Diabetic Retinopathy: Stages & Treatment

What is diabetic retinopathy?

Diabetic retinopathy is a condition that affects people with diabetes and is caused by progressive damage to the small blood vessels of the retina. A person with diabetes is more likely to develop diabetic retinopathy if they:

Page contents

1. What is diabetic retinopathy?
2. What are the stages of diabetic retinopathy?
3. What is diabetic maculopathy?
4. What are the symptoms of diabetic retinopathy?
5. What is the right treatment?
6. Screening with new technologies
7. Which people with diabetes are most at risk
8. How often should a person with diabetes have a fundus examination
9. The tests in detail
10. Treatments in detail
11. Complications of advanced disease
12. Diabetes also affects other parts of the eye
13. How someone with diabetic macular oedema sees
14. Gestational diabetes and pregnancy with diabetes
15. Children and teenagers with type 1 diabetes
16. A lifestyle that protects the eyes
17. Myths about diabetic retinopathy
18. Questions to ask at your eye appointment
19. What happens during an injection, step by step
20. Driving and diabetic retinopathy
21. Why early diagnosis makes the difference
22. Cooperation between the ophthalmologist and your treating doctor
23. The first signs in the fundus
24. Diabetic retinopathy and general health
25. Frequently Asked Questions about Diabetic Retinopathy

• Have had diabetes for many years
• Do not have well-controlled blood sugar levels
• Have high blood pressure
• Have high cholesterol

What are the stages of diabetic retinopathy?

There is a non-proliferative and a proliferative stage.

The non-proliferative stage is divided into mild, moderate, severe and very severe. In these stages we see anything from microaneurysms alone to larger haemorrhages, vascular changes and more. These are caused by progressive damage to the blood vessels from high blood sugar levels.

In the proliferative stage there are new blood vessels, which are abnormal. These vessels grow because of a factor called VEGF, which is produced when an area of the eye becomes ischaemic, that is, does not receive enough blood. These vessels bleed and leak and, if we do not treat them, there is a risk that they will lead to retinal detachment.

What is diabetic maculopathy?

Diabetic maculopathy is the condition in which damage to the small blood vessels around the macula causes oedema (swelling), resulting in reduced central vision.

What are the symptoms of diabetic retinopathy?

In the early stages vision is not affected, so there are no symptoms. Vision starts to be affected if oedema develops in the macula, or in very advanced stages. For this reason, screening is essential to reduce the chances of permanent loss of vision.

What is the right treatment?

We are fortunate that today there are several treatment options to prevent loss of vision.

For diabetic maculopathy, treatment is with intravitreal injections of steroids or anti-VEGF, as well as with a new laser that does not cause scarring, which I was fortunate to use in Oxford.

For the proliferative stage of diabetic retinopathy, treatment for the last 40 years has been laser. In the past year, a new study by a large group of doctors working on diabetic retinopathy in the United States showed that proliferative diabetic retinopathy can also be treated with injections, with the same effectiveness and safety.

With experience of 3,000 patients with diabetes, Dr. Skouteris has seen and treated all the stages, types and possible complications of diabetic retinopathy.

Screening with new technologies

Which people with diabetes are most at risk

Anyone with diabetes, type 1 or type 2, can develop diabetic retinopathy. However, the risk is higher when certain factors are present:

• Duration of diabetes: the more years someone has had diabetes, the greater the likelihood of changes in the retina.
• Poor blood sugar control: a high glycated haemoglobin (HbA1c) over a long period is the most important modifiable factor.
• High blood pressure: it puts a direct strain on the small blood vessels of the eye.
• High cholesterol and triglycerides: they are linked to lipid deposits in the macula.
• Diabetic nephropathy: when the kidneys are affected, the eyes are often affected too.
• Pregnancy: it can speed up the progression of retinopathy.
• Smoking: it further damages the microcirculation.

How often should a person with diabetes have a fundus examination

• Type 2 diabetes: first examination at the time of diagnosis, because diabetes may have been present undiagnosed for years. After that, a yearly examination, as long as there are no changes.
• Type 1 diabetes: first examination about five years after diagnosis or at the start of puberty, and then every year.
• When retinopathy is present: examinations become more frequent, every three to six months or even more often, depending on the stage.
• Pregnancy in a woman with diabetes: examination before conception or in the first trimester, and monitoring throughout the pregnancy.

