Olympia Eye Clinic - diabetic eye care, cataracts surgery, glaucoma treatment, macular degeneration, lasik surgery, eye lid surgery, contact lenses, eye exam, prk

What is diabetic eye disease?

Diabetic eye disease refers to a group of eye problems that people with diabetes may face as a complication of diabetes. All can cause severe vision loss or even blindness.

Diabetic eye disease may include:

• Diabetic retinopathy—damage to the blood vessels in the retina.
• Cataract—clouding of the eye's lens. Cataracts develop at an earlier age in people with diabetes.
• Glaucoma—increase in fluid pressure inside the eye that leads to optic nerve damage and loss of vision. A person with diabetes is nearly twice as likely to get glaucoma as other adults.

Cataracts and Diabetes.

It has been known for many years (ref 1) that patients with diabetes develop a worsening of their retinopathy following cataract surgery, leaving many if not most patients with worse vision than they had prior to the cataract surgery.  Recent scientific work (ref 2) has shown that this is true even with newer small-incision cataract surgery.  In response to these studies Dr. Bodoia has developed a special protocol for pre-treatment, surgery and post-operative care for patients with diabetic retinopathy.  This protocol has been scientifically proven to eliminate the worsening of retinopathy in nearly all patients, and Dr. Bodoia has successfully performed over 1000 cataract surgeries with this protocol, restoring vision to many happy patients with diabetes.

What is diabetic retinopathy?

Video:  Understanding Proliferated Diabetic Retinopathy

Video:  Understanding Nonproliferative Diabetic Retinopathy

Diabetic retinopathy is the most common diabetic eye disease and the leading cause of blindness in American adults. It is caused by changes in the blood vessels of the retina. 
In some people with diabetic retinopathy, blood vessels may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina. The retina is the light-sensitive tissue at the back of the eye. A healthy retina is necessary for good vision.
If you have diabetic retinopathy, at first you may not notice changes to your vision. But over time, diabetic retinopathy can get worse and cause vision loss. Diabetic retinopathy usually affects both eyes.

What are the stages of diabetic retinopathy?

Diabetic retinopathy has four stages:

1. Nonproliferative Retinopathy. At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina's tiny blood vessels.
2. Nonproliferative Retinopathy with swelling of the central retina (macular edema). The macula at the center of the retina is the only part of the retina capable of fine detailed vision such as we need for reading, driving and recognizing faces.  If the macula becomes swollen then it doesn't function well and the vision deteriorates.
3. Severe Nonproliferative Retinopathy. Many more blood vessels become damaged, depriving the retina of its blood supply. These ischemic areas of the retina send signals to the body to grow new blood vessels for nourishment.
4. Proliferative Retinopathy. At this advanced stage, the signals sent by the retina for nourishment trigger the growth of new blood vessels. This proliferation of new vessels is called proliferative retinopathy. These new blood vessels are abnormal and fragile. They grow along the retina or are suspended along the surface of the vitreous gel that fills the inside of the eye. As we move about and use our eyes these fragile vessels may tear, causing the cavity of the eye to gradually fill with blood, resulting in severe vision loss and even blindness.

Causes and Risk Factors

How does diabetic retinopathy cause vision loss?

Blood vessels damaged from diabetic retinopathy can cause vision loss in two ways:

1. Fragile, abnormal blood vessels can develop and leak blood into the center of the eye, blurring vision. This is proliferative retinopathy and is the most advanced stage of the disease.
2. Fluid and protein/lipid deposits can leak into the center of the macula, the part of the eye where sharp, straight-ahead vision occurs. The fluid makes the macula swell, blurring vision. This condition is called macular edema. It can occur at any stage of diabetic retinopathy, although it is more likely to occur as the disease progresses. About half of the people with proliferative retinopathy also have macular edema.

Normal vision

Same scene viewed by a person with diabetic retinopathy

Who is at risk for diabetic retinopathy?

All people with diabetes--both type 1 and type 2--are at risk, as well as people with impaired glucose tolerance ("pre-diabetes"). That's why everyone with diabetes should get a comprehensive dilated eye exam at least once a year. The longer someone has diabetes, the more likely he or she will get diabetic retinopathy. Between 40 to 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy. If you have diabetic retinopathy, your doctor can recommend treatment to help prevent its progression.
During pregnancy, diabetic retinopathy may be a problem for women with diabetes. To protect vision, every pregnant woman with diabetes should have a comprehensive dilated eye exam as soon as possible. Your doctor may recommend additional exams during your pregnancy.

What can I do to protect my vision?

