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Home | Articles | Diabetes and Endocrinology | Diabetic Retinopathy

Diabetic Retinopathy

Last updated 14th May 2021

Introduction

  1. Diabetes is the most common cause of blindness in people age 30 to 69 years. Twenty years after the onset of type 1 diabetes, almost all patients with type 1 diabetes and 60% of patients with type 2 diabetes will have some degree of retinopathy.
  2. Diabetic retinopathy is due to microangiopathy affecting the retinal precapillary arterioles, capillaries and venules. Damage is caused by both microvascular leakage from breakdown of the inner blood-retinal barrier and microvascular occlusion.
  3. Nowadays as a result of national screening programmes  the prevalence of blindness in people with diabetes is no greater than that of the general population

Classification

  1. Diabetic retinopathy can be considered under 6 headings as shown in the following table:
Background diabetic retinopathy or non-proliferative• Micro-aneurysms
• Dot & blot haemorrhages
• Hard exudates
Maculopathy• Macular oedema
• Macular haemorrhages or hard exudates
Pre-proliferativeBackground retinopathy changes plus:
• Cotton-wool spots
• Venous beading & loops
• Retinal haemorrhages
Proliferative• Neovascularisation of the retina, optic disc or iris
• Vitreous haemorrhage
Advanced diabetic eye disease or advanced proliferative retinopathy• Fibrous tissue adherent to vitreous face or retina
•Tractional retinal detachment
Iatrogenic• Laser retinal burns

Background Diabetic Retinopathy

  1. Microaneurysms are small saccular pouches, possibly caused by local distension of capillary walls. They are often the first clinically detectable sign of retinopathy and appear as small red dots, commonly temporal to the macula.
  2. Haemorrhages may occur within the compact middle layers of the retina and appear as “dots” or “blots.” Rarely, haemorrhages occur in the superficial nerve fibre layer, where they appear flame shaped; these are better recognised as related to severe hypertension
  3. Hard exudates which have a waxy white appearance and well defined edges
  4. Background diabetic retinopathy doesn’t usually affect vision and doesn’t usually require any specific treatment other than good control of diabetes and any coexistent hypertension

Maculopathy

  1. Any of the above changes that occur near the macula where they may interfere with vision
  2. Also macular oedema due to leaky capillaries
  3. Can lead to permanent loss of vision if untreated
  4. Usually an indication for laser therapy

Pre-proliferative

  1. Background changes plus distended veins, venous beading, cotton wool spots (retinal infarcts) and more extensive haemorrhages
  2. Usually an indication for laser therapy

Proliferative

  1. Proliferative retinopathy characterised by leashes of new blood vessels (top image, which also shows laser burns in the bottom left quadrant) that bleed causing vitreous haemorrhage (lower image)

Advanced Diabetic Eye Disease

  1. Recurrent vitreous haemorrhage leads to fibrous scars within the vitreous and ultimately to retinal detachment.
  2. Treatment of advanced diabetic retinopathy is by vitrectomy.

Iatrogenic

  1. Laser burns which are the changes you are most likely to see in an exam

References