From hyperglycemia to vision loss

If you have been diagnosed with diabetes, you know how complicated it can be to manage this systemic disease which can affect all organs and tissues in your body over time.

But if there is one thing that you might not be thinking about, but should be doing, is get an eye exam, as in, as soon as possible. “The majority of people with diabetes will eventually develop diabetic retinopathy, which damages the tiny blood vessels in the retina of the eye,” says Lloyd P. Aiello, MD, director of the Beetham Eye Institute at the Joslin Diabetes Center in Boston and professor of ophthalmology at Harvard Medical School. “About a third of these people will develop diabetic macular edema, or DME, which occurs when fluid from these damaged blood vessels seeps into the macula in the center of the retina.” Your chances of developing diabetic retinopathy or DME are not a matter of luck, but directly related to long-term blood sugar control.

This is a real problem because the macula is a very important part of vision: it helps you see objects directly in front of you, as well as fine details, colors and distant objects. If something affects the macula, it will almost always affect your eyesight. While most eye diseases like cataracts and macular degeneration develop in older people, DME can occur much earlier.

“DME is the most common blinding eye disease in people of working age, between the ages of 30 and 50,” says Timothy Murray, MD, ophthalmologist in Miami and past president of the American Society of Retina Specialists. It sounds scary enough, but there is also good news: “DME is very treatable when detected early,” he adds. “We can prevent progression and improve existing disease. ”

An inside look

When you have diabetes, your body does not make enough insulin or becomes resistant to insulin. As a result, the sugar lags around your bloodstream, which ends up damaging the blood vessels in your body by decreasing their elasticity and narrowing them, compromising blood flow and reducing oxygen levels in the blood.

In the retina, this decrease in blood flow causes the pericytes, which are cells to roll up and act as a sealant for the blood vessels, to retract and die, says Dr. Murray. The blood vessels then develop balloon-like bulges inside, essentially mini aneurysms. This swelling increases the area of ​​the blood vessel, so it is thinner and less tight. As a result, fluid, blood and lipids can first escape from the vessels and enter the retina. If the disease progresses to affect the macula, it is called diabetic macular edema, or DME, the leak spreads into the macula and the excess fluid bypasses messages sent to the brain so that the images you see are distorted.

“It may take 10 or 20 years in diabetes before we see DME, but it can also happen in the first year,” says Howard R. Krauss, MD, neuro-ophthalmologist and clinical professor at ophthalmology and neurosurgery at the John Wayne Cancer Institute. in Santa Monica, California.

The most severe stage is known as proliferative diabetic retinopathy (PDR). At this point, the damaged blood vessels close, depriving the retina of oxygen. If enough of the retina does not receive blood, new, abnormal blood vessels may develop. Because these new blood vessels are very fragile, they can leak even more or bleed inside the eye, which is called a vitreous hemorrhage. Scar tissue from growing new blood vessels can also cause the retina to detach. Eventually, complete vision loss can occur.

Consult an ophthalmologist

The standard advice for most conditions (including many eye problems, serious or not) is to see your doctor at the first sign of symptoms. This is not the case with the EMR: you want to see an ophthalmologist as soon as you are diagnostic with diabetes so that you can be monitored at least once a year for diabetic retinopathy and DME before you have symptoms. “There’s a magic window when vision starts to go from 20/20 to around 20/30 or 20/40 when we need to start treatment,” notes Dr. Aiello. At this point, most people probably won’t notice that their vision is changing yet, but they can still have bad edema. Your ophthalmologist can use retinal photography and other diagnostic eye tests to monitor changes in the retina before your vision is affected, says Dr. Krauss.

It is also important to know what type of ophthalmologist you are seeing. A Doctor of Optometry (OD) is like a primary care doctor for your eyes, that doctor. a ophthalmologist, however, is an eye doctor who performs eye surgery and treats more serious eye diseases like diabetic retinopathy and DME. Make an appointment with the latter. A significant part of the exam is dilated with drops at the office. These drops enlarge your pupils so that your ophthalmologist can look inside your eyes and directly view your retina. You may be out of focus for several hours after a dilated eye exam. Some ophthalmologists also have additional training in diseases and surgery of the retina and vitreous of the eye. They are known as retinal specialists or vitreoretinal surgeons and are highly skilled in the treatment of diabetic eye diseases.

In addition to frequent monitoring, you will also need to be on the lookout for any of the following symptoms of DME:

• Blurry, wavy, or distorted vision

• Floaters (dots, strings, or cobwebs) in your vision

• Difficulty reading at any distance

• See washed out or faded colors

• Blind or dark areas or spots in your field of vision

Prevent DME with a Healthy Lifestyle

Keeping your blood sugar under control is one of the most important things you can do to prevent and slow the progression of diabetic retinopathy and DME. “The Landmark Diabetes Control and Complications Trial Has Proven That People With Diabetes Who Keep Their Blood Sugar As Near Normal As Possible Through Intensive Treatment May Slow The Development Of Eye Diseases And Other Complications Explains Dr Murray. High blood pressure (BPH) and high cholesterol levels also increase your risk for DME, so controlling those with medications and lifestyle changes like losing weight, exercising, and quitting smoking is best. also useful. “It’s totally in your power,” says Dr Krauss. “I have many patients who never develop diabetic retinopathy or DME, as well as other diabetic complications.”

Treat EMR with injections and steroids

The first line of defense is anti-VEGF drugs, which are administered as eye injections. VEGF stands for Vascular Endothelial Growth Factor, a natural protein that causes the body to create new blood vessels when under stress and also causes blood vessels to leak. “Anti-VEGF drugs work like spot welders, plugging leaks. This prevents the formation of these new problematic vessels and can lead to the resolution of those already present, ”says Dr. Aiello. Anti-VEGF treatments can slow the progression of DME and retinopathy, but cannot completely reverse the vision that has been lost.

Patients with more advanced DME also have other options. Steroid treatments– in the form of pills, eye drops, injections or implants – can be given with anti-VEGF treatment or alone. Steroids reduce inflammation and swelling, but can also increase the risk of glaucoma and cataracts.

The focal laser to remove fluid in the macula and the panretinal laser to areas of the retina that no longer receive blood – the standard treatments only a decade ago – are still used, but less frequently now. “Laser treatment can cause collateral damage to the rest of the retina,” says Dr. Krauss. “However, it can be a good secondary tool for people with more severe diabetic proliferative retinopathy who are at greater risk of vision loss.”

Vision Quest

The bottom line? Things are looking up for people with diabetes who develop DME. “Anti-VEGF injections have revolutionized treatment,” says Dr Murray. Frequent eye exams by an ophthalmologist and aggressive treatment mean that far fewer people with diabetes will have DME and those who do can be cured. The DME may return, so you’ll still have to watch out, but there’s more good news on the horizon. “Researchers are studying gene therapies that could one day allow the eye to make its own anti-VEGF proteins,” he adds. A possible advance to definitely watch.

Meet our writer

Stephanie Bois

Stephanie Wood is an award-winning freelance writer and former editor-in-chief of a health, nutrition, wellness and parenting magazine.