Understanding Diabetic Retinopathy

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1 Understanding Diabetic Retinopathy

What Is Diabetic Retinopathy? Diabetes damages blood vessels in the rear of the eye. This condition is called diabetic retinopathy. It can lead to vision loss or blindness.

2 What Is Diabetic Retinopathy? Diabetes damages blood vessels in the rear of the eye. This condition is called diabetic retinopathy. It can lead to vision loss or blindness. You already may have diabetic retinopathy, or be at risk for it. But you can take steps to reduce your risk of vision loss from this condition. Diabetes and Vision Loss A glance out the window helps you choose between a sweater and a raincoat. Reading to your grandchild turns a normal day diabetes may threaten your visual link with the world. That s frightening. But you can work with your healthcare team to manage your diabetes and keep diabetic retinopathy under control. Diabetic Retinopathy and Its Symptoms At first, diabetic retinopathy may cause no vision loss or other symptoms. But over time, it can still harm vision. If you have symptoms of diabetic retinopathy, they may include: cloudy vision. floaters (dark spots) or black lines. Maintain your vision so you have it for the things you love. If You Become Pregnant Pregnancy can make diabetic retinopathy worse. If you re thinking of having a baby, see your eye doctor right away. your eyes before you become pregnant, if possible. You ing your pregnancy, especially during the first 3 months. 2 This booklet is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem. 2001, 2002, 2013 Krames StayWell, LLC All rights reserved. Made in the USA.

Learning About Diabetic Retinopathy Your healthcare team will help you learn more about diabetic retinopathy and how to control it. When you meet with your doctors, ask questions.

3 Learning About Diabetic Retinopathy Your healthcare team will help you learn more about diabetic retinopathy and how to control it. When you meet with your doctors, ask questions. Take notes, or have a family member or friend take notes. Ask for written instructions from your healthcare team. And read this booklet to learn more. Your Eye Doctor Eye doctors are medical doctors. They oversee vision care and diagnose and treat eye disorders. Together, you and your eye doctor will design a treatment plan to protect your vision. Keeping your appointments and following your treatment plan will help save your sight. Table of Contents Eye Anatomy Diabetes and the Eye Can Change Using the Amsler Grid Evaluating Your Eyes Working with Your Your eye doctor oversees your vision care. 3

4 Eye Anatomy The eye receives and processes light. The retina (the inside lining of the eye) turns light into nerve signals. These become visual images in the brain.

4 4 Eye Anatomy The eye receives and processes light. The retina (the inside lining of the eye) turns light into nerve signals. These become visual images in the brain. Tiny capillaries (blood vessels) bring blood to nourish the retina. How You See Light enters the eye through the pupil. The light passes through the clear tissue of the lens and the vitreous (the clear gel that fills the eye). The light then strikes the retina, where special cells send signals to the brain. The brain turns these signals into visual images what you see. Pupil Iris Lens Sclera (white of the eye) The Healthy Retina A healthy retina includes: macula, the area of the retina where sharp central vision takes place. fovea, the most sensitive part of the macula. periphery, which surrounds the macula. This provides peripheral (side) vision what we see outside our sharp central vision. Capillaries that nourish the retina with blood. Vitreous Front view of a healthy retina Retina Optic nerve Fovea Macula Blood vessels Periphery Optic nerve Macula Fovea Capillaries

Diabetes and the Eye Diabetes can cause capillaries on the retina to leak or collapse. Then fragile new capillaries may grow on the retina, causing more damage.

They can also reduce the amount of blood nourishing the retina. Reduced blood flow causes fragile new capillaries to grow on the retina (neovascularization).

These may leak fluid and fatty substances (hard exudates). This leakage can cause macular edema (swelling). cotton wool spots (soft exudates). (dot-blot hemorrhages).

