See answer below
With the exception of arterio-venous nicking (AVN) which is the result of hypertension, the following lesions are usually seen in more advanced cases of diabetes related retinopathy. DRR is referred to as a proliferative retinopathy (PR) when neovascularization is present. The lesions listed below are more commonly associated with PR and may cause permanent vision loss. Some of the lesions that may occur with diabetes related retinopathy (DRR) are defined1-4 and identified on the following images below.
Definition of Retinal Lesions: Part II
Diabetes can cause structural changes referred to as lesions to the retina of the eye. Under continuing conditions of hyperglycemia these lesions may cause permanent vision loss. Some of the different lesions that may occur with diabetes related retinopathy (DRR) are defined1-3 and identified on the following images below.
Definition of Retinal Lesions
1. Taylor R, Batey D. Handbook of retinal screening in diabetes: Diagnosis & management. 2 edition ed: Wiley-Blackwell; 2012.
2. Cassin B, Rubin ML. Dictionary of eye terminology 6th edition. Triad Publishing Company; 2011.
3. Group ETDRSR. Grading diabetic retinopathy from stereoscopic color fundus photographs--an extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991;98(5 Suppl):786-806.
Use of a red-free filter makes blood appear darker and allows for more accurate evaluation of DRR lesions (below).
Can you identify the various lesions? Click to see the various lesions labeled.
Successful self-management of diabetes and reducing vision loss from diabetes related retinopathy (DRR) requires behavior change by the person with diabetes that incorporates new strategies for optimal self-care to sustain optimal quality of live and reduce potential loss of vision. It also requires planning coordination and collaboration on the diabetes care provider.
The person with diabetes may need assistance maneuvering the potential minefield of barriers to their individual self-care. For example, insurance coverage, limited ability to pay, transportation, accessibility, language, education about importance of screening, fear of diabetes or vision loss and depression may only a few of the factors to be discussed and addressed first before screening can take place1-8. By using a patient first orientation the diabetes care provider can cultivate patient trust educate about DRR and reduce perceived barriers to DRR screening1,6,8-11. Having a coordinated and collaborative screening protocol in place in addition to intelligent use of technology strengthens the vision screening process8,12-14. For example, studies have shown that the convenience of conducting vision screening with diabetes education at a primary care level has been associated with better self-care6,15,16. Advancements in digital retinal imaging (DRI) have made DRR screening potentially more cost efficient, convenient (e.g., accessible, performed without pupil dilation and ease of imaging by staff)17,18 and provides a permanent digital record to review and evaluate progression. Alternative DRR screening strategies have been employed utilizing primary care practitioners19,20 and specially trained health care personnel21-23. The type of DRR screening program can be uniquely tailored to the human, financial and professional resources available to the community.
Image adapted and modified from from: https://www.linkedin.com/pulse/deep-learning-diabetic-retinopathy-detection-alexander-rakhlin
1. Lu Y, Serpas L, Genter P, et al. Divergent Perceptions of Barriers to Diabetic Retinopathy Screening Among Patients and Care Providers, Los Angeles, California, 2014–2015. Preventing chronic disease. 2016;13:E140.
2. Parikh PB, Yang J, Leigh S, et al. The impact of financial barriers on access to care, quality of care and vascular morbidity among patients with diabetes and coronary heart disease. J Gen Intern Med. 2014;29(1):76-81.
3. Baumeister SE, Schomerus G, Andersen RM, et al. Trends of barriers to eye care among adults with diagnosed diabetes in Germany, 1997-2012. Nutrition, metabolism, and cardiovascular diseases : NMCD. 2015.
4. Dervan E, Lillis D, Flynn L, et al. Factors that influence the patient uptake of diabetic retinopathy screening. Irish Journal of Medical Science. 2008;177(4):303-308.
5. Chou CF, Sherrod CE, Zhang X, et al. Barriers to eye care among people aged 40 years and older with diagnosed diabetes, 2006-2010. Diabetes Care. 2014;37(1):180-188.
