seen in the study of emerging and already formed microaneurysm vessels. There are foci of hemorrhage – first in the form of points that grow to rounded spots (sometimes revealed hemorrhage in the form of dashes and short dashes). They are dark in color are defined in a Central portion of the fundus, and in the study of deep zones of the retina in the course of the larger veins. Also closer to the center of the retina revealed pockets of fluid (exudation, or in simple words – moisture), white and yellow, partially with clear, partially with blurred boundaries. Important point: when nonproliferative retinopathy is observed retinal edema, if it is not – this is another form of diabetic retinopathy. The swelling must be sought in the Central part of the retina or in close proximity to large veins.

With preproliferative retinopathy are visible changes in the retinal veins. They look like a rosary (like with strings large beads), meandering in some places in the form of loops. Normally, the diameter of the veins was more or less the same, with preproliferative retinopathy it varies considerably. There are “cotton” (similar to balls of cotton wool uneven “fluff”) exudates. Also there is a large number of hemorrhages of the retina.

In proliferative retinopathy changes are observed not only in the retina, but go beyond it. Fragments of the retina to sprout new blood vessels – primarily this process involves the optic disc. Throughout the volume of the vitreous body is determined by a variety of diffuse hemorrhage – both point merging with each other and forming a kind of conglomerate. After some time in areas of hemorrhage formed fibrous tissue to replace the areas of the vitreous. Bleeding is a bad prognostic symptom: after the primary can occur secondary, which will lead to the weakened detachment of the retina and blindness. Another severe complication is rubios (sprouting vessels of the iris) – a direct path to the development of secondary glaucoma.

Also used classification, which takes into account the morphological manifestations of the stages of diabetic angiopathy. It is described in the National guidelines on eye diseases.

According to her, in diabetic retinopathy there are two forms:

  • preproliferative;
  • proliferative.

In turn, preproliferative form identifies the following phases:

  • vascular – with the growing changes in the wall of retinal vessels;
  • exudative – with the emergence of a kind of condensation in the retina;
  • hemorrhagic – with hemorrhage developing; in some cases occur simultaneously, the fluid (condensate) and developed hemorrhage, then the phase is defined as exudative-hemorrhagic.

In the National guidelines on eye diseases proliferative form is characterized by such forms:

  • with growth of the tissues with blood vessels (neovascularization);
  • with gliosis;
  • with partial or complete detachment of the retina.

Glioz is an increased number of glia, which consists of cells filling the space between neurons. In diabetic retinopathy according to the classification there are 4 degree:

  • when gliosis 1 degree of glial cells observed in the posterior part of the retina or middle portion in the area of the vascular arcades (arches), but do not capture the optic disc;
  • glios, 2nd degree extends to the optic disc;
  • if 3 degrees of gliosis glia are equally applicable to both the optic disc and vascular arcades;
  • glios, 4 degrees is the most dangerous, when it glia in the form of circular stripes extend to the optic nerve of the arch (arcade) vessels and the areas between the arches.

Gradium clinical classification of diabetic retinopathy into 4 varieties – is:

  • focal edema is in the ophthalmic examination of the retina can be determined foci of edema;
  • diffuse edematous swelling distributed throughout the retina;
  • ischemic – initially dominated by changes in the retinal vessels, which lead to oxygen starvation;
  • combined – both the observed and the swelling of tissues of the retina, and ischemic changes.
Symptoms of diabetic retinopathy

In the early stages of diabetic retinopathy clinical symptoms – the patient is not concerned about not a decrease in visual acuity, no pain, no visual distortion.

If a patient with diabetes complains that it was bad to see – it means the pathological process in the tissues of the retina has gone away, and moreover, it is irreversible.

Clinical manifestations in diabetic retinopathy the following:

  • flashing “flies” before the eyes and spots, which subconsciously want to get rid of, pamargan or rubbing his eyes; the patient sees them due to the fact that in the vitreous body of accumulated blood clots formed due to destructive changes in the retina; they are more clearly visible, if you look at the light source;
  • difficulties when working with texts (reading, writing) at a close distance – this indicates the development of oedema of the retina, in particular, its Central fragment of the macula, which is responsible for visual acuity;
  • 0менем can to solidify;
  • a gradual decrease in visual acuity.
  • partial loss of visual capability;
  • complete loss of vision.

If a patient with diabetes before my eyes appeared “floaters” and the veil, you need to see an ophthalmologist in urgent manner for help, otherwise you can quickly lose sight.

Diagnosis

As the clinical symptoms of diabetic retinopathy appear late for timely diagnosis of important instrumental methods of examination of the retina:

  • direct – study directly to the retina;
  • indirect, when we study the remaining fragments of the eyeball, the change of which may indirectly inform about the irregularities in the retina of the eye.

First apply such methods of research:

  • visiometry;
  • definition of eye pressure;
  • biomicroscopic study of the anterior eye.

If the patient’s intraocular pressure in the normal range, then research methods can be applied, which require pharmacological pupil dilation:

  • biomicroscopic study of the crystalline lens, and vitreous body (performed with the use of a slit lamp);
  • ophthalmoscopy – direct and inverse; performed in all meridians of the eyeball, with sequence from the Central segment to the peripheral areas;
  • examination of the optic disc with an emphasis on the macular region;
  • the study of the state of the vitreous and retina using a 3-mirror lens Goldman;
  • a photograph of the fundus (this is done using the so-called fundus camera, also nemidreatic camera);
  • stereoscopic photograph of the fundus (preferably series of images);
  • fluorescencia angiography (the injection of fluorescein, and then filled them the vessels of the retina were examined with the aid of the lamp).