5 Diabetes and the Eye Diabetes can cause capillaries on the retina to leak or collapse. Then fragile new capillaries may grow on the retina, causing more damage. Both types of damage to the retina are forms of diabetic retinopathy. An Unhealthy Retina Damaged capillaries can interfere with vision. They can also reduce the amount of blood nourishing the retina. Reduced blood flow causes fragile new capillaries to grow on the retina (neovascularization). As diabetic retinopathy progresses, vision loss can get worse. Damage from existing capillaries microaneurysms (bulges in the capillary wall). These may leak fluid and fatty substances (hard exudates). This leakage can cause macular edema (swelling). cotton wool spots (soft exudates). (dot-blot hemorrhages). Traction Neovascularization Dot-blot hemorrhage Cotton wool spots Damage from new capillaries Fragile new capillaries may: on the retina (traction). Traction can cause bleeding, create scar tissue, or dislodge the retina from the back of the eye (traction retinal detachment). 5

How Your Vision Can Change Diabetic retinopathy may progress from its early stage (nonproliferative) to its later stage (proliferative). Either stage may cause vision loss.

Nonproliferative Diabetic Retinopathy At this stage, capillaries in the retina have been damaged. But there s no growth of fragile new capillaries on the retina.

6 How Your Vision Can Change Diabetic retinopathy may progress from its early stage (nonproliferative) to its later stage (proliferative). Either stage may cause vision loss. There may be little or no vision loss at first. But even without early vision loss, diabetic retinopathy still damages the retina. Severe vision loss even blindness may occur later. Nonproliferative Diabetic Retinopathy At this stage, capillaries in the retina have been damaged. But there s no growth of fragile new capillaries on the retina. This stage of diabetic retinopathy may cause no symptoms. Or it may result in some vision loss. This stage is also called background diabetic retinopathy. Damaged capillaries Proliferative Diabetic Retinopathy At this stage, fragile new capillaries begin to grow on the retina. This capillary growth may result in bleeding or traction, causing severe vision loss. This stage is more common in people who have had diabetic retinopathy for many years. Weak new capillaries In the nonproliferative stage, capillaries are damaged. But weak new capillaries haven t started to grow on the retina. In the proliferative stage, weak new capillaries are growing throughout the retina. Bleeding into the vitreous may occur. 6

No vision loss yet Problems such as leakage, closed capillaries, or capillary growth may be present. But they may not yet have affected your vision.

7 No vision loss yet Problems such as leakage, closed capillaries, or capillary growth may be present. But they may not yet have affected your vision. Slight to moderate vision loss Problems with capillaries, such as swelling due to focal leakage (leakage near the fovea), cotton wool spots, or capillary closure may result in the first signs of vision loss. Moderate to severe vision loss swelling due to diffuse leakage (leakage throughout the macula) or other worsening problems with capillaries. Cloudy, blurry vision This often results when weak new capillaries growing into the vitreous begin to bleed. What You May See As diabetic retinopathy progresses, seeing clearly may become more difficult. without warning. Or it may slowly worsen over time. Severely reduced vision Capillary growth and scar tissue in the vitreous may result in traction. Traction may cause the retina to detach from the back of the eye (traction retinal detachment). If this occurs, vision may be severely impaired. 7

8 Managing Your Health You can greatly reduce your risk of vision loss from diabetic retinopathy by managing your overall health. Start by closely managing your diabetes.

Control Your Risk Factors Other factors that damage blood vessels can make diabetic retinopathy worse. These include: Work with your healthcare team to control these problems and help lower your risk.

8 8 Managing Your Health You can greatly reduce your risk of vision loss from diabetic retinopathy by managing your overall health. Start by closely managing your diabetes. And take care of other health problems that can make diabetic retinopathy worse. Monitor your blood sugar level closely to help keep diabetes under control. Control Your Risk Factors Other factors that damage blood vessels can make diabetic retinopathy worse. These include: Work with your healthcare team to control these problems and help lower your risk. A diabetes educator can help you control blood pressure and high cholesterol. stop-smoking programs. Manage Your Diabetes The best way to protect your vision is to keep your blood sugar level in a healthy range. Check your blood sugar regularly. Follow your diabetes management plan. And work with your primary care physician or endocrinologist (diabetes doctor) if you are having trouble keeping your blood sugar in a healthy range. A diabetes educator can help you develop an action plan to control your risk factors.

