​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.

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 defined​1-3 and identified on the following images below.

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. 

References

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 ] 

References

​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]

References

     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. 

References

​     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.

ª The Mediterranean diet is characterized by:

References