Diabetic Retinopathy

Topic Overview

What is diabetic retinopathy?

Retinopathy is a disease of the retina. The retina is the nerve layer that lines the back of your eye. It is the part of your eye that 'takes pictures' and sends the images to your brain. Many people with diabetes get retinopathy. This kind of retinopathy is called diabetic retinopathy (retinal disease caused by diabetes).

Diabetic retinopathy can lead to poor vision and even blindness. Most of the time, it gets worse over many years. At first, the blood vessels in the eye get weak. This can lead to blood and other liquid leaking into the retina from the blood vessels. This is the most common kind of retinopathy.

If blood sugar levels stay high, diabetic retinopathy will keep getting worse. New blood vessels grow on the retina. This may sound good, but these new blood vessels are weak. They can break open very easily, even while you are sleeping. If they break open, blood can leak into the middle part of your eye in front of the retina and change your vision. This bleeding can also cause scar tissue to form, which can pull on the retina and cause the retina to move away from the wall of the eye (retinal detachment).

Retinopathy can also cause swelling of the macula of the eye. This is called macular edema. The macula is the middle of the retina, which lets you see details. When it swells, it can make your vision much worse. It can even cause legal blindness.

See a picture of the eye .

What causes diabetic retinopathy?

High blood sugar causes diabetic retinopathy. If you are not able to keep your blood sugar levels near normal, it can hurt your blood vessels. Diabetic retinopathy happens when high blood sugar damages the tiny blood vessels of the retina.

When you have diabetic retinopathy, high blood pressure can make it worse. High blood pressure can cause more damage to the weakened vessels in your eye, clouding more of your vision.

What are the symptoms?

Most of the time, there are no symptoms of diabetic retinopathy until it starts to change your vision. When this happens, diabetic retinopathy is already severe. Having your eyes checked every year can find diabetic retinopathy early enough to treat it and help prevent vision loss.

If you notice problems with your vision, call an eye doctor (ophthalmologist or optometrist) right away. Changes in vision can be a sign of severe damage to your eye. These changes can include floaters, pain in the eye, blurry vision, or new vision loss.

How is diabetic retinopathy diagnosed?

An eye exam by an eye specialist (ophthalmologist or optometrist) is the only way to diagnose diabetic retinopathy. Having an eye exam every year can help find retinopathy before it changes your vision. If you are at low risk for vision problems, your doctor may consider follow-up exams every 2 years. On your own, you may not notice symptoms until the disease becomes severe.

Can diabetic retinopathy be prevented?

You can lower your chance of damaging small blood vessels in the eye by keeping your blood sugar levels, blood pressure, and cholesterol levels near normal. If you smoke, quit. All of this decreases the risk of damage to the retina. It can also help slow down how quickly your retinopathy gets worse and can prevent future vision loss.

If you have an eye exam every one to two years, you and your doctor can find diabetic retinopathy before it has a chance to get worse. Finding retinopathy early gives you a better chance of avoiding vision loss and blindness.

How is it treated?

You may not need treatment for diabetic retinopathy unless it has affected the middle part of your eye. But you will need to see your eye doctor for regular follow-up exams.

Surgery, laser treatment, or medicine may help slow the vision loss caused by diabetic retinopathy. You may need to be treated more than once as the disease gets worse.

Frequently Asked Questions

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Cause

Diabetes damages small blood vessels throughout the body, leading to reduced blood flow. When these changes affect the tiny blood vessels in the eyes, diabetic retinopathy may develop.

In the early stage of diabetic retinopathy, tiny blood vessels in the eye weaken and develop small bulges that may burst and leak into the retina. Later, new fragile blood vessels grow on the surface of the retina. These blood vessels may break and bleed into the eye, clouding vision and causing scar tissue to form.

The scar tissue may pull on the retina, leading to retinal detachment. Retinal detachment occurs when the two layers of the retina become separated from each other and from the wall of the eye. This can lead to vision loss.

Symptoms

You may have diabetic retinopathy for a long time without noticing any symptoms. Typically, retinopathy does not cause noticeable symptoms until significant damage has occurred and complications have developed.

Symptoms of diabetic retinopathy and its complications may include:

• Blurred or distorted vision or difficulty reading.
• Floaters in your vision.
• Partial or total loss of vision or a shadow or veil across your field of vision.
• Pain in the eye.

