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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
| {{Infobox_Disease
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| | Name = Diabetic retinopathy
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| | Image =
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| | Caption =
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| | DiseasesDB = 29372
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| | ICD10 = {{ICD10|H|36||h|30}} ({{ICD10|E|10|3|e|10}} {{ICD10|E|11|3|e|10}} {{ICD10|E|12|3|e|10}} {{ICD10|E|13|3|e|10}} {{ICD10|E|14|3|e|10}})
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| | ICD9 = {{ICD9|250.5}}
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| | ICDO =
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| | OMIM =
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| | MedlinePlus =
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| | MedlinePlus_mult=
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| | MeshID =
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| }}
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| {{Diabetic retinopathy}} | | {{Diabetic retinopathy}} |
| {{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{CZ}}; [[Afsaneh Morteza|Afsaneh Morteza, MD-MPH]] [mailto:afsaneh.morteza@gmail.com] | | {{CMG}}; {{AE}} {{RBS}} [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{CZ}}; [[Afsaneh Morteza|Afsaneh Morteza, MD-MPH]] [mailto:afsaneh.morteza@gmail.com] |
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| == [[Diabetic Retinopathy Overview| Overview]] ==
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| == [[ Diabetic Retinopathy Historical Perspective| Historical Perspective]] ==
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| == [[Diabetic Retinopathy paPathophysiology ==
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| The [[retina]] is a multicellular photon sensor, a unique component of the central nervous system, which is structured on the vessels.
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| Promoted by the observations that there is a selective loss of [[pericytes]] early in diabetic retinopathy, many researchers were attracted to these cells as the origin of the disease.<ref>Understanding diabetic retinopathy by Pardianto G et al., in Mimbar Ilmiah Oftalmologi Indonesia.2005;2: 65-6.</ref>. Pericytes are enigmatic cells, which are regular components of all human [[tissues]] and [[organs]]. In contrast to [[arteries]] and [[arterioles]] where the coverage consists of the smooth muscle cells, the capillary system is individually covered by the pericytes. Pericytes are codependent on the endothelial cells. Normal pericytes have a contractile function that helps to regulate capillary blood flow. The loss of pericytes, due to [[diabetic inflammation]], is followed by the loss of capillary [[endothelial]] cells. [[Apoptosis]] of the pericytes, leads to the disappearance of both types of cells. Since neurons in the retina have high metabolic requirements, the hypoxia that results from extensive retinal capillary cell death is a probable stimulus for the increased expression of molecules that enhance the breakdown of the [[blood–retinal barrier]] and lead to vascular proliferation or [[angiogenesis]]. <ref name="pmid14702427">{{cite journal| author=Frank RN| title=Diabetic retinopathy. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 1 | pages= 48-58 | pmid=14702427 | doi=10.1056/NEJMra021678 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14702427 }} </ref>
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| Angiogenesis is a complex process, characterized by a cascade of events:
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| 1: Initial [[vasodilatation]] of existing vessels
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| 2: Increased vascular permeability and degradation of the surrounding matrix,
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| 3: [[Migration]] and tube forming of the activated and proliferating [[endothelial cells]]
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| 4: Maturation and remodeling of these new vessels takes place to form a vascular network.
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| These new blood vessels are abnormal and fragile. They grow along the retina and along the surface of the [[vitreous]]. By themselves, these blood vessels do not cause symptoms or vision loss. However, they have thin, fragile walls, and they ultimately leak blood. Retinal damage can result from persistent [[vitreous haemorrhage]]. On the other hand, contraction of associated fibrous tissue formed by proliferative disease tissue can result in deformation of the retina and tractional retinal detachment. The detachment may tear the retina [[(rhegmatogenous) ]]or may not [[(non-rhegmatogenous)]]. The non-rhegmatogenous retinal detachment is worse and is characterized by the
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| 1: Confined retina
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| 2: A taut and shiny appearance
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| 3: Concave retina toward the pupil
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| 4: Disappearance of the sub retinal fluid shifting
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| The cascade of these events causes vision loss.<ref name="pmid12597922">{{cite journal| author=Witmer AN, Vrensen GF, Van Noorden CJ, Schlingemann RO| title=Vascular endothelial growth factors and angiogenesis in eye disease. | journal=Prog Retin Eye Res | year= 2003 | volume= 22 | issue= 1 | pages= 1-29 | pmid=12597922 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12597922 }} </ref>
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| Recent studies which are focused on the neural component of the retina, have shown that [[diabetic neuropathy]] of the neuroglial cells may play an important role in the pathophysiology of disease.<ref name="pmid22143324">{{cite journal| author=Berner AK, Brouwers O, Pringle R, Klaassen I, Colhoun L, McVicar C et al.| title=Protection against methylglyoxal-derived AGEs by regulation of glyoxalase 1 prevents retinal neuroglial and vasodegenerative pathology. | journal=Diabetologia | year= 2012 | volume= 55 | issue= 3 | pages= 845-54 | pmid=22143324 | doi=10.1007/s00125-011-2393-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22143324 }} </ref>
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| == Classification==
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| The disease is classified according to types of lesions detected on fundoscopy into non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR). Diabetic retinopathy affect both eyes in parallel.
