Diabetes is a disease caused by diabetes in the retina and retinal vessels at the back of the eye, and is one of the most common causes of vision loss in adults.
The retina consists of a network rich in blood vessels that line the inner surface of the eyeball and sugar. It is a very sensitive target tissue for the disease. The nerve fibers it carries come together in the macula (yellow spot) region and is the first and most important tissue of the "Vision" function, as a nerve transmission organ that extends to the visual center in the brain, called the "Optic Nerve".
How Does Diabetes Affect the Retinal Vessels?
In fact, diabetes affects not only the retinal vessels in the eye, but also all eye vascular structures and even the vascular structures in the whole organism.
The two main cells of the vascular structure are “Endothelium” cells lining the inner vascular surface and “Pericyte” cells lining the outer vascular surface; The intermediate product of the Glucose/Sugar metabolism disorder that occurs with diabetes is disrupted and becomes dysfunctional under the influence of substances.
Deterioration of these cells, which are lined up along the vascular wall and serve as sealing and skeletal structure; Expansion and ballooning of the vessels in these areas cause the serum/plasma content of the blood to leak from the vessel to the outside and into the retina. Serum leakage into the retina causes tissue swelling, or "edema". Leaking serum is usually rich in lipids found in blood. The appearance of lipids in the tissue is in the form of hard-white deposits.
The loss of function and destruction of endothelial cells, especially on the inner surface of the vessels, and the structural disorder of red blood cells and platelet (clotting) cells, which are blood cellular elements affected by sugar metabolism disorders, cause blood in the retinal vessels. It causes flow slowdown and blockages. While intra-, anterior or sub-retinal hemorrhages develop in the occluded vessel area, retinal nutrition is disrupted in the following period, causing permanent retinal nerve cell damage.
The macula is the most central region of the retina and is also the most sensitive area of central vision. . Unfortunately, damages such as edema, bleeding and malnutrition due to diabetes manifest themselves primarily and intensely in this region and in the form of "VISION DECREASE".
Diabetic retinopathy; It is usually seen in both eyes. However, the stage and degree of the disease may not be equal in the eyes.
What Complaints Does Diabetic Retinopathy Cause?
There are no findings or complaints during the first 5-10 years of the development of diabetes. development is not expected. In other words, when the first signs and symptoms of the disease are detected in the eye, it is known that this patient actually has a longer history of sugar metabolism disorder.
There are no signs of pain in the early and middle stages of diabetic retinopathy.
In this table. The first sign and symptom is usually blurred vision and decreased vision due to macular (macular) bleeding and edema. In these stages, limited bleeding can be described by patients as dark spots - spots floating in the eye. In the advanced stages of the disease, vision decreases due to the effect of diabetes and additional disorders such as cataracts, bleeding in the eye, and dry eye, while the changes in the retina progress; It can progress to a late-stage disease with intense intraocular bleeding, new vascular formations that bleed quickly, nutritional disorders in the optic nerve, and finally tears in the retina and separations called detachment.
In untreated or delayed cases; Blindness is an undesirable but not uncommon outcome.
How is Diabetic Retinopathy Diagnosed?
First of all, diabetes and eye involvement of diabetes in the patient and/or his family. Having a medical history requires regular visits to the ophthalmologist, even without any complaints. Even if there are no complaints, 1-2 yearly check-ups are recommended for our patients diagnosed with diabetes. Time between checks; It is adjusted entirely according to the control of the patient's blood sugar level, the result of the test called HbA1C (Glycosized Hemoglobin), which expresses long-term blood sugar, and the presence of accompanying heart diseases and hypertension.
Following the evaluation of the patient's vision; After dilating the pupil, the fundus - retina is examined using different methods, preferably by an ophthalmologist experienced in "retina". The presence of edema, bleeding, vascular occlusion, and lipid leaks mentioned before are investigated and these findings are evaluated. Depending on the severity of the disease, the disease is graded as the "EARLY - MIDDLE - ADVANCED" stage.
It should be reminded that after the examination by dilating the pupil, patients may experience blurred vision, especially near vision, for hours or even days depending on the medication used.
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ADVANCED EXAMINATION RESEARCH
OCT (Optical Coherence Tomography):It is a test that allows monitoring of all layers of the retina in the presence of a transparent intraocular structure. Just like fundus examination, it is performed by imaging the fundus of the eye while the patient is in a sitting position.
OCT Angiography (Optical Coherence Tomography Angiography): It is a technology that enables the visualization of vascular structures by utilizing the basic mechanism of OCT.