6. Lindenmeyer A, Sturt JA, Hipwell A, et al. Influence of primary care practices on patients’ uptake of diabetic retinopathy screening: A qualitative case study. British Medical Journal. 2014;64(625):e484-e492.
7. Keenum Z, McGwin G, Jr, et al. PAtients’ adherence to recommended follow-up eye care after diabetic retinopathy screening in a publicly funded county clinic and factors associated with follow-up eye care use. JAMA ophthalmology. 2016.
8. Kwan BM, Jortberg B, Warman MK, et al. Stakeholder engagement in diabetes self-management: patient preference for peer support and other insights. Family Practice. 2017;34(3):358-363.
9. Polonsky WH, Fisher L, Guzman S, et al. Are patients' initial experiences at the diagnosis of type 2 diabetes associated with attitudes and self-management over time? Diabetes Educator. 2010;36(5):828-834.
10. Ting DSW, Tay-Kearney ML, Vignarajan J, et al. Diabetic retinopathy screening: Can the viewing monitor influence the reading and grading outcomes. Eye. 2012;26(12):1511-1516.
11. Horigan G, Davies M, Findlay-White F, et al. Reasons why patients referred to diabetes education programmes choose not to attend: a systematic review. Diabetic medicine : a journal of the British Diabetic Association. 2016.
12. McDonald J, Jayasuriya R, Harris MF. The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus. BMC health services research. 2012;12(1):63-63.
13. Franklin VL, Greene A, Waller A, et al. Patients' engagement with "Sweet Talk" - a text messaging support system for young people with diabetes. Journal of medical Internet research. 2008;10(2):e20.
14. Skaggs JB, Zhang X, Olson DJ, et al. Screening for Diabetic Retinopathy: Strategies for Improving Patient Follow-up. North Carolina medical journal. 2017;78(2):121-123.
15. Rees G, Lamoureux EL, Nicolaou TE, et al. Feedback of personal retinal images appears to have a motivational impact in people with non-proliferative diabetic retinopathy and suboptimal HbA1c: Findings of a pilot study. Diabetic Medicine. 2013;30(9):1122-1125.
16. Wagner H, Pizzimenti JJ, Daniel K, et al. Eye on diabetes: A multidisciplinary patient education intervention. The Diabetes Educator. 2008;34(1):84-89.
17. Bragge P, Gruen RL, Chau M, et al. Screening for presence or absence of diabetic retinopathy: A meta-analysis. Archives of Ophthalmology. 2011;129(4):435-444.
18. Cuadros J. Telemedicine-based diabetic retinopathy screening programs: an evaluation of utility and cost-effectiveness. Smart Homecare Technology and TeleHealth. 2015;3(2015):119-127.
19. Romero P, Sagarra R, Ferrer J, et al. The incorporation of family physicians in the assessment of diabetic retinopathy by non-mydriatic fundus camera. Diabetes research and clinical practice. 2010;88(2):184-188.
20. Farley TF, Mandava N, Prall FR, et al. Accuracy of primary care clinicians in screening for diabetic retinopathy using single-image retinal photography. Annals of Family Medicine. 2008;6(5):428-434.
21. Schuett F, Bruckner T, Schaefer K, et al. Fundus screening by medical technicians. Ophthalmologe. 2013;110(2):154-159.
22. Cavallerano JD, Silva PS, Tolson AM, et al. Imager evaluation of diabetic retinopathy at the time of imaging in a telemedicine program. Diabetes Care. 2012;35(3):482-484.
23. Papavasileiou E, Dereklis D, Oikonomidis P, et al. An effective programme to systematic diabetic retinopathy screening in order to reduce diabetic retinopathy blindness. Hellenic journal of nuclear medicine. 2014;17 (S1):30-34.