If you have diabetes get a comprehensive dilated eye exam at least once a year and remember:

• Proliferative retinopathy can develop without symptoms. At this advanced stage, you are at high risk for vision loss.
• Macular edema can develop without prior symptoms at any stage of diabetic retinopathy.
• You can develop both proliferative retinopathy and macular edema and still see fine. However, you are at high risk for vision loss.
• Dr. Bodoia can tell if you have macular edema or any stage of diabetic retinopathy. Whether or not you have symptoms, early detection and timely treatment can prevent vision loss.

If you develop diabetic retinopathy, you will need an eye exam more often. People with proliferative retinopathy can reduce their risk of blindness by 95 percent with timely treatment and appropriate follow-up care.

The Diabetes Control and Complications Trial (DCCT) showed that better control of blood sugar levels slows the onset and progression of retinopathy. The people with diabetes who kept their blood sugar levels as close as possible to normal also had much less kidney and nerve disease. Better control also reduces the need for sight-saving laser surgery.

This level of blood sugar control may not be best for everyone, including some elderly patients, children under age 13, or people with heart disease. Be sure to ask your doctor if such a control program is right for you.

Other studies have shown that controlling elevated blood pressure and cholesterol can reduce the risk of vision loss. Controlling these will help your overall health as well as help protect your vision.

Symptoms and Detection

Does diabetic retinopathy have any symptoms?

Often there are no symptoms in the early stages of the disease, nor is there any pain. Don't wait for symptoms. Be sure to have a comprehensive dilated eye exam at least once a year.
Blurred vision may occur when the macula—the part of the retina that provides sharp central vision—swells from leaking fluid. This condition is called macular edema.

If new blood vessels grow on the surface of the retina, they can bleed into the eye and block vision.

What are the symptoms of proliferative retinopathy if bleeding occurs?

At first, you will see a few specks of blood, or spots, "floating" in your vision. If floaters occur, call our office as soon as possible. You may need treatment before more serious bleeding occurs. Hemorrhages tend to happen more than once, often during sleep.

Sometimes, without treatment, the spots clear, and you will see better. However, bleeding can reoccur and cause severely blurred vision. You need to call us at the first sign of blurred vision, before more bleeding occurs.

If left untreated, proliferative retinopathy can cause severe vision loss and even blindness. Also, the earlier you receive treatment, the more likely treatment will be effective.

How are diabetic retinopathy and macular edema detected?

Diabetic retinopathy and macular edema are detected during a comprehensive eye exam that includes:

1. Visual acuity test. This eye chart test measures how well you see at various distances.
2. Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. This allows Dr. Bodoia to see more of the inside of your eyes to check for signs of the disease. Dr. Bodoia uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye problems. After the exam, your close-up vision may remain blurred for several hours.
3. Tonometry. An instrument measures the pressure inside the eye. Numbing drops may be applied to your eye for this test.

Dr. Bodoia checks your retina for early signs of the disease, including:

• Leaking blood vessels.
• Retinal swelling (macular edema).
• Pale, fatty deposits on the retina--signs of leaking blood vessels.
• Damaged nerve tissue.
• Any changes to the blood vessels.

If Dr.Bodoia believes you need treatment for macular edema, he may suggest a fluorescein angiogram. In this test, a special dye is injected into your arm. Pictures are taken as the dye passes through the blood vessels in your retina. The test allows Dr.Bodoia to identify any leaking blood vessels and recommend treatment.

Treatment

How is diabetic retinopathy treated?

During the first three stages of diabetic retinopathy, no treatment is needed, unless you have macular edema. To prevent progression of diabetic retinopathy, people with diabetes should control their levels of blood sugar, blood pressure, and blood cholesterol.

Proliferative retinopathy is treated with laser surgery. This procedure is called Pan Retinal Photocoagulation (PRP) treatment. PRP helps to shrink the abnormal blood vessels. Dr.Bodoia places hundreds of laser burns in the areas of the retina away from the macula, causing the abnormal blood vessels to shrink. Although you may notice some loss of your side vision, PRP laser treatment can save the rest of your sight. PRP laser treatment may slightly reduce your color vision and night vision.

PRP laser treatment works better before the fragile, new blood ves sels have started to bleed, underscoring Dr. Bodoia's creed that Early Detection and Timely Treatment Are Crucial to Preserving Vision. That is why it is important to have regular, comprehensive dilated eye exams. Even if bleeding has started, PRP laser treatment may still be possible, depending on the amount of bleeding.

How is a macular edema treated?

Macular edema is treated with laser surgery. This procedure is called focal laser treatment. Dr.Bodoia uses a pinpoint (one five-hundredths of an inch, 0.002 inch) laser spot to cauterize the individual tiny leaky capillaries in the areas of retinal leakage surrounding the macula. This allows the fluid in the retina to gradually reabsorb. The surgery is usually completed in one session. Further treatments may be needed as new leaks develop.

