• Macular ischemia occurs when small blood vessels (capillaries) close. Vision blurs because the macular no longer receives sufficient blood supply to work properly. 

PDR is present when abnormal new vessels (neovascularization) begin growing on the surface of the retina of the optic nerve.  The main cause of PDR is widespread closure of retinal blood vessels, preventing adequate blood flow.  The retina responds by growing new blood vessels in an attempt to supply blood to the area where the original vessels closed.

Unfortunately, the new abnormal blood vessels do not resupply the retina with normal blood flow.  The new vessels are often accompanied by scar tissue that may cause wrinkling or detachment of the retina. 

PDR may cause more severe vision loss than NPDR because it can affect both central and peripheral vision.

Proliferative diabetic retinopathy causes visual loss in the following ways:

Vitreous hemorrhage:  The fragile new vessels may bleed into the vitreous, a clear, gel-like substance that fills the center of the eye. If the vitreous hemorrhage is small, a person might see only a few new, dark floaters.  A very large hemorrhage might block out all vision.

It may take days, months, or even years to reabsorb the blood, depending on the amount of blood present.  If the eye does not clear the vitreous blood adequately within a reasonable time, vitrectomy surgery may be recommended. Vitreous hemorrhage alone does not cause permanent vision loss.  When the blood clears, vision may return to its former level unless the macular is damaged. 

Tractional retinal detachment:  When PDR is present, scar tissue associated with neovascularization can shrink, wrinkling and pulling the retina from its normal position. Macular wrinkling can cause visual distortion. More severe vision loss can occur if the macula or large areas of the retina are detached.

Neovascular glaucoma:  Occasionally, extensive retinal vessel closure will cause new, abnormal blood vessels to grow on the iris (colored part of the eye) and in the drainage channels in the front of the eye.  This can block the normal flow of fluid out of the eye. Pressure in the eye can build up, resulting in neovascular glaucoma, a severe eye disease that causes damage to the optic nerve.

How is diabetic retinopathy diagnosed?

 How is diabetic retinopathy treated?

The best treatment is to prevent the development of retinopathy as much as possible.  Strict control of your blood sugar will significantly reduce the long-term risk of vision loss from diabetic retinopathy.  If high blood pressure and kidney problems are present, they need to be treated.

Medical Treatment: In certain cases, your Eye M.D. may choose to treat your macular edema with injections of medicine in your eye.  These special shots of medicine--called intravitreal injections--may be steroids or other medications.  They are designed to shrink the swelling of the macula.

Laser surgery:  Laser surgery is often recommended for people with macular edema, PDR, and neovascular glaucoma. 

For macular edema, the laser is focused on the damaged retina near the macula to decrease the fluid leakage.  The main goal of treatment is to prevent further loss of vision.  It is uncommon for people who have blurred vision from macular edema to recover normal vision, although some may experience partial improvement.  A few people may see the laser spots near the center of their vision following treatment.  The spots usually fade with time but may not disappear.

For PDR, the laser is focused on all parts of the retina except the macula.  This panretinal photocoagulation treatment causes abnormal new vessels to shrink and often prevents them from growing in the future.  It also decreases the chance that vitreous bleeding or retinal distortion will occur.

Multiple laser treatments over time are sometimes necessary.  Laser surgery does not cure diabetic retinopathy and does not always prevent further loss of vision. 

Vitrectomy:  In advanced PDR, your ophthalmologist may recommend a vitrectomy.  During this microsurgical procedure, which is performed in operating room, the blood-filled vitreous is removed and replaced with a clear solution.  Your ophthalmologist may wait for several months to see if the blood clears on its own before performing a vitrectomy.

Vitrectomy often prevents further bleeding by removing the abnormal vessels that caused the bleeding. If the retina is detached, it can be repaired during vitrectomy surgery.  Surgery should usually be done early because macular distortion or tractional retinal detachment will cause permanent visual loss.  The longer the macula is distorted or out of place, the more serious the vision loss will be.

Vision loss is largely preventable

If you have diabetes, it is important to know that today, with improved methods of diagnosis and treatment, a smaller percentage of people who develop retinopathy have serious vision problems.  Early detection of diabetic retinopathy is the best protection against loss of vision.

You can significantly lower your risk of vision loss by maintaining strict control of your blood sugar and visiting your ophthalmologist regularly.

When to schedule an examination

People with diabetes should schedule examinations at least once a year. More frequent medical eye examinations may be necessary after a diagnosis of diabetic retinopathy.

Pregnant women with diabetes should schedule an appointment in the first trimester, because retinopathy can progress quickly during pregnancy.

If you need to be examined for eyeglasses, it is important that your blood sugar be consistently under control for several days when you see your ophthalmologist.  Eyeglasses that work well when blood sugar is out of control will not work when blood sugar is stable.

Rapid changes in blood sugar can cause fluctuating vision in both eyes even if retinopathy is not present.

You should have your eyes checked promptly if you have visual changes that:

• affect either one or both eyes;
• last more than a few days;
• are not associated with a change in blood sugar

When you are first diagnosed with diabetes, you should have your eyes checked:

• within five years of the diagnosis if you are 29 years old or younger;
• within a few months of the diagnosis if you are 30 years old and older.

Diabetic Retinopathy. A Closer Look. (2007).  American Academy of Ophthalmology.  San Francisco.