Reducing Vision Loss from Diabetes Related Retinopathy: Defining the Challenge Diabetes related retinopathy (DRR) is the leading cause of blindness among working age adults between 20-74 years in the United States and one of the four leading causes of blindness and low vision (e.g., the other three are age related macular degeneration, cataracts and glaucoma)1. The annual financial cost in the US as a result of DRR and related blindness is calculated to be $500 million2. Individually (per capita) direct and indirect health costs, and work sick days added an annual cost due to DRR of between $6.5 - $8.3 thousand and 3.77-4.87 more sick days than with diabetes without DRR3. If CDC forecasts prove accurate, the US population over 40 years of age with any DRR will number 16 million people, including 3.4 million people with sight threatening DRR, by 20504.
One possible solution is routine DRR screening/examinations. The American Diabetes Association Standards of Care for 2018 recommend an initial comprehensive eye exam after diagnosis and within five years of onset for type 2 and type 1 respectively. After an unspecified number of annual eye exams the time between exams may vary (e.g., shorter intervals if DRR is present or longer intervals if DRR is absent)5. According to the American Academy of Ophthalmology this routine care combined with timely intervention and treatment will reduce severe vision loss from DRR by up to 90%6. In England and Wales, which have universal health care and offer routine DRR screening, DRR “is no longer the leading cause of certifiable blindness for working age adults”7. Like England and Wales, Iceland reduced blindness form DRR from 2.4% to .5% after institution of a public screening program8.
In the United States where health care (organized DRR screening) availability and access is a contentious political item only 50-60% of persons with diabetes are seen for routine retinopathy screening9. In addition to socio-economic conditions other factors such as: a) no perceived need, b) cost/lack of insurance, c) lack of transportation, d) lack of eye care providers or appointment times, e) depression, f) insulin use, and g) lack of diabetes education have been identified10-13. For these 40-50% of individuals with diabetes not routinely evaluated, proper screening at an early stage and timely triage may reduce vision loss14. Writing from the United Kingdom, Scanlon et al. estimate, “one missed attendance at a retinal screening appointment is associated with a threefold increase in needing laser photocoagulation subsequently”15. [Next week - Reducing Vision Loss from Diabetes Related Retinopathy: Defining the Challenge Part 2 ]
1. Centers for Disease Control and Prevention. Vision health initiative. 2013; http://www.cdc.gov/visionhealth/basic_information/eye_disorders.htm. Accessed July 15, 2015.
2. Zhang X, Saaddine JB, Chou CF, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. Jama. 2010;304(6):649-656.
3. Brook RA, Kleinman NL, Patel S, et al. United States comparative costs and absenteeism of diabetic ophthalmic conditions. Postgraduate medicine. 2015;127(5):455-462.
4. Centers for Disease Control and Prevention. Projection of diabetic retinopathy and other major eye diseases among people with diabetes mellitus United States, 2005-2050. 2015; http://www.cdc.gov/visionhealth/publications/diabetic_retinopathy.htm. Accessed January 6, 2016.
5. American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(Supplement 1):S1-S112.
6. American Academy of Ophthalmology. Diabetic retinopathy PPP- 2014. 2014; http://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp--2014. Accessed September 3, 2015.
7. Liew G, Michaelides M, Bunce C. A comparison of the causes of blindness certifications in England and Wales in working age adults (16-64 years), 1999-2000 with 2009-2010. BMJ open. 2014;4(2):e004015.
8. Stefansson E. Prevention of diabetic blindness. The British journal of ophthalmology. 2006;90(1):2-3.
9. Sloan FA, Yashkin AP, Chen Y. Gaps in receipt of regular eye examinations among medicare beneficiaries diagnosed with diabetes or chronic eye diseases. Ophthalmology. 2014;121(12):2452-2460.
10. Chou CF, Sherrod CE, Zhang X, et al. Barriers to eye care among people aged 40 years and older with diagnosed diabetes, 2006-2010. Diabetes Care. 2014;37(1):180-188.
