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Key Features

Essentials of Diagnosis

  • Present in about one-third of all diagnosed diabetic patients and about one-third of those have sight-threatening disease

  • Present in about 20% of type 2 diabetic patients at diagnosis

  • Background retinopathy: mild retinal abnormalities without visual loss

  • Maculopathy: macular edema, exudates, or ischemia

  • Proliferative retinopathy: retinal new vessels (neovascularization)

General Considerations

  • Worldwide, there are approximately 93 million people with diabetic retinopathy, including 28 million with vision-threatening disease

  • The leading cause of new blindness among adults aged 20–65 years

  • The number of affected individuals aged 65 years or older is increasing

  • Retinopathy increases in prevalence and severity with increasing duration and poorer control of diabetes

  • Broadly classified as

    • Nonproliferative, which is subclassified as mild, moderate or severe

    • Proliferative, which is less common but causes more severe visual loss

  • Maculopathy and proliferative retinopathy may coexist, particularly in severe disease

Clinical Findings

  • Nonproliferative retinopathy manifests as

    • Dilation of veins

    • Microaneurysms

    • Retinal hemorrhages

    • Venous beading

    • Retinal edema

    • Hard exudates

  • Reduction of vision is most commonly due to diabetic macular edema, which may be focal or diffuse, but it can also be due to macular ischemia

  • Macular involvement is the most common cause of legal blindness in type 2 diabetes

  • Macular edema may be associated with treatment with thiazolidinediones (glitazones)

  • In background retinopathy, the abnormalities are mild and do not cause any impairment of visual acuity

  • Pre-proliferative retinopathy is characterized by marked vascular abnormalities and retinal hemorrhages

  • Proliferative retinopathy

    • Characterized by neovascularization, arising from either the optic disk or the major vascular arcades

    • Vitreous hemorrhage is a common sequel

    • Proliferation into the vitreous of blood vessels, with their associated fibrous component, may lead to tractional retinal detachment

Diagnosis

  • Patients with diabetes should undergo regular screening, including

    • Fundal photography, preferably after pupillary dilation (mydriasis)

    • Slit-lamp examination after pupillary dilation

  • More frequent monitoring is required in women during pregnancy and in those planning pregnancy

  • Patients with type 2 diabetes mellitus should have a complete ophthalmologic examination shortly after diagnosis

  • Assessment of maculopathy requires

    • Visual acuity testing

    • Stereoscopic examination of the retina

    • Retinal imaging with optical coherence tomography

    • Fluorescein angiography (occasionally)

Treatment

  • Optimize blood glucose, blood pressure, kidney function, and serum lipids, although such measures are probably more important in preventing retinopathy than in influencing its subsequent course

Medications

  • Fenofibrate and renin-angiotensin system inhibitors are beneficial even in established retinopathy

  • Proliferative diabetic retinopathy is not a contraindication to treatment with thrombolytic agents, aspirin, or warfarin unless there has been recent intraocular hemorrhage

  • Intravitreal corticosteroid may be beneficial in macular edema and exudates but not ischemia

  • Vascular endothelial growth factor (VEGF) inhibitor therapy

    • May be beneficial in macular edema and exudates but not in ischemia

    • Can achieve regression of neovascularization in proliferative retinopathy

Therapeutic Procedures

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