Facts About Diabetic Eye Disease

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What is diabetic eye disease?

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Diabetic eye disease can affect many parts of the eye, including the retina, macula, lens and the optic nerve.

Diabetic eye disease is a group of eye conditions that can affect people with diabetes.

  • Diabetic retinopathy affects blood vessels in the light-sensitive tissue called the retina that lines the back of the eye. It is the most common cause of vision loss among people with diabetes and the leading cause of vision impairment and blindness among working-age adults.
  • Diabetic macular edema (DME). A consequence of diabetic retinopathy, DME is swelling in an area of the retina called the macula.

Diabetic eye disease also includes cataract and glaucoma:

  • Cataract is a clouding of the eye’s lens. Adults with diabetes are 2-5 times more likely than those without diabetes to develop cataract. Cataract also tends to develop at an earlier age in people with diabetes.
  • Glaucoma is a group of diseases that damage the eye’s optic nerve—the bundle of nerve fibers that connects the eye to the brain. Some types of glaucoma are associated with elevated pressure inside the eye. In adults, diabetes nearly doubles the risk of glaucoma.

All forms of diabetic eye disease have the potential to cause severe vision loss and blindness.

How are diabetic retinopathy and DME detected?

Diabetic retinopathy and DME are detected during a comprehensive dilated eye exam that includes:

  1. Visual acuity testing. This eye chart test measures a person’s ability to see at various distances.
  2. Tonometry. This test measures pressure inside the eye.
  3. Pupil dilation. Drops placed on the eye’s surface dilate (widen) the pupil, allowing a physician to examine the retina and optic nerve.
  4. Optical coherence tomography (OCT). This technique is similar to ultrasound but uses light waves instead of sound waves to capture images of tissues inside the body. OCT provides detailed images of tissues that can be penetrated by light, such as the eye.

A comprehensive dilated eye exam allows the doctor to check the retina for:

  1. Changes to blood vessels
  2. Leaking blood vessels or warning signs of leaky blood vessels, such as fatty deposits
  3. Swelling of the macula (DME)
  4. Changes in the lens
  5. Damage to nerve tissue

If DME or severe diabetic retinopathy is suspected, a fluorescein angiogram may be used to look for damaged or leaky blood vessels. In this test, a fluorescent dye is injected into the bloodstream, often into an arm vein. Pictures of the retinal blood vessels are taken as the dye reaches the eye.

How can people with diabetes protect their vision?

Vision lost to diabetic retinopathy is sometimes irreversible. However, early detection and treatment can reduce the risk of blindness by 95 percent. Because diabetic retinopathy often lacks early symptoms, people with diabetes should get a comprehensive dilated eye exam at least once a year. People with diabetic retinopathy may need eye exams more frequently. Women with diabetes who become pregnant should have a comprehensive dilated eye exam as soon as possible. Additional exams during pregnancy may be needed.

Studies such as the Diabetes Control and Complications Trial (DCCT) have shown that controlling diabetes slows the onset and worsening of diabetic retinopathy. DCCT study participants who kept their blood glucose level as close to normal as possible were significantly less likely than those without optimal glucose control to develop diabetic retinopathy, as well as kidney and nerve diseases. Other trials have shown that controlling elevated blood pressure and cholesterol can reduce the risk of vision loss among people with diabetes.

Treatment for diabetic retinopathy is often delayed until it starts to progress to PDR, or when DME occurs. Comprehensive dilated eye exams are needed more frequently as diabetic retinopathy becomes more severe. People with severe nonproliferative diabetic retinopathy have a high risk of developing PDR and may need a comprehensive dilated eye exam as often as every 2 to 4 months.

How is DME treated?

DME can be treated with several therapies that may be used alone or in combination.

Anti-VEGF Injection Therapy. Anti-VEGF drugs are injected into the vitreous gel to block a protein called vascular endothelial growth factor (VEGF), which can stimulate abnormal blood vessels to grow and leak fluid. Blocking VEGF can reverse abnormal blood vessel growth and decrease fluid in the retina. Available anti-VEGF drugs include Avastin (bevacizumab), Lucentis (ranibizumab), and Eylea (aflibercept). Lucentis and Eylea are approved by the U.S. Food and Drug Administration (FDA) for treating DME. Avastin was approved by the FDA to treat cancer, but is commonly used to treat eye conditions, including DME.

The NEI-sponsored Diabetic Retinopathy Clinical Research Network compared Avastin, Lucentis, and Eylea in a clinical trial. The study found all three drugs to be safe and effective for treating most people with DME. Patients who started the trial with 20/40 or better vision experienced similar improvements in vision no matter which of the three drugs they were given. However, patients who started the trial with 20/50 or worse vision had greater improvements in vision with Eylea.

Most people require monthly anti-VEGF injections for the first six months of treatment. Thereafter, injections are needed less often: typically three to four during the second six months of treatment, about four during the second year of treatment, two in the third year, one in the fourth year, and none in the fifth year. Dilated eye exams may be needed less often as the disease stabilizes.

Avastin, Lucentis, and Eylea vary in cost and in how often they need to be injected, so patients may wish to discuss these issues with an eye care professional.

The retina of a person with diabetic retinopathy and DME, as viewed by optical coherence tomography (OCT). The two images were taken before (Top) and after anti-VEGF treatment (Bottom). The dip in the retina is the fovea, a region of the macula where vision is normally at its sharpest. Note the swelling of the macula and elevation of the fovea before treatment.

Focal/grid macular laser surgery. In focal/grid macular laser surgery, a few to hundreds of small laser burns are made to leaking blood vessels in areas of edema near the center of the macula. Laser burns for DME slow the leakage of fluid, reducing swelling in the retina. The procedure is usually completed in one session, but some people may need more than one treatment. Focal/grid laser is sometimes applied before anti-VEGF injections, sometimes on the same day or a few days after an anti-VEGF injection, and sometimes only when DME fails to improve adequately after six months of anti-VEGF therapy.

Corticosteroids. Corticosteroids, either injected or implanted into the eye, may be used alone or in combination with other drugs or laser surgery to treat DME. The Ozurdex (dexamethasone) implant is for short-term use, while the Iluvien (fluocinolone acetonide) implant is longer lasting. Both are biodegradable and release a sustained dose of corticosteroids to suppress DME. Corticosteroid use in the eye increases the risk of cataract and glaucoma. DME patients who use corticosteroids should be monitored for increased pressure in the eye and glaucoma.

Current Research

What is the NEI doing to advance research on diabetic eye disease?

The NEI is conducting and supporting research that seeks better ways to detect, treat, and prevent vision loss in people with diabetes. This research is being conducted in labs and clinical centers across the country.

For example, the Diabetic Retinopathy Clinical Research Network (DRCR.net) conducts large multi-center trials to test new therapies for diabetic eye disease, and to compare different therapies. The network formed in 2002 and comprises more than 350 physicians practicing at more than 140 clinical sites across the country. Many of the sites are private practice eye clinics, enabling the network to quickly bring innovative treatments from research into community practice.

NEI-funded scientists are also seeking ways to detect diabetic retinopathy at earlier stages. For example, researchers are harnessing a technology called adaptive optics (AO) to improve imaging techniques such as OCT. AO was developed by astronomers seeking to improve the resolution of their telescopes by filtering out distortions in the atmosphere. In the clinic, diagnostic devices that use AO may improve the detection of subtle changes in retinal tissue and blood vessels.