11. Lee DJ, Kumar N, Feuer WJ, et al. Dilated eye examination screening guideline compliance among patients with diabetes without a diabetic retinopathy diagnosis: the role of geographic access. BMJ open diabetes research & care. 2014;2(1).
12. Hipwell AE, Sturt J, Lindenmeyer A, et al. Attitudes, access and anguish: a qualitative interview study of staff and patients' experiences of diabetic retinopathy screening. BMJ open. 2014;4(12).
13. Paksin-Hall A, Dent ML, Dong F, et al. Factors contributing to diabetes patients not receiving annual dilated eye examinations. Ophthalmic epidemiology. 2013;20(5):281-287.
14. Hautala N, Aikkila R, Korpelainen J, et al. Marked reductions in visual impairment due to diabetic retinopathy achieved by efficient screening and timely treatment. Acta Ophthalmology. 2013.
15. Scanlon PH, Stratton IM, Leese GP, et al. Screening attendance, age group and diabetic retinopathy level at first screen. Diabetic Medicine. 2015;[Prepublished online 6 Oct](2015):1-8.
Image retrieved and adapted from: http://retinagallery.com/displayimage.php?album=883&pid=7463#top_display_media
The American Association of Clinical Endocrinologists and the American College of Endocrinology has released its 2018 Comprehensive Type 2 Diabetes Management Algorithm 2018 – Executive Summary. A complete written Consensus Statement or a PowerPoint presentation is available for download. Selective PowerPoint slides are presented for review below.
Also available on the same website are the 2015 Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan as a document or as a PowerPoint presentation.
It is important to understand the common terminology used by eye care professionals when discussing diabetes related retinopathy and the effects of diabetes on the eye. The human eye ranges between 22mm (7/8”) and 27 mm (1 1/16”) in diameter 1-4; the approximate size of a ‘boulder’ in a marble gave. For its small size the eye packs an oversized punch in our daily lives.
If we compare the globe to an onion with multiple strata, the external covering of the eye is composed of the clear cornea, and the white sclera. Their intersection forms a ring called the limbus 1-4. [see below]
The underlying vascular layer contains the choroid (which supplies blood to the outer portion of the retina), the ciliary body (which controls the crystalline lens focus and produces a clear fluid called the aqueous humor), and the iris (which gives rise to eye color and regulates pupil size in reaction to light intensity) 1-4. [see below]
Analogous to a camera the retinal layer composes the ‘film’ of the eye by which a ‘digital’ image is captured and transmitted via the optic nerve for further processing by brain 1-4. [see below]
The innermost chamber of the eye is further separated into the anterior chamber (composed of the aqueous humor produced by the ciliary body), the clear crystalline lens (which focuses light on the retina), and the vitreous humor, a clear ‘Jello’ like substance 1-4. [see below]
Images retrieved and adapted from: https://pixabay.com/en/blue-eye-eyelash-optic-optical-2027392/ and https://kenhub.com
1. Taylor R, Batey D. Chapter 3: The eye in diabetes. Handbook of Retinal Screening in Diabeetes: Diagnosis and Management: John Wiley & Sons, Ltd.; 2012:18-28.
2. Kels BD, Grzybowski A, Grant-Kels JM. Human ocular anatomy. Clin Dermatol. 2015;33(2):140-146.
3. American Academy of Ophthalmology. Eye anatomy. 2018; https://www.aao.org/search/results?q=Anatomy&realmName=HTTP&wt=json&rows=10&start=0. Accessed 26 Jan 2018.
4. Bron A, Tripathi R, Tripathi B. Wolff's anatomy of the eye and orbit. 8th ed. Boca Raton, FL: CRC Press; 1998.
Retrieved and adapted from: http://www.bigtipsters.com/super-vision.html
Because of their sensitivity to toxic gases canaries were once used to determine if it was safe to breathe the air within claustrophobic mine shafts. Like canaries the success of contact lens wearers with diabetes may be affected by diabetes 1. The lack of tears is higher with diabetes. One study showed a 54% incidence of reported dry eye for persons diagnosed with diabetes 2.
