The accelerated growth of diabetic retinopathy in the last decade has millions of Americans potentially dealing with not only a decrease in their visual acuity or blindness, but this trend could also have national workforce and medical care implications as well.

 By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net


According to a recent analysis sponsored by the National Eye Institute (NEI)  and the Prevent Blindness America organizations, the United States is losing the battle on diabetic-related eye disease, especially diabetic retinopathy. In Americans 40 or older, 7.7 million now suffer from the disease. From 2000 to 2010, prevalence of the disease increased 89 percent and it is now the leading cause of blindness of working age Americans.

While the disease can take years for people with diabetes to develop, it can do so while remaining asymptomatic, leading people to slowly lose acuity without even realizing it.

In light of these facts, organizations such as NEI and Prevent Blindness America believe it is imperative for people with diabetes as well as medical providers to know this information and begin to communicate the importance of regular eye exams for everyone, especially those with diabetes.

Julia A. Haller, MD, is Ophthalmologist-in-Chief of the world renowned Wills Eye Institute, and professor and chair of the department of ophthalmology at Thomas Jefferson University, both in Philadelphia, Pa. Dr. Haller (pictured, lower right) believes the substantial increase in diabetic eye disease is a multi-factorial problem including people living longer with diabetes, and the burgeoning obesity problem. 

Dr. Haller sees how this growing problem has large potential ramifications for America including impacting the country’s productivity if thousands of working age people become blind or suffer decreased vision in the years to come. 

The good news is that the country’s struggle with eye disease can be addressed with regular eye exams for everyone. And for those with diabetes, staying within good control can help delay the onset of diabetic retinopathy. The disease does not have to be a complication that is a sign of being a diabetes veteran. In addition, new medicines and treatments are being developed in the ophthalmic field.

DiabetesCare.net recently spoke to Dr. Haller about the importance of annual eye exams, preventative eye disease measures, and what exciting developments are in the pipeline for treatment.

DiabetesCare.net: Can you provide an overview of how diabetes impacts the blood vessels in the retina?

Haller: What a huge epidemic this is, partly because of the aging population, but especially with people with diabetes living longer, and exacerbating the increasing issue is the nation’s problem with  obesity.

The number one organ target for diabetes complications is the eyes. Specifically, the eye is impacted by two major types of diabetic eye disease—diabetic macular edema (DME) and proliferative diabetic retinopathy.

Both are due to damage caused to the blood vessels, and blood flow,  in the retina. 

When the vessels start leaking, and they are no longer water tight, this results in diabetic macular edema. In eyes with DME, the small blood vessels leak fluid from the blood, including serum, protein, cholesterol, and other blood components. This accumulate and cause swelling in the macula, which is the central part of the retina used for central vision for everything from reading to recognizing faces to driving. And DME is the most common cause of decreased vision in working-aged Americans. So, this has a huge impact on our labor force and productivity.

The second way diabetes impacts on the eye is through proliferative diabetic retinopathy. In this form of the disease, the blood vessels in the retina are so damaged much that they no longer carry blood or nutrients to the cells anymore. The eye produces abnormal new blood vessels that actually make matters worse: the new vessels are very fragile, accompanied by scare tissue, and lead to intraocular hemorrhaging, retinal detachment and total loss of vision. 

Proliferative diabetic retinopathy is the most significant blinding problem associated with the diabetes.

Whereas, DME causes blurriness and loss of central vision, diabetic retinopathy causes blindness.

DiabetesCare.net: Are there any other eye diseases people with diabetes are at risk for?

Haller: Yes. The most common is cataracts. People with diabetes often get cataracts earlier, and they get a slightly different type of cataracts than the rest of the population. Fortunately, cataract surgery is the most successful commonly performed surgery today.

Another issue for people with diabetes is that they are prone to get more eye-related infections. For example, people with diabetes who wear contact lenses are more likely to get more scratches on their corneas and therefore more corneal infections and ulcers.

And problems with small blood vessels not only impact the retina, but they can impact the optic nerve, so diabetics are more likely to get optic neuropathy due to vascular compromise.  They can also get muscle problems in the eye, again due to damage and blockage of blood flow in the small blood vessels that supply the nerves. This can lead to ocular misalignment, where one eye starts to turn inward or outward. This can cause disabling double vision. The good news is that this type of problem often gets better in time, and if not, it can be treated with prisms and sometimes surgery.
 
DiabetesCare.net: Should primary care providers refer a patient to an ophthalmologist as soon as the patient is diagnosed with diabetes?

Haller: Yes, that is our recommendation. While we know it takes some years for the diabetic damage to build up in the eyes and cause permanent harm, the problem is that many people are diagnosed with diabetes well after they have had it for years. Ophthalmologists, believe it or not, are often the ones who pick up that a patient has diabetes because they will examine a patient’s eyes and recognize diabetic eye disease.

