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Diabetic eye disease

Specialties > Ophthalmology

Background knowledge 🧠

Definition

  • Diabetic eye disease encompasses a group of eye conditions in patients with diabetes.
  • It primarily includes diabetic retinopathy, diabetic maculopathy, and diabetic cataract.
  • Diabetic retinopathy is the most common cause of blindness among working-age adults in the UK.

Epidemiology

  • Affects approximately 40% of diabetic patients.
  • Higher prevalence in patients with longer duration of diabetes and poor glycaemic control.
  • Type 1 diabetes patients often develop retinopathy 10-15 years after onset; earlier in type 2 diabetes.
  • Risk is higher in certain ethnic groups, such as South Asians and Afro-Caribbeans.

Aetiology and Pathophysiology

  • Chronic hyperglycaemia leads to damage of retinal microvasculature.
  • Results in microaneurysms, capillary leakage, and ischaemia.
  • VEGF (Vascular Endothelial Growth Factor) is upregulated, promoting neovascularisation.
  • Maculopathy occurs due to macular oedema and exudates.

Types

  • Background diabetic retinopathy: Microaneurysms, dot-and-blot haemorrhages, hard exudates.
  • Pre-proliferative diabetic retinopathy: Venous beading, intraretinal microvascular abnormalities (IRMA).
  • Proliferative diabetic retinopathy: Neovascularisation on the disc (NVD) or elsewhere (NVE).
  • Diabetic maculopathy: Involves macular oedema, may be focal or diffuse.

Clinical Features 🌡️

Symptoms

  • Often asymptomatic in early stages.
  • Blurring of vision, especially in maculopathy.
  • Floaters may be seen in proliferative retinopathy.
  • Sudden loss of vision in cases of vitreous haemorrhage or retinal detachment.

Signs

  • Microaneurysms, retinal haemorrhages, and hard exudates seen on fundoscopy.
  • Neovascularisation, either on the disc or elsewhere.
  • Macular oedema may cause distortion of the foveal reflex.
  • Advanced cases may show preretinal or vitreous haemorrhage.
  • Cotton wool spots in pre-proliferative retinopathy.

Investigations 🧪

Tests

  • Fundoscopy: Mainstay for diagnosis, done with dilated pupils.
  • Optical Coherence Tomography (OCT): For assessing macular oedema.
  • Fluorescein Angiography: Used in certain cases to identify areas of retinal ischaemia and neovascularisation.
  • Visual Acuity Testing: Monitors disease progression.

Management 🥼

Management

  • Good glycaemic control: Essential to slow progression.
  • Laser photocoagulation: Main treatment for proliferative diabetic retinopathy.
  • Anti-VEGF therapy: Used in diabetic macular oedema.
  • Vitrectomy: Considered in cases of vitreous haemorrhage or tractional retinal detachment.
  • Control of hypertension and lipid levels.

Complications

  • Vitreous haemorrhage: May cause sudden loss of vision.
  • Tractional retinal detachment: Can lead to permanent vision loss.
  • Neovascular glaucoma: Caused by neovascularisation of the iris.
  • Cataracts: Diabetic patients have an increased risk.

Prognosis

  • Depends on stage at diagnosis and promptness of treatment.
  • Early detection and treatment significantly improve outcomes.
  • Poor control of diabetes leads to a worse prognosis.
  • Visual loss can often be prevented but not always reversed.

Key Points

  • Regular screening is crucial for early detection of diabetic eye disease.
  • Good glycaemic control is the most important preventive measure.
  • Laser therapy and anti-VEGF are the mainstays of treatment.
  • Timely intervention can prevent blindness in many cases.

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Ophthalmology