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| NPDR is subdivided into mild and moderate-to-severe forms.
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| ===Mild NPDR===
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| # [[Microaneurysms]]
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| # Dot and blot hemorrhages
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| # Hard (intra-retinal) exudate
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| ===Moderate-to-severe NPDR===
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| Is mild NPDR plus:
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| # [[Cotton-wool]] spots
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| # [[Venous beading]] and loops
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| # Intraretinal microvascular abnormalities ( IRMA )
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| ===PDR===
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| # Neovascularization of the retina, [[optic disc]] or [[iris]]
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| # [[Fibrous tissue]] adherent to vitreous face of retina
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| # [[Retinal detachment]]
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| # [[Vitreous hemorrhage]]
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| # Pre-retinal hemorrhage
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| Some people develop a condition called [[macular edema]]. It occurs when the damaged [[blood vessels]] leak fluid and [[lipid]]s onto the [[macula]]. The fluid makes the [[macula]] swell, which blurs vision.
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| == Epidemiology and Demographics ==
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| The prevalence of retinopathy is strongly related to the duration of diabetes. Between 40 to 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy. <ref name=NIHSenior>{{cite web | title =NIHSeniorHealth: Diabetic Retinopathy - Causes and Risk Factors | publisher=NIHSenior Health | work =Diabetic Retinopathy | url=http://nihseniorhealth.gov/diabeticretinopathy/causesandriskfactors/02.html | year = 2005 }}</ref> After 20 years of diabetes, nearly all patients with type 1 diabetes and >60% of patients with type 2 diabetes have some degree of retinopathy. In the Wisconsin Epidemiologic Study of Diabetic Retinopathy, 3.6% of patients with type 1 diabetes and 1.6% of type 2 diabetes were legally blind. In the type 1 diabetes, 86% of blindness was attributable to diabetic retinopathy. The cumulative incidence of any retinopathy in type 1 diabetes was 97%. In the type 2 diabetic patients, where other eye diseases were common, one-third of the cases of legal blindness were due to diabetic retinopathy. <ref name="pmid18025409">{{cite journal| author=Hirai FE, Moss SE, Klein BE, Klein R| title=Relationship of glycemic control, exogenous insulin, and C-peptide levels to ischemic heart disease mortality over a 16-year period in people with older-onset diabetes: the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR). | journal=Diabetes Care | year= 2008 | volume= 31 | issue= 3 | pages= 493-7 | pmid=18025409 | doi=10.2337/dc07-1161 | pmc=PMC2773445 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18025409 }} </ref>
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| === Genetics ===
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| There are evidence that not every diabetic patients has the same risk of diabetic retinopathy. Studies have shown that polymorphisms of [[Tumor Necrosis Factor Alpha]] play an important role in the risk of patients with diabetic retinopathy.<ref name="pmid22105495">{{cite journal| author=Paine SK, Sen A, Choudhuri S, Mondal LK, Chowdhury IH, Basu A et al.| title=Association of tumor necrosis factor α, interleukin 6, and interleukin 10 promoter polymorphism with proliferative diabetic retinopathy in type 2 diabetic subjects. | journal=Retina | year= 2012 | volume= 32 | issue= 6 | pages= 1197-203 | pmid=22105495 | doi=10.1097/IAE.0b013e31822f55f3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22105495 }} </ref>
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| ==Risk Factors==
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| All patients with diabetes mellitus are at risk of developing diabetic retinopathy. This includes those with [[Type I diabetes]] and those with [[Type II diabetes]]. During [[pregnancy]], diabetic retinopathy may also be a problem for women with diabetes. It is recommended that all pregnant women with diabetes have dilated [[eye examination]]s each [[trimester]] to protect their vision.
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| ==Screening==
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| All patients with [[type 2 diabetes]] should be visited by an [[ophthalmologist]] prior to diabetes diagnosis.
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| ==History and Symptoms==
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| * When the disease first starts, there are no symptoms.