You will find more about screening in our article on diabetes and eye examinations.

The tests in detail

• Dilated fundus examination: the basic test, which allows the ophthalmologist to see microaneurysms, haemorrhages, exudates and new vessels.
• Fundus photography: it records the appearance of the retina so that it can be compared objectively from year to year.
• Optical coherence tomography (OCT): it detects macular oedema, even before vision is affected, and guides treatment with injections.
• Angiography: with fluorescein, or with OCT angiography without an injection, it shows areas of poor blood supply and new vessels.

Treatments in detail

Controlling diabetes and risk factors

The foundation of every treatment is good control of blood sugar, blood pressure and lipids, in cooperation with your physician or endocrinologist. Improving these parameters significantly reduces the risk of retinopathy developing and progressing. One point to note: when blood sugar falls very sharply after years of poor control, retinopathy can temporarily get worse. That is why closer eye monitoring is needed when treatment is changed in this way.

Intravitreal injections

For diabetic macular oedema, intravitreal injections of medicines against vascular endothelial growth factor (anti-VEGF) are today the first choice. They reduce fluid leakage and improve vision in many patients. They are given at the clinic under local anaesthetic drops, and usually a series of injections is needed at first, followed by less frequent ones. In selected patients, longer-acting corticosteroid implants are also used.

Laser photocoagulation

In proliferative diabetic retinopathy, where new, fragile blood vessels have formed, laser is applied to the periphery of the retina. The treatment reduces the signals that cause new vessels to form and protects against haemorrhage and detachment. Laser is also used in some forms of oedema.

Vitrectomy

When there is a vitreous haemorrhage that does not clear, or fibrous tissue that pulls on the retina, surgery is needed. In this operation, vitrectomy, the blood is removed and the retina is released.

Complications of advanced disease

• Vitreous haemorrhage: a sudden shower of floaters, a shadow or sudden blurring of vision.
• Tractional retinal detachment: fibrous tissue pulls the retina out of place.
• Neovascular glaucoma: new vessels block the eye’s drainage and the pressure rises sharply, with pain and redness.

In most cases, all these complications can be prevented with early diagnosis and treatment.

Diabetes also affects other parts of the eye

• Cataract: it appears earlier in people with diabetes. Before cataract surgery, any macular oedema must be checked for and treated.
• Glaucoma: diabetes increases the risk of glaucoma.
• Fluctuating vision: large changes in blood sugar temporarily change the refraction of the lens, so vision “comes and goes”. That is why we do not change glasses during a period of poor control.
• Dry eye and corneal sensitivity: more common because of diabetic neuropathy.

Dr. Vasileios Skouteris, who specialised in retinal diseases and diabetic retinopathy in Oxford, monitors and treats patients with diabetes at his clinic in Neo Psychiko, Athens. To book an appointment, call +30 210 677 0007.

How someone with diabetic macular oedema sees

When fluid builds up in the macula, central vision becomes blurred, as if looking through water. Reading becomes difficult, faces lose their detail and straight lines may look wavy. Colours fade and vision gets worse in low light. Peripheral vision usually remains good, which is why many patients move around comfortably but struggle with fine tasks. The change can be so gradual that at first it is put down to “tiredness” or the need for new glasses.

Gestational diabetes and pregnancy with diabetes

Gestational diabetes, which appears for the first time in pregnancy, rarely affects the retina. In contrast, women who already had type 1 or type 2 diabetes before pregnancy need special attention, because hormonal and circulatory changes can speed up retinopathy. Ideally, an examination is done before conception and repeated in each trimester and after the birth. When treatment is needed, it is adapted so that it is safe for both mother and baby.

Children and teenagers with type 1 diabetes

In children, diabetic retinopathy is rare before puberty. With puberty, however, hormonal changes and blood sugar control that is often more difficult increase the risk. That is why regular eye examinations usually start from the age of 10 to 12, or a few years after diagnosis. This check-up is also an opportunity to explain to the young patient why good control protects their vision in the long term.