Generally speaking, we recommend that patients get evaluated right away, because they could have diabetic eye damage already, even if they just recently were diagnosed with diabetes. 
 
DiabetesCare.net: Why is it vital for people with diabetes to be followed by an ophthalmologist?

Haller: People have often developed diabetic eye disease well before they are aware of it. An eye exam is required to recognize the early changes in time to treat them and conserve vision.

Also, some people may have vision loss in one eye and not even realize it until they go into their ophthalmologist`s office, because their good eye takes over and does all the work.

The most important fact about diabetic eye disease is that people are often unaware of it and thus it goes undetected. And when patients lose the advantage of getting diagnosed early, they may lose the chance to retain good vision. The earlier patients can be diagnosed, the better their chances are of halting progression of the disease, and preventing vision loss.

Sadly, diabetic retinopathy is still under diagnosed overall, with up to 50 percent of diabetics failing to get recomended examinations.

DiabetesCare.net: How often should someone with diabetes see an ophthalmologist who is newly diagnosed and is not showing signs of a disease state, and how often should someone with diabetic retinopathy be seen?

Haller: We have well-researched guidelines based on the epidemiology and the progression of the disease. In someone who does not have any diabetic retinopathy, we recommend a once a year check-up.

And then depending on how much more severe the disease, a patient might need to be seen more often, possibly every 3 to 6 months.

 

 

 

 

 

 

 

 

 

 

 

In the top left photo is a normal retina; in the upper right image is a patient with diabetic retinopathy; and the image below shows a close up of abnormal blood vessels within a patient with proliferative diabetic retinopathy.


DiabetesCare.net:
Are there any preventative health measures that patients can practice to avoid diabetic retinopathy?

Haller: The three key preventative steps are: keeping your blood sugar as normal as you possibly can; keeping your blood pressure under good control; and maintaining normal blood lipid levels. It is vital for those who smoke, to quit. This is a huge additive risk factor. I like to tell my patients to think of diabetic eye disease risk factors as being similar to those of cardiac disease. Things that are heart healthy in general are diabetes healthy too. 
 
DiabetesCare.net: Are there differences in how diabetic retinopathy progresses in people with type 1 diabetes and type 2 diabetes?

Haller: Yes, there certainly can be differences. People with type 1 diabetes may have a more precipitousky downhill course if the disease gets out of control, and they are typically more at risk of rapidly progressing in terms of their eye disease. Wit people with type 2 diabetes their overall controlof their underlying medical condition is key as well. We look at A1c levels, so if someone has a very high A1c, and they have type 2 diabetes, then we worry much more about their eye disease and its pace. 

DiabetesCare.net: Is there anything to slow down the disease’s progression?

Haller: We use the same health measures for disease treatment as we do for prevention (good control of glucose, blood pressure, and lipids). We also have some new medicines that may impact specifically on the progression of the diabetic retinopathy. There are none that are orally given that are FDA approved yet.

We do administer drugs by injection into the eye once patients have developed vision-threatening diabetic retinopathy, and these help slow the progression of the disease. While it does not sound very appealing to be getting ocular injections, it is important to note that patients tolerate them very well. We also perform laser photocoagulation to the eye to prevent retinopathy progression and cause regression of the disease.

We are hopeful for more treatments down the road that systemically slow down the progression of the diabetic retinopathy. We do know that for every point the A1c that gets lowered, there are positive impacts on eye disease.

DiabetesCare.net: There are not any oral medications or drops patients can administer themselves for diabetic retinopathy?

Haller: Correct. If the disease progresses, patients could potentially be treated with injections, laser treatments, or surgery—again depending on the progression of their disease state.

DiabetesCare.net: Any exciting news to report about research or treatment in terms of treating diabetic retinopathy?

Haller: There are many drugs that are targeted and in development right now. There is a very exciting drug that is going in front of the FDA on July 26 for the treatment of vitreomacular traction that might have applicability to diabetic eyes. This drug is called Ocriplasmin, and it was previously known as Microplasmin. It is injected into the eye and causes the vitreous to liquefy and separate from the retina.  It is unproven yet, but there are exciting speculative possibilities that it may help with the progression of diabetic retinopathy. There are also new types of laser treatments that can be done expeditiously with less side effects and less pain.

We also have smaller instruments that allows us to get in and out of the eye more easily now when we have to do surgery. Utilizing these instruments doesn’t require surgeons to use sutures because these are very tiny incisions being done in minimally invasive procedures.

Overall, this is one of the most exciting areas of medical research. We are on the cusp of a whole host of new treatments. Because of the huge health problems associated with diabetes, this is one of the most targeted areas of ophthalmology, and where we have made the most progress in the last 10 years. I am optimistic about what lies ahead in terms of the therapies for treating diabetic eye disease.

To learn more about diabetic retinopathy and other eye-related diseases and ailments, go to the Wills Eye Institute website. To read about a pediatric endocrinologist`s personal experience with her recent diagnosis with diabetic retinopathy go here.