What Happens

Diabetic retinopathy begins as a mild disease. During the early stage of the disease, the small blood vessels in the retina become weaker and develop small bulges called microaneurysms. These microaneurysms are the earliest signs of retinopathy and may appear a few years after the onset of diabetes. They may also burst and cause tiny blood spots (hemorrhages) on the retina but they do not usually cause symptoms or affect vision.

As retinopathy progresses, fluid and protein leak from the damaged blood vessels and cause the retina to swell. This may cause mild to severe vision loss, depending on which parts of the retina are affected. If the center of the retina (macula) is affected, vision loss can be severe. Swelling and distortion of the macula (macular edema), which results from a buildup of fluid, is the most common complication of retinopathy.

In some people retinopathy progresses over the course of several years. In these cases, reduced blood flow to the retina stimulates the growth (proliferation) of fragile new blood vessels on the surface of the retina. This is called proliferative diabetic retinopathy. As the new blood vessels multiply, one or more complications may develop and damage the person's vision. These complications can include:

• The formation of scar tissue that pulls on the retina, which may lead to retinal detachment.
• Bleeding inside the eye (preretinal or vitreous hemorrhage).
• The growth of new blood vessels on the surface of the iris (rubeosis iridis), which eventually leads to a form of severe glaucoma called neovascular glaucoma.

Any of these later complications may cause severe, permanent vision loss.

What Increases Your Risk

Your risk of developing diabetic retinopathy depends largely on two factors: how long you have had diabetes and whether or not you have kept good control of your blood sugar.

You can control some risk factors that may increase your risk for diabetic retinopathy and its complications. Risk factors that you can control include:

• Pregnancy. Women who have diabetes are at increased risk of developing retinopathy during pregnancy. In about half of women who already have retinopathy when they become pregnant, the condition becomes worse during pregnancy.¹
• Consistently high blood sugar. Long-term studies show that high blood sugar levels increase your risk of retinopathy. Keeping your blood sugar level near normal can reduce your risk of diabetic retinopathy and can slow the progression of the disease if it has already developed.^{2, 3}
• High blood pressure. In general, people with diabetes who also have high blood pressure are more likely to develop complications that affect the blood vessels in the body, including those in the eyes. The results of long-term studies suggest that retinopathy is more likely to progress to the severe (proliferative) form of the disease and to macular edema in people who have high blood pressure.^{4, 1}
• Delayed diagnosis and treatment. Getting an eye exam every one to two years cannot prevent retinopathy, but it may reduce your risk of severe vision loss from complications of retinopathy. Early treatment can prevent vision loss and delay the progression of the disease.
• High cholesterol. Some studies suggest that having a high cholesterol level increases the risk of retinopathy. But it is not known whether reducing high cholesterol levels affects the progression of retinopathy over time.¹
• Smoking. Although smoking has not been proven to increase the risk of retinopathy, smoking does increase your blood pressure and may make many of the other health problems faced by people with diabetes worse, including disease of the small blood vessels.

If you have type 2 diabetes and use the medicine rosiglitazone (Avandia, Avandamet, Avandaryl) to treat your diabetes, you may have a higher risk for problems with the center of the retina (the macula). The U.S. Food and Drug Administration (FDA) and the makers of the drug have warned that taking this medicine could cause swelling in the macula, which is called macular edema.

When To Call a Doctor

Call your doctor immediately if you have diabetes and notice:

• Floaters in your field of vision. Floaters often appear as dark specks, globs, strings, or dots. A sudden shower of floaters may be a sign of a retinal detachment, which is a serious complication of diabetic retinopathy.
• A new visual defect, shadow, or curtain across part of your vision. This is another sign of retinal detachment.
• Eye pain or a feeling of pressure in your eye.
• New or sudden vision loss. The sudden onset of partial or complete vision loss is a symptom of many disorders that can occur within or outside the eye, including retinal detachment or bleeding within the eye. Sudden vision loss is always a medical emergency.

Watchful Waiting

Watchful waiting is not an option if you have diabetes and notice changes in your vision.