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| * [[Blurred vision]] and slow vision loss over time
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| * Eye floaters and spots
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| * Shadows or missing areas of vision
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| * Trouble seeing at night
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| * Fluctuating vision
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| * Blurry and/or distorted vision
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| * [[Double vision]]
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| * Other symptoms are related to diabetic ocular disease
| | ==[[Diabetic retinopathy overview|Overview]]== |
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| After the [[hemorrhage]] due to PDR, most of the symptoms occurs. The first time, it may not be very severe.
| | ==[[Diabetic retinopathy historical perspective|Historical Perspective]]== |
| In most cases, it will leave just a few specks of [[blood]], or spots, floating in a person's visual field, though the spots often go away after a few hours.These spots are often followed within a few days or weeks by a much greater leakage of blood, which blurs vision. In extreme cases, a person will only be able to recognize the light.
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| <gallery>
| | ==[[Diabetic retinopathy classification|Classification]]== |
| Image:Human eyesight two children and ball normal vision.jpg|Normal vision. Courtesy [[National Institutes of Health|NIH]] [[National Eye Institute]]
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| Image:Human eyesight two children and ball with diabetic retinopathy.jpg|The same view with diabetic retinopathy.
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| </gallery>
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| == Physical Examination == | | ==[[Diabetic retinopathy pathophysiology|Pathophysiology]]== |
| * History taking is the first step.
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| * Blood pressure measurement,
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| * [[BMI]] calculation
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| * Monitoring fasting [[blood sugar]]
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| * Measuring HbA1c,
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| * The history of any visual symptoms and changes in the vision
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| * Visual acuity test
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| * Fundoscopic examination using ophthalmoscopy or slit lamp bio-microscopy
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| The personnel performing the examination require considerable training accreditation.
| | ==[[Differentiating Diabetic retinopathy from other diseases|Differentiating Diabetic retinopathy from other Diseases]]== |
| On [[fundoscope|fundoscopic]] the physician is looking for [[cotton wool spots]], [[flame hemorrhages]], [[dot-blot hemorrhages]] and [[boat hemorrhages]].
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| ===Cotton Wool Spots=== | | ==[[Diabetic retinopathy epidemiology and demographics|Epidemiology and Demographics]]== |
| [[Image:Proliferative retinopathy.JPG|thumb|left|An ophthalmoscopic view of the retina showing advanced signs of diabetic retinopathy including two pale cotton wool spots.]] | |
| [[Cotton wool spots]] are an abnormal finding on [[fundoscope|fundoscopic]] exam of the [[retina]]. They appear as puffy white patches on the [[retina]]. They are caused by damage to nerve fibers. The nerve fibers are damaged by swelling in the surface layer of the retina. The cause of this swelling is due to the reduced [[axonal]] transport (and hence backlog of intracellular products) within the nerves because of the ischemia.{{clr}}
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| ===Flame Hemorrhages===
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| [[Image:Flame-hemorrhage.jpg|thumb|left|A dark red flame hemorrhage in the retina of a diabetic is shown at the arrow: Credit: University of Michigan Kellogg Eye Center]] [[Flame hemorrhages]] are flame shaped hemorrhages located in the superficial nerve fiber layer of the retina that appear dark dark red on fundoscopic examination. Flame hemorrhages are caused by leakage from arterioles due to ischemic damage or from veins that are ischemic or in under high pressure.{{clr}}
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| ===Dot Hemorrhages=== | | ==[[Diabetic retinopathy risk factors|Risk Factors]]== |
| [[image:Dot-hemorrhage.jpg|thumb|left|White arrow points to a dot hemorrhage in a dibetic patient. Credit: University of Michigan Kellogg Eye Center]] | |
| [[Dot hemorrhages]] are dark red round spots of hemorrhage seen on fundoscopic exam. They are frequently observed in patients with diabetic retinopathy. Dot hemorrhages are due to either capillary or venular leak. The site of hemorrhage is deep within the retina. {{clr}}
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| ===Boat Hemorrhages===
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| [[Image:Boat-hemorrhage.jpg|left|thumb|White arrow points to a boat hemorrhage in a dibetic patient. Credit: University of Michigan Kellogg Eye Center]]
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| [[Boat hemorrhages]] are rectangular dark red spots of hemorrhage seen on fundoscopic exam. They are frequently observed in patients with diabetic retinopathy. Boat hemorrhages are due to either [[capillary]] or venular leak. The site of hemorrhage is at the interface between the [[retina]] and the [[vitreous humor]]. The contents that leak out are under such high-pressure that they break through the internal membrane of the [[retina]].
