Diabetic Retinopathy

Aka: Diabetic Retinopathy, Diabetic Macular Edema

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II. Epidemiology

  1. Occurs in 20% of patients with Diabetes Mellitus
  2. Occurs equally in Type I and Type II Diabetes Mellitus

III. Risk Factors

  1. Longer duration of Diabetes Mellitus (>72 months)
  2. Poor Blood Glucose control (Hgb A1C > 8.0)
  3. Increased Microalbuminuria levels (>9.5)
  4. Saum (2002) Br J Gen Pract 52:214-6 [PubMed]

IV. Types

  1. Nonproliferative Retinopathy
    1. Retinal veins dilated
    2. Cotton Wool exudates or spots
    3. Hard exudates
    4. Macular edema
    5. Intraretinal Hemorrhages
    6. Microaneurysms
  2. Proliferative Retinopathy
    1. Neovascularization
    2. Preretinal Hemorrhages
    3. Vitreous Hemorrhages
    4. Vascular fibrosis

V. Symptoms

  1. Vision Loss, fluctuating Visual Acuity or Visual Field Defects
  2. Floater or flashes of light (photopsia)

VI. Protocol: Ophthalmology Exam Intervals with no Retinal Disease

  1. Children with Diabetes
    1. Initial Exam: Age 10 years (or after 3-5 years of Diabetes Mellitus)
    2. Subsequent Exams: Annually
  2. Adults with Type 2 Diabetes
    1. Initial Exam: At diagnosis
    2. Subsequent Exams: Annually

VII. Protocol: Ophthalmology Exam Intervals for those with Retinal Disease

  1. Mild to moderate nonproliferative Diabetic Retinopathy
    1. No Macular edema
      1. Exams every 6-12 months
    2. Macular edema present
      1. Consider laser photocoagulation
      2. Intravitreal injection of Vascular Endothelial Growth Factors (e.g. Bevacizumab, aflibercept, ranibizumab)
        1. Wells (2015) N Engl J Med 372(13): 1193-203 +PMID:25692915 [PubMed]
      3. Intravitreal Corticosteroid Injection or implant (Cataract risk)
        1. Grover (2008) Cochrane Database Syst Rev (1):CD005656 +PMID:18254088 [PubMed]
  2. Severe nonproliferative Diabetic Retinopathy
    1. Eye Examinations every 2-4 months
    2. Consider laser photocoagulation
    3. See Macular edema management as above
  3. Proliferative Diabetic Retinopathy
    1. Consider laser photocoagulation
  4. Vitreous Hemorrhage (or refractory course)
    1. Intravitreal injection of Vascular Endothelial Growth Factors (e.g. Bevacizumab, aflibercept, ranibizumab)
      1. Osaadon (2014) Eye 28(5): 510-20 [PubMed]

VIII. Prevention: Slowing Diabetic Retinopathy progression

  1. Fenofibrate
    1. Wong (2012) Am J Ophthalmol 154(1): 6-12 [PubMed]
  2. Tighter glycemic control reduces progression risk
    1. However, diabetes goals have loosened to prevent Hypoglycemia (A1C 8.5% in older adults)
    2. Stratton (2001) Diabetologia 44(2): 156-63 [PubMed]
  3. Blood Pressure Control
    1. Optimal Blood Pressure control does decrease Diabetic Retinopathy Incidence
    2. However, optimal Blood Pressure control does NOT slow Diabetic Retinopathy progression after onset
    3. Do (2023) Cochrane Database Syst Rev 3(3):CD006127 +PMID: 36975019 [PubMed]

IX. References

  1. Pelletier (2016) Am Fam Physician 94(3):219-26 [PubMed]

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