If you have diabetes, even if you do not have any symptoms of eye disease, you still need to have your eyes and vision checked every year by an eye specialist (ophthalmologist or optometrist). If you wait until you have symptoms, it is more likely that complications and severe damage to the retina will have already developed. These may be more difficult to treat and may result in permanent vision loss.

Watchful waiting is not an option if you already have diabetic retinopathy but do not have symptoms or vision loss. You will need to return to your ophthalmologist for frequent evaluations (every few months in some cases) so that your doctor can closely monitor changes in your eyes. There is no cure for the disease, but treatment can slow its progression. Your ophthalmologist can tell you how often you need to be evaluated.

Who To See

People with diabetes need to see a doctor who specializes in eye care for their eye evaluations.

• Ophthalmologist
• Optometrist

If you have diabetic retinopathy and need laser treatment or surgery, you need to consult an ophthalmologist who specializes in treating the retina and has special training in the care of eye disease caused by diabetes.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Diabetic retinopathy can be detected during an exam by an ophthalmologist or optometrist. An exam by your primary doctor, during which your eyes are not dilated, is not an adequate substitute for a full exam done by an ophthalmologist. Eye exams for people with diabetes should include:

• Visual acuity testing. Visual acuity testing measures the eye's ability to focus and to see details at near and far distances. It can help detect vision loss and other problems.
• Ophthalmoscopy and slit lamp exam. These tests allow your doctor to see the back of the eye and other structures within the eye. They may be used to detect clouding of the lens (cataract), changes in the retina, and other problems.
• Gonioscopy. Gonioscopy is used to find out whether the area where fluid drains out of your eye (called the drainage angle) is open or closed. This test is done if your doctor thinks you may have glaucoma, a group of eye diseases that can cause blindness by damaging the optic nerve.
• Tonometry. This test measures the pressure inside the eye, which is called intraocular pressure (IOP). It is used to help detect glaucoma. Diabetes can increase your risk of glaucoma.

Your doctor may also perform a test called fluorescein angiogram to check for and locate leaking blood vessels in the retina, especially if you have symptoms, such as blurred or distorted vision, that suggest damage to or swelling of the retina.

Fundus photography can track changes in the eye over time in people who have diabetic retinopathy and especially in those who have been treated for it. Fundus photography produces accurate pictures of the back of the eye (the fundus). An eye doctor can compare photographs taken at different times to monitor the progression of the disease and evaluate the effectiveness of treatment.

Early Detection

Early detection and treatment of diabetic retinopathy can help prevent vision loss. For people in whom diabetic retinopathy has not been diagnosed, the American Diabetes Association recommends that screening be done based on the following guidelines:⁵

• People with type 1 diabetes who are age 10 and older should have an eye exam within 3 to 5 years after diabetes is diagnosed and then every year. If you are at low risk for vision problems, your doctor may consider follow-up exams every 2 years.
• People with type 2 diabetes should have an exam as soon as diabetes is diagnosed and then every year. If you are at low risk for vision problems, your doctor may consider follow-up exams every 2 years.
• Women with type 1 or type 2 diabetes who become pregnant should have an exam before becoming pregnant, if possible, and then once during the first 3 months (first trimester) of pregnancy. The eye doctor can decide whether you need further screening for retinopathy during pregnancy based on the results of the first-trimester exam.

Note: Pregnant women who develop gestational diabetes are not at risk for diabetic retinopathy and do not need to be screened for it. (But women who develop gestational diabetes during pregnancy have a greater chance of developing type 2 diabetes later in life, which can put them at increased risk for retinopathy and other eye problems.)

People who have diabetes are also at increased risk for other eye diseases, including glaucoma and cataracts. Regular eye exams can help detect these diseases early and prevent or delay vision loss.

Treatment Overview

There is no cure for diabetic retinopathy. However, laser treatment (photocoagulation) is usually very effective at preventing vision loss if it is done before the retina has been severely damaged. Surgical removal of the vitreous gel (vitrectomy) may also help improve vision if the retina has not been severely damaged. Because symptoms may not develop until the disease becomes severe, early detection through regular screening is important. The earlier retinopathy is detected, the easier it is to treat and the more likely vision will be preserved.

You may not need treatment for diabetic retinopathy unless it has affected the center (macula) of the retina or, in rare cases, if your side (peripheral) vision has been severely damaged. But you do need to have your vision checked every year.