A lifestyle that protects the eyes

• Stable blood sugar control: targets are set by your treating doctor, and gradual improvement is better than sudden changes.
• Blood pressure control: just as important for the eyes as blood sugar.
• A Mediterranean-style diet: vegetables, pulses, fish, olive oil and limited processed carbohydrates.
• Physical activity: regular walking or other exercise, taking care to avoid sudden heavy lifting when there is proliferative retinopathy or a recent haemorrhage.
• Stopping smoking.
• Keeping your appointments: the yearly examination is the most effective preventive “medicine”.

Myths about diabetic retinopathy

• “I can see well, so my eyes are fine.” The disease can progress considerably without any symptoms. Only a fundus examination shows the real picture.
• “I’m on insulin or tablets, so I’m not at risk.” The risk depends on how well controlled the diabetes is and how long you have had it, not on the type of treatment.
• “Eye injections are dangerous and painful.” They are given with anaesthetic drops, take a few seconds and serious complications are rare. The benefit for vision is significant.
• “Laser ruins your vision.” Laser to the periphery protects vision from serious complications. It may slightly affect peripheral or night vision, but it prevents blindness.

Questions to ask at your eye appointment

• Do I have retinopathy, and at what stage?
• Is there oedema in the macula?
• How often should I be examined?
• Do I need treatment, and which one?
• Is there anything I should tell my endocrinologist?

What happens during an injection, step by step

Many patients feel anxious at the idea of an injection in the eye. However, the procedure is short and well organised:

1. we measure your vision and perform OCT to decide whether an injection is needed that day
2. we put in anaesthetic drops so that the eye does not feel pain
3. we clean the eye and eyelids with an antiseptic solution to protect against infection
4. a special instrument holds the eyelids open
5. the injection is given with a very fine needle into the white of the eye and takes a few seconds
6. we check your vision and eye pressure before you leave

After the injection there may be mild irritation, a small red mark or a few floaters from the bubble of medicine, which settle within a few days. Severe pain, increasing redness or reduced vision in the following days require you to contact the doctor immediately.

Driving and diabetic retinopathy

Most people with mild or moderate diabetic retinopathy drive without any problem. However, when there is macular oedema or extensive laser treatment has been carried out, visual acuity, contrast or the peripheral field may be affected. In these cases the ophthalmologist may recommend visual field testing to assess safely whether you are fit to drive.

Why early diagnosis makes the difference

Diabetic retinopathy is one of the leading causes of vision loss in adults of working age. At the same time, it is one of the most preventable. When changes are detected in the early stages, good diabetes control is often enough to stop progression. When oedema or new vessels are diagnosed early, injections and laser protect vision very effectively. In contrast, when a patient comes for the first time because their vision has already dropped, the damage may be partly permanent.

The message is simple: everyone with diabetes needs a fundus examination at least once a year, even when they see perfectly.

Cooperation between the ophthalmologist and your treating doctor

The findings in the retina are a “mirror” of the state of the small blood vessels throughout the body. When we find that retinopathy is progressing, we inform the patient so that they can discuss with their endocrinologist or physician the control of blood sugar, blood pressure and lipids, as well as checking their kidneys. Close cooperation between specialties protects not only the eyes but also the patient’s general health.

The first signs in the fundus

In the early stages, the ophthalmologist sees tiny bulges in the walls of the capillaries, the microaneurysms, and small dot haemorrhages. Later, yellowish lipid deposits, the hard exudates, appear, together with white spots that indicate areas of poor blood supply. As these areas increase, the retina “asks” for more oxygen and produces substances that lead to the formation of new vessels. The aim of monitoring is to intervene before we reach this stage.

With regular check-ups, good control and timely treatment, the vast majority of people with diabetes keep useful vision throughout their lives. Prevention starts with a simple appointment for a fundus examination.

Diabetic retinopathy and general health

The presence of retinopathy shows that diabetes has started to affect the small blood vessels of the body. That is why its diagnosis is also a signal for closer checks of the heart, kidneys and the nerves of the hands and feet, always in cooperation with the treating doctor.

Frequently Asked Questions about Diabetic Retinopathy

Medically reviewed by: Dr. Vasileios Skouteris MD, FEBO