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Key Features

Essentials of Diagnosis

  • Present in about 33% of all diagnosed diabetic patients

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

  • Retinopathy is not detectable in type 1 diabetic patients for the first 5 years after diagnosis

  • By 20 years after diagnosis of diabetes, 99% of type 1 diabetic patients and 60% of type 2 diabetic patients will have diabetic retinopathy

  • Nonproliferative diabetic retinopathy

    • Can be mild, moderate or severe

    • Microvascular changes are limited to the retina

  • Proliferative diabetic retinopathy: new blood vessels grow on the surface of the retina, optic nerve, or iris

  • Diabetic macular edema

    • Central retinal swelling

    • Can occur with any severity level of diabetic retinopathy

    • Reduces visual acuity if center involved

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

    • Microaneurysms

    • Retinal hemorrhages

    • Venous beading

    • Retinal edema

    • Hard exudates

  • In mild nonproliferative retinopathy, there are retinal abnormalities without visual loss

  • 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)

  • 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 associated fibrosis, may lead to vitreous hemorrhage and tractional retinal detachment

Diagnosis

  • Patients with diabetes should undergo regular screening, including

    • Fundus 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

Medications

  • VEGF inhibitor (ranibizumab [Lucentis], bevacizumab [Avastin], or aflibercept [VEGF Trap-Eye, Eylea]) or corticosteroids used for macular edema and exudates

    • VEGF inhibitor therapy improves diabetic retinopathy severity in eyes at ...

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