If the macula has been damaged by macular edema, you may need laser treatment. For more severe retinopathy, you may need either laser treatment or vitrectomy. These procedures can help prevent, stabilize, or slow vision loss when they are done before the retina has been severely damaged.

Surgical removal of the vitreous gel (vitrectomy) is done only when there is bleeding (vitreous hemorrhage) or retinal detachment, which are rare in people with early-stage retinopathy. Vitrectomy is also done when there is severe scar tissue formation.

Treatment for diabetic retinopathy is often very effective in preventing, delaying, or reducing vision loss, but it is not a cure for the disease. People who have been treated for diabetic retinopathy need to be monitored frequently by an eye doctor to check for new changes in their eyes. Many people with diabetic retinopathy need to be treated more than once as the condition progresses.

Also, controlling your blood sugar levels is always important. This is true even if you have been treated for diabetic retinopathy and your eyes are better. In fact, good blood sugar control is especially important in this case so that you can help keep your retinopathy from getting worse.

Ideally, laser treatment should be done early in the course of the disease to prevent serious vision loss rather than to try to treat serious vision loss after it has already developed.

People with diabetes who have any signs of retinopathy need to be examined as soon as possible by an ophthalmologist.

Prevention

There are steps you can take to reduce your chance of vision loss from diabetic retinopathy and its complications:

• Control your blood sugar levels. Long-term studies show that keeping blood sugar levels as close to normal as possible reduces the risk of the development and progression of retinopathy.^{3, 5} Keep blood sugar levels near normal by eating a healthful diet, frequently monitoring your blood sugar levels, getting regular physical exercise, and taking insulin or medicines for type 2 diabetes if prescribed. One study found that teens who kept their blood sugar levels near normal reduced their risk for developing diabetic retinopathy and also reduced kidney damage during young adulthood.⁶
• Control your blood pressure. Long-term studies suggest that retinopathy is more likely to progress to the severe form and that macular edema is more likely to occur in people who have high blood pressure. It is not clear whether treating high blood pressure can directly affect long-term vision but, in general, keeping blood pressure levels close to normal can reduce the risk of many different complications of diabetes.⁵ For more information about how to control your blood pressure, see the topic High Blood Pressure (Hypertension).
• Have your eyes examined by an eye specialist (ophthalmologist or optometrist) every year. If you are at low risk for vision problems, your doctor may consider follow-up exams every 2 years. Screening for diabetic retinopathy and other eye problems will not prevent diabetic eye disease, but it can help you avoid vision loss by allowing for early detection and treatment.
• See your eye doctor if you have changes in your vision. Changes in vision-such as floaters, pain or pressure in the eye, blurry or double vision, or new vision loss-may be symptoms of serious damage to your retina. In most cases, the sooner the problem can be treated, the more effective the treatment will be.

The risk of developing severe retinopathy and vision loss may be even less if you:

• Reduce high cholesterol. It is not known whether reducing high cholesterol levels directly affects the progression of retinopathy and vision loss, but some studies suggest that high cholesterol may increase the risk of vision loss in people with diabetes.⁷
• Don't smoke. Although smoking has not been proven to increase the risk of retinopathy, smoking does increase your blood pressure and may aggravate many of the other health problems faced by people with diabetes, including disease of the small blood vessels.
• Avoid hazardous activities. Certain physical activities, like weight lifting or some contact sports, may trigger bleeding in the eye through impact or increased pressure. Avoiding these activities when you have diabetic retinopathy can help reduce the risk of damage to your vision.
• Get adequate exercise. Exercise helps keep blood sugar levels near normal, which can reduce the risk of vision damage from diabetic retinopathy.⁸

Home Treatment

You can help prevent or slow the progression of diabetic retinopathy. Even if you have vision loss, it is important for you to be an active participant in your daily diabetes care. The following key points can help you maintain an active and healthy lifestyle.