9 Using the Amsler Grid An Amsler grid helps you track any changes in your vision that may occur. Use the grid below. Or, use one supplied by your eye doctor. Use the grid as often as he or she suggests. Keep the grid where you ll remember to use it. If you notice any vision changes even if your vision improves call your eye doctor. How to Use the Amsler Grid 1. Use the grid in a welllighted area. 2. Wear glasses or contacts if you usually wear them. 3. normal reading distance (about 16 inches). 4. Cover your left eye. 5. Look at the dot in the grid s center with your right eye. 6. While looking at the dot, notice if any of the lines appear wavy or disappear, 7. Jot down any changes from the last time you used the grid. 8. Repeat with your other eye. 9. If you have noticed ANY vision changes, call your eye doctor right away. 9

Evaluating Your Eyes the doctor will review your medical history, check your Your Medical History Your eye doctor will ask about: treatments (such as insulin), and how you monitor your blood sugar

10 Evaluating Your Eyes the doctor will review your medical history, check your Your Medical History Your eye doctor will ask about: treatments (such as insulin), and how you monitor your blood sugar level. whether any relative has had diabetes or diabetic retinopathy. medical procedures you ve had. supplements you use, including those you buy over-the-counter. Your Eye Exam Your eye doctor uses an eye chart and other tools to check your vision. Then he or she of disease. After eyedrops are used to dilate (widen) your pupils, you may have one or more of the following tests: Tonometry, to measure fluid pressure inside the eye. A slit lamp exam, to view the structures of the eye. Imaging tests, to form pictures of the retina and nearby structures. These tests can include ultrasound and optical coherence tomography (OCT), which are both noninvasive. Your eye doctor with a slit lamp. 10

Fluorescein Angiography Fluorescein angiography reveals changes in the capillaries with the use of photographs and

The dye highlights capillaries in the retina. Photographs are taken before and after the dye is injected.

After the procedure, your skin, eyes, and urine may appear yellow for a few hours.

Microaneurysms Fluorescein angiography reveals even slight changes to your capillaries.

11 Fluorescein Angiography Fluorescein angiography reveals changes in the capillaries with the use of photographs and special dye. Before this procedure, dye is injected into your arm or hand. The dye highlights capillaries in the retina. Photographs are taken before and after the dye is injected. During the procedure, you may briefly feel some nausea. After the procedure, your skin, eyes, and urine may appear yellow for a few hours. Angiograms A healthy retina What s the Next Step? Microaneurysms Fluorescein angiography reveals even slight changes to your capillaries. Your eye doctor will work with you to design a treatment plan that s best for you. Common treatments, including laser photocoagulation and vitrectomy, are described in injections into the eye, may also be used to help treat diabetic retinopathy. Your doctor will go over such treatment options with you as needed. New capillary growth and leakage 11

Having Laser Treatment Laser photocoagulation uses a laser (a high-energy light source) to treat diabetic retinopathy. This treatment doesn t cure diabetic retinopathy.

It also slows or stops new capillary growth. Types of Laser Treatment Focal treatment uses the laser to seal up tiny bulges in capillaries near the fovea.

12 Having Laser Treatment Laser photocoagulation uses a laser (a high-energy light source) to treat diabetic retinopathy. This treatment doesn t cure diabetic retinopathy. But it may slow or halt the progress of the disease. How Is the Laser Used? During the procedure, a laser beam is focused on the retina. The laser seals weak capillaries. It also slows or stops new capillary growth. Types of Laser Treatment Focal treatment uses the laser to seal up tiny bulges in capillaries near the fovea. the eye Laser light Special contact lens and location of damaged capillaries. Treatment may take from a few minutes to a half hour or so. You may need more than one treatment session or type of treatment. Grid treatment uses the laser to treat swelling in different areas of the macula. Risks and Complications of Laser Treatment vision Retina Panretinal treatment reduces growth of new capillaries throughout the retina. peripheral vision 12

Preparing for Laser Treatment Tell your eye doctor about all medications, herbal remedies, and supplements you use. This includes aspirin, ibuprofen, blood thinners, and ginkgo.