FUNDUS FLUORESEIN ANGIOGRAPHY (FFA)
It is an examination performed to examine the integrity of the retinal vascular circulation and, if any, the retinal structures affected by the disorder in this system. It is the imaging process by taking photographs for seconds after a dyed substance administered through a vein in the arm fills the eye vessels.
It is determined that the dye does not progress in the presence of blockage in the vessels, in case of leakage in the vessel, the dye spreads within the retina and edema occurs, and the bleeding areas remain dark due to not being stained.
Since the dyed substance given is excreted through the kidneys, it cannot be applied to patients with advanced renal failure. If application is necessary, dyestuff is used in appropriate doses.
Following the examination, excretion in urine may take up to 24-48 hours. The patient and his/her relatives should be informed that the urine color will be red and the skin color will be yellow.
Control of Diabetes
Diabetic patients whose condition was not known before or whose condition was detected to be progressing even though it was known before. Patients with retinopathy should be referred to an internal medicine specialist, and if possible, an endocrinologist, for the purpose of blood sugar control and detection of other sugar-related organ-system disorders.
Ophthalmic treatment may not be required in the early stages of diabetic retinopathy, especially when macular edema does not develop. But avoid progression of the disease to make; Blood sugar level, blood cholesterol and blood pressure levels should be kept under strict control.
Macular Edema Treatment
Macular edema can occur alone or in different stages of the disease. It can be found in different shapes and intensity. It is the most common cause of low vision.
Depending on the type and cause of macular edema, different methods can be applied alone or in combination. However, the main thing is to control diabetes and additional findings of diabetes systemically.
Laser Treatment
Retinal edema causes , leaking vessels are surrounded by laser beams of appropriate dose, number and diameter. With this method, which causes minor burns to the retina due to increased temperature, the leakage areas are closed and the retina is thinned. The effectiveness of the laser spreads over a period of several weeks in parallel with the tissue changes it creates.
During the laser treatment process, the patient sees flashes of light. Light flashes and the effect of the laser on the tissue, although rare, may be described as painful by the patient.
Drug Injection into the Eye
In macular edema, As a sole treatment method to reduce and eliminate vascular leaks in the macular area, thin the retina and increase vision; It is used to increase the effectiveness of laser treatment by thinning the retina in the macula or macula and to reduce the dose and number of laser treatments to be applied.
The medications used vary depending on the retinal findings detected, the effectiveness/ineffectiveness of previously used treatment agents, and the patient's preference. There are 2 main groups of drugs.
Containing Cortisone (Steroids):
White, milky "Triamcinolone" group steroids injected into the eye are effective in the treatment of macular edema. . However, while it may cause complaints of blackening during its stay in the eye, it may cause undesirable effects such as increased pressure in the eye and the development of cataracts. Application of this group of steroids into the eye; Depending on whether the drug is allowed to be administered to the eye, it should be done with an "information letter" (consent form) to be obtained after informing the patient.
Anti-VEGF Drugs:
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The first use of these drugs, which have been applied/injected into the eye in the field of ophthalmology since 2004, was the age type of Age-Related Macular Degeneration.
As a principle of use, these drugs are administered 3 times with an interval of 1 month, based on the results of many centered studies, but more importantly, with the decision of the physician, according to the patient's current condition and response to treatment. It is then applied at certain intervals (monthly - 6 weeks) or according to the plan, depending on the need and tissue response.
The basic principle in application is; ensuring appropriate sterile conditions, surgical cleaning and isolation around the patient's eye. For this purpose, the injection can be performed in operating room conditions, but it is also applied in office/consultancy conditions if this environment is provided.
The injection is performed with drop anesthesia, and then protection is provided, in principle, with the application of antibiotic drops. Local or systemic measures can be taken for the patient to prevent a temporary increase in intraocular pressure.
Vitrectomy:
In advanced stage diabetic eye diseases with complications, especially the membranes that develop in front of the retina. Vitrectomy is an operation performed to save the retina from these effects in cases where the retinal membranes are present and these membranes cause detachment due to edema or traction in the retina.
Since the retinal vessels affected by diabetes and the new vessels formed are vessels with a high tendency to bleed, bleeding within the eye is quite common. It is a common complication. Although it is often possible to allow time for bleeding to subside on its own, surgery can also be performed immediately in patients with advanced diabetic findings.
In summary;
The prevalence of diabetes and diabetic retinopathy in the society. It is a disease that increases with the effect of extended lifespan and changes in eating habits.
It causes damage to the eyes, vision loss and related social problems, as well as loss of work force and personal grievances.
Early diagnosis and Vision loss can be prevented with the treatment process that ensures full compliance with the applied / practitioner.
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