Keep blood sugar levels near normal

Keeping your blood sugar levels near normal is one of the most effective ways you can prevent diabetic retinopathy or delay it from getting worse. If you control your diet and get adequate exercise, you can help keep your blood sugar levels near normal.⁸

• If you do not have signs of diabetic retinopathy, keeping your blood sugar levels near normal can help lower your risk for developing the condition by 76%.³
• If you already have diabetic retinopathy, keeping your blood sugar levels near normal can lower your risk for progression of the condition by 54% if you have type 1 diabetes and 20% to 25% if you have type 2 diabetes.^{3, 2} For more information on controlling blood sugar levels, see the topics Type 1 Diabetes and Type 2 Diabetes: Living With the Disease.

Have regular eye exams

Your eye specialist can tell you how often you need to return for follow-up eye exams. Follow the schedule he or she recommends. Call for an earlier appointment if you notice any changes in your vision. These changes may be a sign that complications of diabetic retinopathy have developed. Remember, early detection and treatment can help prevent vision loss.

If you have diabetic retinopathy and are planning to become pregnant, have an eye exam sometime during the year before you become pregnant, and then have regular eye exams while you are pregnant.

If you have vision loss

You need to find ways to adapt so that you can use your remaining eyesight to its greatest potential.

• Have an eye evaluation. If your eye specialist has told you that your visual acuity is 20/70 or worse with glasses or contacts, have a complete low-vision evaluation done by a vision specialist. This evaluation will help you use your remaining vision and identify the kinds of vision aids that are most helpful for you.
• Make some changes. You can continue to do most-if not all-of your daily diabetes care and other activities even though your eyesight is not good and may fluctuate from day to day. Some simple tricks, such as using felt-tip markers to label your medicines and diabetic supplies, may be all that you need. If diabetic retinopathy has severely damaged your vision, there are vision aids that can help you with daily tasks. Use the information below to help you find the things that can help you remain independent and in control of your diabetes care.

  Diabetes: Performing daily diabetes tasks when you can't see well

  Vision problems: Living with poor eyesight

Medications

There are no medicines proven to prevent or slow the development of diabetic retinopathy. However, some medicines have been found to be helpful in preventing or delaying complications from diabetes.⁷

Surgery

Surgical removal of the vitreous gel (vitrectomy) is one of only two effective treatments for diabetic retinopathy. Laser treatment is the other. Vitrectomy does not cure the disease, but it may improve vision in people who have developed bleeding into the vitreous gel (vitreous hemorrhage), retinal detachment, or severe scar tissue formation.

Without either surgery or laser treatment, vision loss caused by diabetic retinopathy and its complications may progress until blindness occurs. Early treatment is therefore vital to slowing vision loss, which can happen quickly otherwise.

Unfortunately, by the time some people are diagnosed with retinopathy (especially late-stage retinopathy), it is often too late for vitrectomy or laser treatment to provide much benefit. Even with treatment, vision will continue to decline.

Early detection of retinopathy through yearly eye exams can help you decide to have surgery when it is most effective.

Surgery Choices

Vitrectomy is the surgical removal of the vitreous gel.

For more information about laser treatment (photocoagulation), see the Other Treatment section of this topic.

What To Think About

Vitreous surgery (vitrectomy) for diabetic retinopathy is effective in preventing vision loss when a person has bleeding into the vitreous gel (vitreous hemorrhage) or retinal detachment, but it is not a cure.⁷ This surgery is not usually done unless these complications or severe scar tissue has already developed.

After a person has had most of the vitreous gel removed by vitrectomy, surgery to remove scar tissue or to repair a new retinal detachment may be needed.

Vitrectomy is a more complicated procedure than laser treatment. It requires general anesthesia and, in some cases, an overnight hospital stay. Laser treatment is almost always an outpatient procedure.

Other Treatment

Laser treatment (photocoagulation) can be an effective treatment for diabetic retinopathy, but it does not cure the disease. It can prevent, delay, and sometimes reverse vision loss. Without either laser treatment or surgery, vision loss caused by diabetic retinopathy and its complications may progress until blindness occurs. Early treatment is therefore vital to slowing vision loss, which can otherwise happen quickly.

When diabetic retinopathy causes bleeding (hemorrhage) into the vitreous gel, extensive scar tissue formation, or retinal detachment, surgical removal of the vitreous gel (vitrectomy) may be needed before laser treatment is considered.

Unfortunately, by the time some people are diagnosed with diabetic retinopathy, it is often too late for treatment to provide much benefit. Even with treatment, vision will continue to decline.