The last two ways are considered the most sensitive and informative in detecting changes in the blood vessels of the retina triggered by diabetic retinopathy.

Optometrist examines not only the retina, but other parts of the eyeball for the purpose of differential (distinctive) diagnosis, as “floaters”, a veil before the eyes, reduction of visual acuity associated with other ophthalmic diseases (not just ophthalmic).

Treatment of diabetic retinopathy, the fundamental approaches and methods

Assignments carried out jointly by the endocrinologist and ophthalmologist. An important point in the treatment of diabetic retinopathy are purpose directed against diabetes – in the first place, regulation of blood sugar levels. If the treatment of CHF has applied the latest methods, but blood sugar is unregulated, all the manipulation will lead to a positive effect for a very short time.

The importance of therapeutic diet. Its basic rules:

  • the maximum limit fats to replace animal vegetable;
  • to consume foods that have a high content of lipotropic substances – all types of fish, cottage cheese, oatmeal in various forms (flakes, cereals), fruits, vegetables (except potatoes);
  • forget about easily digestible carbohydrates – these include jam (even subjectively, the taste is not very sweet), all kinds of candy, sugar.

Diabetic retinopathy requires serious intervention – in particular, invasive (with the introduction into the tissues of the eyeball). Despite the high degree of malignancy of the processes that underlie diabetic retinopathy, to save the patient from blindness in 80% of cases of interventions, using invasive techniques of treatment.

Laser photocoagulation – local “pinpoint” cauterization of the affected areas of the retina that is performed to stop abnormal growth of blood vessels. Performed on a laser coagulator. Principle of the procedure is simple: in the burned vessels, blood coagulates, stops the process of their deformation, causing edema and retinal detachment, who had already formed the “extra” vessels of the overgrown connective tissue.

This is one of the most effective treatments for diabetic retinopathy.

If it is completed on time, it is possible to suspend the destruction of the retina:

  • in 75-85% of cases, if the produced photocoagulation for preproliferative stage;
  • in 58-62% of the cases where a photocoagulation was applied during the proliferative stage of the process.

Even if you apply this method in the late stages of pathology development, vision still manages to keep 55-60% of patients for 9 to 13 years. Sometimes these patients immediately after the manipulation decreases visual acuity, in particular, deteriorating night vision. But it’s digestible results in comparison with that will cease the germination of retinal new vessels that apply to it destructive.

If diabetic retinopathy happened bleeding in the vitreous body, is vitrectomy. This operation, which is performed under anesthesia.

It is prescribed in the following cases:

  • clots formed as a result of hemorrhage into the vitreous body, does not dissipate more than six months;
  • old fibrous germination of the vitreous body of different severity and localization;
  • a significant decrease of vision due to “debris” vitreous blood clots.
  • During vitrectomy kompromentirovat and remove the vitreous body, instead, it is administered in a special sterile solution. Vitrectomy can restore vision in 78-92% of patients suffering from diabetic retinopathy.

Also used following medication:

  • antioxidant binding free radicals, prevent damage to the blood vessels of the retina;
  • sosudoukreplyayuschee funds profilaktirujut fragility of the blood vessels of the retina;
  • enzymes help to dissolve the clot resulting from haemorrhage;
  • drugs that do not allow to grow new blood vessels (Avastin, Lucentis, etc.);
  • vitamins – first and foremost, the representatives of group B, which significantly strengthens the vascular wall. Also effective are vitamins C, P and E. All of them should be used internally (pharmacy vitamineless, natural in products), and injection – method of introducing a better alternate.
Prevention

Preventative measures that doctors can prevent diabetic retinopathy, are all those methods that aimed at competent treatment of diabetes, stabilization of flow and transfer in a controlled direction.

This:

  • proper assignment of antidiabetic drugs (including insulin);
  • a permanent control of the sugar levels in blood and urine;
  • competently painted diet;
  • preventive medication that will support the proper condition of the blood vessels of the retina (angioprotectors, vitamins);
  • the categorical rejection of bad habits, primarily tobacco in any form.

Even if all these requirements are executed with the utmost punctuality, the subjective condition of the patient and meets his doctor, and not the slightest changes in the view – should punctually be screened by an ophthalmologist. But not superficial, at the level of the conversation, and complete, with all possible instrumental methods of diagnosis. Due to the sensitive nature of the retina diabetic retinopathy can develop very quickly and just as quickly lead to irreversible changes in the structures of the eyeball – primarily the retina and vitreous.

Forecast

If diabetic retinopathy is identified in its earliest stages, vision can be saved. Because blood sugar acts destructively on the walls of blood vessels of the retina, over time, the vision will gradually deteriorate even when perfectly set up the treatment, but this increase is not catastrophic. Patients clearly observes the correct medical appointments, adhering to a healthy lifestyle, regularly visiting a competent ophthalmologist, blindness does not threaten.

One thought on “Diabetic retinopathy – eye disease in diabetes

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