13 Preparing for Laser Treatment Tell your eye doctor about all medications, herbal remedies, and supplements you use. This includes aspirin, ibuprofen, blood thinners, and ginkgo. Be sure to arrange for an adult to drive you home after surgery. You should also have dark sunglasses to wear on the way home. During Laser Treatment Laser treatment may be done at the doctor s office, hospital, or eye center. You ll be awake during treatment. The doctor uses eyedrops to dilate your pupil. Then the doctor holds a special contact lens against your eye. Controlling Pain Laser treatment may cause some discomfort. If so, you ll be given medication to control it. If the discomfort continues, tell your doctor. After Laser Treatment You may be given a patch to protect your eye for a few days. Ask your doctor how long you or swimming. Also ask when you can return to work. During laser treatment, you may see flashes and hear clicking sounds coming from the laser. When to Call Your Doctor If you have sudden pain or notice decreasing vision after surgery, call your eye doctor. 13

14 Having Vitrectomy If blood or debris in the vitreous is clouding your vision, your doctor may recommend vitrectomy. This surgery removes the cloudy vitreous.

14 14 Having Vitrectomy If blood or debris in the vitreous is clouding your vision, your doctor may recommend vitrectomy. This surgery removes the cloudy vitreous. The vitreous is replaced with fluid or gas. If vision problems continue after vitrectomy, you may need additional surgery. Preparing for Vitrectomy Tell your doctor about any medications, herbal remedies, and supplements you use. This includes aspirin, ibuprofen, blood thinners, and ginkgo. Before surgery, an anesthesiologist (a doctor who provides medication to control pain) will meet with you. You ll talk about the type of anesthetic (pain medication) to be used during surgery. During Vitrectomy Tiny instruments are inserted through small incisions in the sclera. The vitreous is removed. It s replaced with saline (saltwater) solution or a gas bubble to hold the retina in place. Surgery may take several hours. When to Call Your Doctor If pain or vision loss worsens after you go home, call your eye doctor. After Vitrectomy Cloudy vitreous after the procedure. Be sure to wear dark sunglasses on the way. Before leaving, you ll be told how to care for your patch or bandages. You ll also receive medication to control pain. Don t rub, bump, or touch your eye. Risks and Complications of Vitrectomy (cataract)

Working with Your Healthcare Team You are the most important member of your healthcare team. Only you can work with the doctors and other healthcare providers to manage your diabetes.

15 Working with Your Healthcare Team You are the most important member of your healthcare team. Only you can work with the doctors and other healthcare providers to manage your diabetes. To help control diabetic retinopathy, keep visiting your eye Keep Your Medical Appointments Diabetes can harm blood vessels throughout your body as well as inside your eyes. Protect your health and vision with your healthcare providers. or urine tests done as directed. Follow Your Treatment Plan Your treatment plan will help reduce your risk of vision loss. To control diabetic retinopathy: as directed. health. Don t smoke. Follow your doctor s advice about other symptoms to your eye doctor right away. 15

Finding Help with Vision Care Your healthcare team will help you protect your vision. If you have questions, ask your doctors or other healthcare providers.

16 Finding Help with Vision Care Your healthcare team will help you protect your vision. If you have questions, ask your doctors or other healthcare providers. For help with diabetes and vision care, call or write your state or local commission on the blind. Or contact the groups listed below. Resources American Council of the Blind American Diabetes Association Lighthouse International National Eye Institute Consultant: Content Specialist: Edward Y. Koo, MD, Ophthalmology With contributions by: Gerald A. Brooksby, MD, Ophthalmology Mark A. Peters, MD, Ophthalmology Take our Patient Survey. Help us help other patients. Please visit to provide your feedback on this booklet

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