Early detection of retinopathy through yearly eye exams can provide the opportunity to have laser treatment when it is most effective.

Other Treatment Choices

Laser photocoagulation uses the heat from a laser to seal or destroy abnormal, leaking blood vessels in the retina.

What To Think About

Laser treatment (photocoagulation) can prevent or delay the progression of diabetic retinopathy, but it is not a cure.⁷

• Laser treatment for macular edema lowers the risk of moderate vision loss by 20% in people who have mild to moderate diabetic retinopathy.⁷
• Pan-retinal laser treatment is used to treat several spots on the retina during one or, most often, two sessions. It reduces the risk of serious bleeding and the progression of severe proliferative retinopathy. It also decreases the need for more invasive surgery (vitrectomy) by 50% in people with type 2 diabetes and people age 40 and older with type 1 diabetes who already have severe retinopathy.⁷

Laser photocoagulation can result in some loss of vision, because it destroys some of the nerve cells in the retina. With pan-retinal photocoagulation, this most often affects the outside (peripheral) vision, because the laser is directed at that area. Your vision may be worse right after treatment. But vision loss caused by laser treatment is mild compared with the vision loss that may be caused by untreated retinopathy.

Other Places To Get Help

Organizations

Related Information

• Diabetic Nephropathy
• Diabetic Neuropathy
• Retinal Detachment
• Type 1 Diabetes
• Type 1 Diabetes: Living With Complications
• Type 1 Diabetes: Living With the Disease
• Type 1 Diabetes: Recently Diagnosed
• Type 2 Diabetes
• Type 2 Diabetes: Living With Complications
• Type 2 Diabetes: Living With the Disease
• Type 2 Diabetes: Recently Diagnosed

References

Citations

1. Neely KA, et al. (1998). Diabetic retinopathy. Medical Clinics of North America, 82(4): 847-876.

2. Kohner EM, et al. (1998). United Kingdom prospective diabetes study. Archives of Ophthalmology, 116(3): 297-303.

3. The Diabetes Control and Complications Trial Research Group (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine, 329(14): 977-986.

4. Klein R, et al. (1998). The Wisconsin epidemiology study of diabetic retinopathy: XVII. The 14-year incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. Ophthalmology, 105(10): 1801-1815.

5. Fong D, et al. (2004). Retinopathy in diabetes. Diabetes Care, 27(Suppl 1): S84-S87.

6. Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group (2001). Beneficial effects of intensive therapy of diabetes during adolescence: Outcomes after the conclusion of the Diabetes Control and Complications Trial (DCCT). Journal of Pediatrics, 139(6): 804-812.

7. Begg IS, et al. (2001). Eye disease. In HC Gerstein, RB Haynes, eds., Evidence-Based Diabetes Care, pp. 396-428. Hamilton, ON: BC Decker.

8. Colucciello M (2004). Diabetic retinopathy: Control of systemic factors preserves vision. Postgraduate Medicine, 116(1): 57-64.

Other Works Consulted

• Aiello LM, et al. (2005). Ocular complications of diabetes mellitus. In Joslin's Diabetes Mellitus, 14th ed., pp. 901-924. Philadelphia: Lippincott Williams and Wilkins.

• Diabetes Control and Complications Trial Research Group (1998). Early worsening of diabetic retinopathy in the Diabetes Control and Complications Trial. Archives of Ophthalmology, 116(7): 874-886.

• Frank RN (2004). Medical progress: Diabetic retinopathy. New England Journal of Medicine, 350(1): 48-58.

• Grant MB, et al. (2000). The efficacy of octreotide in the therapy of severe nonproliferative and early proliferative diabetic retinopathy. Diabetes Care, 23(4): 504-509.

• Group Health Cooperative (2002). Diabetic retinal screening. Guidelines for Patients With Diabetes, pp. 45-53. Seattle: Group Health Cooperative.

• Harding S (2005). Diabetic retinopathy, search date November 2004. Online version of Clinical Evidence (14): 1-8.

• Holl RW, et al. (1998). Diabetic retinopathy in pediatric patients with type 1 diabetes: Effect of diabetes duration, prepubertal and pubertal onset of diabetes, and metabolic control. Journal of Pediatrics, 132(5): 790-794.

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