Contact lenses are routinely prescribed for vision correction. They function by floating on a layer of tears that cover the cornea of the eye (Image 1). The cornea is one of the most highly innervated structures of the body. This increased sensitivity to pain and touch the protects the eye from injury and maintains corneal health 3. Unmanaged diabetes reduces tear production and corneal sensitivity 1,4-6. These negative changes increase with the increased presence of retinopathy and neuropathy 2,6. Under these conditions improper contact lens care (e.g. lack of cleaning, extended wear, not replacing old lenses) increases contact lens discomfort and the risk of developing a corneal abrasion, ulcer and interfere with corneal wound healing 1.
It is important to realize that diabetes may influence contact lens success. More importantly with proper eyecare, new contact lens designs and self-management skills contact lenses are a safe alternative to glasses or surgical options to correct vision for people diagnosed with diabetes.
1. O'Donnell C, Efron N. Diabetes and contact lens wear. Clinical & experimental optometry : journal of the Australian Optometrical Association. 2012;95(3):328-337.
2. Manaviat MR, Rashidi M, Afkhami-Ardekani M, et al. Prevalence of dry eye syndrome and diabetic retinopathy in type 2 diabetic patients. BMC ophthalmology. 2008;8:10.
3. Kubilus JK, Linsenmayer TF. Developmental Corneal Innervation: Interactions between Nerves and Specialized Apical Corneal Epithelial Cells. Investigative Ophthalmology & Visual Science. 2010;51(2):782-789.
4. Cousen P, Cackett P, Bennett H, et al. Tear production and corneal sensitivity in diabetes. Journal of diabetes and its complications. 2007;21(6):371-373.
5. Wu YC, Buckner BR, Zhu M, et al. Elevated IGFBP3 levels in diabetic tears: a negative regulator of IGF-1 signaling in the corneal epithelium. The ocular surface. 2012;10(2):100-107.
6. Yu L, Chen X, Qin G, et al. Tear film function in type 2 diabetic patients with retinopathy. Ophthalmologica Journal international d'ophtalmologie International journal of ophthalmology Zeitschrift für Augenheilkunde. 2008;222(4):284-291.
A recently published systematic review in the European Journal of Epidemiology suggest that eating a Mediterranean dietª (MD) and three independent components of the MD, namely high fruit, vegetable and fish intake may offer protection against developing diabetes related retinopathy (DRR) and macular edema (ME) 1. The article also reviewed dietary intake of other individual foods, macro or micro-nutrients, dietary supplements, and dietary patterns but found conflicting findings linking these nutritional components and reduced risk of retinopathy. One study included in the review found a 40-60% reduced risk of retinopathy associated with an increased inclusion of a Mediterranean diet supplemented with olive oil into daily eating routine 2. Even with a limited number of articles reviewed the results give support to the potential role of healthy eating in reducing vision loss from the micro-vascular complications of DRR and ME.
Mediterranean diet retrieved and adapted from: https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/mediterranean-diet/art-20047801
ª The Mediterranean diet is characterized by:
1. Dow C, Mancini F, Rajaobelina K, et al. Diet and risk of diabetic retinopathy: A systematic review. European Journal of Epidemiology. 2017.
2. Díaz-López A, Babio N, Martínez-González MA, et al. Mediterranean Diet, Retinopathy, Nephropathy, and Microvascular Diabetes Complications: A Post Hoc Analysis of a Randomized Trial. Diabetes Care. 2015;38(11):2134-2141.
3. Willett WC, Sacks F, Trichopoulou A, et al. Mediterranean diet pyramid: A cultural model for healthy eating. American Journal of Clinical Nutrition. 1995;61(6 Suppl):1402s-1406s.
John E McDonald, OD, MS DEdMgt