If you have macular edema in both eyes and require laser surgery, generally only one eye will be treated at a time, usually several weeks apart.

Focal laser treatment stabilizes vision. In fact, with Early Detection and Timely Treatment  Dr. Bodoia has been successful in preventing blindness in thousands of patients in Washington State and Alaska.  Although time is of the essence and we much prefer to catch macular edema before the patient suffers vision loss, Dr. Bodoia has restored vision for many patients who have lost vision while under the care of others, or before obtaining care.  In some patients with severe diabetic macular edema it is beneficial to place injections of Avastin into the vitreous cavity.

What happens during laser treatment?

Both focal and scatter laser treatment are performed at our surgery office on the waterfront in downtown Olympia. Before the surgery, we will dilate your pupil and apply drops to numb the eye.  As you sit facing the laser machine, Dr. Bodoia will hold a special lens to your eye. During the procedure, you may see flashes of light. These flashes eventually may create a stinging sensation that can be uncomfortable. You will need someone to drive you home after surgery. Because your pupil will remain dilated for a few hours, you should bring a pair of sunglasses.
For the rest of the day, your vision will probably be a little blurry.

 

 

 

What is a vitrectomy?

If you have a lot of blood in the center of the eye (vitreous gel), you may need a vitrectomy to restore your sight.  A vitrectomy is performed under either local or general anesthesia. Your doctor makes an incision in your eye and a high speed cutting tool (vitrector) is used to remove the vitreous gel that is clouded with blood.   The vitreous gel is replaced with a clear fluid.  You will probably be able to return home after the vitrectomy. Some people stay in the hospital overnight. Your eye will be red and sensitive. Most patients will develop a clouding of the lens of the eye (cataract) in the months following the surgery.  You also will need to use medicated eyedrops to protect against infection.  Unfortunately, invasive surgeries such as vitrectomies carry considerable risk of very serious complications (cataracts, glaucoma, infection, retinal detachment, and even complete loss of the eye).  The good news is that with Early Detection and Timely Treatment of diabetic retinopathy vitrectomy surgery can be avoided in almost all diabetics.  Since 1989 Dr. Bodoia has treated many thousands of patients with diabetes, and through timely intervention with over 10,000 successful laser surgeries he has enabled over 99% of these patients to avoid the complications of vitrectomy surgery.

Is scatter laser treatment effective in treating proliferative retinopathy?

Yes. Pan Retinal Photocoagulation (PRP) laser surgery is very effective in reducing vision loss. People with proliferative retinopathy have less than a five percent chance of becoming blind within five years when they get timely and appropriate treatment. However, the amount of laser treatment needed varies tremendously from patient to patient.  Most patients respond after the first few sessions of PRP, but some patients require several sessions.  Although PRP has a high success rate, it does not cure diabetic retinopathy.
Once you have proliferative retinopathy, you always will be at risk for new bleeding. You may need treatment more than once to protect your sight.

Early Detection and Timely Treatment are Crucial to Preserving Vision.

We’ve all heard the old adage about “an ounce of prevention is worth a pound of cure”.  This is particularly true for diabetic retinopathy.  If we catch it early and treat before the patient loses vision, we can prevent blindness in the vast majority of patients with diabetes. Accordingly, the American Diabetes Association recommends that all patients with diabetes should get an eye exam at least yearly.  Once retinopathy develops the exams must be even more frequent.  All medical insurances recognize the importance of timely evaluations for diabetic retinopathy, and provide coverage for these exams (even if the patient’s “Vision Coverage” is just for exams every two years).

Remember: your diabetic eye exam is only effective if the examiner is adept at recognizing the early signs of threatening changes inside your eye.  With 21 years of specialization in Diabetic Eye Care, Dr. Rodger Bodoia has the skills and experience to help you retain your best possible vision.  Having performed more than 10,000 successful diabetic laser surgeries and over 2,000 diabetic cataract surgeries, Dr. Bodoia is uniquely qualified to assess and treat all of the different effects of diabetes on your eyes – everything from diabetic retinopathy to diabetic cataract surgery and diabetic glaucoma.

<sub>Ref 1: Benson WE, Brown GC, et al. Extracapsular Cataract Extraction with Placement of a Posterior Chamber Lens in Patients with Diabetic Retinopathy.  Ophthalmology 1993; 100: 730-738.

Ref 2:  Hong T, Mitchell P, et al.  Development and Progression of Diabetic Retinopathy 12 months after Phacoemulsification Cataract Surgery.  Ophthalmology 2009;  116:  1510-1514.</sub>