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| | ==[[Diabetic retinopathy screening|Screening]]== |
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| | ==[[Diabetic retinopathy natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| | ==Diagnosis== |
| | [[Diabetic retinopathy history and symptoms|History and Symptoms]] | [[Diabetic retinopathy physical examination|Physical Examination]] | [[Diabetic retinopathy laboratory findings|Laboratory Findings]] | [[Diabetic retinopathy electrocardiogram|Electrocardiogram]] | [[Hashiomoto's thyroiditis chest x ray|Chest X Ray]] | [[Diabetic retinopathy CT|CT]] | [[Diabetic retinopathy MRI|MRI]] | [[Diabetic retinopathy echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Diabetic retinopathy other imaging findings|Other Imaging Findings]] | [[Diabetic retinopathy other diagnostic studies|Other Diagnostic Studies]] |
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| ==Treatment== | | ==Treatment== |
| People with advanced retinopathy have a 90 percent chance to retain their vision when they get treatment before the retina is severely damaged. Besides of the tight diabetic management, there are three major treatments for diabetic retinopathy.
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| * [[Laser surgery]]
| | [[Diabetic retinopathy medical therapy|Medical Therapy]] | [[Diabetic retinopathy surgery|Surgery]] | [[Diabetic retinopathy primary prevention|Primary Prevention]] | [[Diabetic retinopathy secondary prevention|Secondary Prevention]] | [[Diabetic retinopathy cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Diabetic retinopathy future or investigational therapies|Future or Investigational Therapies]] |
| * [[Triamcinolone]] injection to the eye
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| * [[vitrectomy]]
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| Caution should be exercised in treatment with laser surgery since it causes a loss of retinal tissue. It is often more prudent to inject triamcinolone. In some patients it results in a marked increase of vision, especially if there is an edema of the macula.
| | ==Case Studies== |
| Avoiding tobacco use and correction of associated [[hypertension]] are important therapeutic measures in the management of diabetic retinopathy. <ref name=AMN>{{cite web | Umesh Masharani, MB, BS, MRCP | title =Diabetes Ocular complications | publisher=Armenian Medical Network | work =Chronic Complications of Diabetes | url=http://www.health.am/db/diabetes-ocular-complications/ | year = 2006 }}</ref>
| | [[Diabetic retinopathy case study one|Case #1]] |
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| === Laser surgery ===
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| A type of laser surgery called ''panretinal photocoagulation'', or PRP, is used to treat severe [[macular edema]] and PDR. The goal is to create 1 000 - 2 000 burns in the retina to reduce retina's oxygen demand, and hence the possibility of ischemia. In treating advanced diabetic retinopathy, the burns are used to destroy the abnormal blood vessels that form at the back of the eye.
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| Rather than focus the light on a single spot, the eye care professional may make hundreds of small laser burns away from the center of the retina, a procedure called ''scatter laser treatment'' or ''panretinal photocoagulation''.The treatment shrinks the abnormal blood vessels.
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| Patients may lose some of their peripheral vision after this surgery, but the procedure saves the rest of the patient's sight.
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| Laser surgery may also slightly reduce color and night vision.
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| === Vitrectomy ===
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| A [[vitrectomy]] is performed when there is a lot of blood in the [[vitreous humour|vitreous]].
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| It involves removing the cloudy vitreous and replacing it with a saline solution made up of [[salt]] and [[water]].
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| Because the vitreous is mostly water, there should be no change between the saline solution and the normal vitreous. Studies show that people who have a vitrectomy soon after a large hemorrhage are more likely to protect their vision than someone who waits to have the operation.
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| ==References==
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| {{reflist|2}}
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| {{WikiDoc Help Menu}}
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| {{WikiDoc Sources}}
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| [[Category:Disease]]
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| ==Related chapters== | | ==Related chapters== |
| *[[List of terms associated with diabetes]] | | *[[List of terms associated with diabetes]] |
| ==External links== | | *[[Diabetic neuropathy]] |
| | *[[Diabetes]] |
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| | ==External Links== |
| *[http://www.nei.nih.gov/health/diabetic/retinopathy.asp Diabetic Retinopathy] Resource Guide from the National Eye Institute (NEI). | | *[http://www.nei.nih.gov/health/diabetic/retinopathy.asp Diabetic Retinopathy] Resource Guide from the National Eye Institute (NEI). |
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| [[Category:Ophthalmology]] | | [[Category:Ophthalmology]] |
| [[Category:Diabetes]] | | [[Category:Pediatrics]] |
| [[Category:Blindness]]
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| [[Category:Endocrinology]] | | [[Category:Endocrinology]] |
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