“The eyes may have it”, and for those with diabetes –
an area of potential microvascular disease
Ophthalmologist Richard Wacksman, M.D.is closing in with his ophthalmoscope to examine the dilated eyes of a new patient --VN. As he examines the retina (which makes vision possible), he notices some blood vessel fluid leakage and fat lipids on the macula (center part of the retina) – evidence of the blurred vision the patient reported when he made the appointment. Dr. Wacksman refers to the patient’s chart and notes slightly elevated blood pressure, being controlled by medication.
Dr. Wacksman: “I’m seeing some blood vessels leaking fluid in and around your retina. When was the last time you had your blood sugar levels checked?”
Patient: “I don’t think it’s been checked recently. Why?”
Dr. Wacksman: “That question is one I get almost every day in my practice. Sometimes, ophthalmologists are the first to spot signs of diabetes. Usually, individuals with diabetes develop some changes in the retina within 15-20 years of diagnosis. My patient was relatively young, but has slightly elevated blood pressure. High blood pressure is often a companion to diabetes.
“Diabetic retinopathy starts when the disease begins damaging tiny blood vessels in the retina. My patient had macular edema – that is, damaged blood vessels had leaked fluids and fat lipids onto the macula. The macula was swollen, and resulted in the blurred vision reported by the patient. If a patient has glasses or contact lenses, the first sign of diabetes may be a sudden inability to see well.
“If the patient does have diabetes and gets his blood sugar under control, we may be able to delay progression of retinopathy. We want to see patients with diabetes for an annual eye exam each year. For patients with gestational diabetes, we want to examine their eyes every trimester.
“As diabetic retinopathy progresses, it enters the proliferative stage, where new, very fragile blood vessels grow along the retina and the clear vitreous that fills the inside of the eye. These vessels develop as the circulatory system tries to maintain adequate oxygen levels within the retina. These blood vessels can hemorrhage, blur vision and destroy the retina. In the earliest advanced stages, patients may see spots or “floaters” in their vision. When that occurs, we want to hear from the patient right away.
“If retinopathy is allowed to progress without treatment, these abnormal vessels continue to grow. Scar tissue may lead to retinal tears, detachment of the retina, or glaucoma. Tears are usually sealed with laser surgery. If the retina is detached, ophthalmologists surgically re-attach the retina to the back of the eye.”
Treatments used for diabetic retinopathy:
- Scatter laser surgery, done in the ophthalmologist’s office as an outpatient procedure. The patient’s eyes are dilated, and eyes are numbed with eyedrops. A laser creates flashes of light to destroy oxygen-deprived retinal tissue outside the patient’s central vision. The procedure seals blood vessels, and prevents continued abnormal blood vessel growth.
- Vitrectomy for patients with a vitreous hemorrhage, or bleeding into the gel-like material in the eye’s center. Blood and vitreous gel are removed from the eye, and replaced with a clear salt solution. Vitreous strands attached to the retina may be carefully cut to prevent retinal detachment or tears. Early vitrectomy is critical to preserving vision in insulin-dependent diabetics. Post-procedure, the patient wears an eyepatch, and uses special drops to protect against infection.
“Both treatments are very effective in reducing vision loss, but they do not cure diabetic retinopathy,” notes Dr. Wacksman.
VN returns to Dr. Wackman’s office with a diagnosis of Type 2 diabetes. Following focal laser surgery, his vision returns to normal.
“We want to treat vision changes related to diabetes sooner, rather than later,” says Dr.Wacksman. “If blood sugar is not well controlled in patients with diabetes, it can, in extreme cases, lead to blindness, kidney failure, and non-healing wounds that can result in amputation.
“In this case, the patient’s primary care physician started treatment to control his blood sugar, and I was able to treat this patient very effectively with laser surgery – because we caught the disease process early.”