Malaysian Society of Ophthalmology (MSO)

Diabetic Retinopathy

About Diabetic Retinopathy

Diabetes

Diabetes mellitus is a disease where there is too much sugar (glucose) in the blood. It is caused by abnormal metabolism of insulin, a hormone that regulates blood sugar in the body. Unless it is treated, diabetes will damage the eyes, kidneys and other important organs in the body.

Diabetes is a major health problem in Malaysia, affecting more and more people each year. In 2015, the Malaysian Health Ministry estimated that 1 out of 6 persons (17.5%) aged 18 years and above had diabetes. Currently, Malaysia has the highest rates of diabetes and obesity in South East Asia, ranking among the highest in the world.

What is Diabetic Retinopathy?

Diabetic retinopathy is a complication of diabetes that can cause blindness. Diabetes damages blood vessels in the light-sensitive nerve layer inside the eye (retina). When damaged blood vessels leak, they cause the retina to swell. They may also get blocked, causing less oxygen to reach the retina. The longer a person has had diabetes, the more likely it is for diabetic retinopathy to develop.

Diabetic retinopathy usually affects both eyes. It is a common cause of poor eyesight in diabetes. It is also a leading cause of blindness among adults of working age.

Watch how diabetes retinopathy affected Johan's life

Types of Diabetic Retinopathy

There are 3 main ways to describe diabetic retinopathy:

1. Non-proliferative diabetic retinopathy (NPDR)

This is an earlier and less severe stage. Blood vessel damage can be seen as areas of bleeding, leaking and swelling on the retina. Patients usually do not notice any eyesight problems at this time.

Healthy retina

2. Proliferative diabetic retinopathy (PDR)

This is a later and more serious stage where abnormal new blood vessels and scar tissue form inside the eye. These new blood vessels break easily, causing bleeding into the eyeball. As the condition gets worse, patients start to have problems with their eyesight. The retina will become permanently scarred if proliferative retinopathy is not detected and treated quickly.

Bleeding and leaking on the retina

3. Diabetic maculopathy

The macula is the vital part of the retina that is responsible for sharp vision. When diabetic retinopathy affects the macula (diabetic maculopathy), patients will find it difficult to read small print or to recognise faces easily.

Bleeding into eye ball

Signs and Symptoms

At first, there are no symptoms and most patients are unaware that they have retinopathy. Later, they may experience:

Spots or other shadows floating in the vision (floaters)
Blurred or fluctuating vision
Dark areas in the vision
Flashes of light
Loss of vision

Complications, Preventions & Treatment Options

How Does Diabetes Lead to Blindness?

Diabetic retinopathy damages vision in the following ways:

Abnormal blood vessels bleed into the clear gel inside the eye - vitreous haemorrhage. If the amount of bleeding is small, the patient may see only a few dark spots (floaters) in the vision. Severe bleeding can block vision completely.
The blood in the vitreous may clear on its own over weeks or months, with vision returning to the previous level. However, if fresh bleeding occurs repeatedly, the vision will remain poor.
Scar tissues form that pull the retina away from the back of the eye - retinal detachment.
Abnormal new blood vessels in the front of the eye block the normal outflow of fluid from the eyeball, causing high eye pressure - neovascular glaucoma. The high pressure damages the nerve for vision (optic nerve).

Vitreous Haemorrhage

Retinal Scarring

Diabetic retinopathy, neovascular glaucoma, or both can finally lead to blindness. Although the blind eye is usually painless, patients with neovascular glaucoma frequently experience constant eye irritation or pain.

Can I Avoid Getting Diabetic Retinopathy?

The longer a person has had diabetes, the higher the risk of developing diabetic retinopathy. Although diabetic retinopathy is not completely avoidable, you can reduce your risk of getting it, if you:

Control your blood sugar levels

This is crucial. Eating a healthy diet; taking the prescribed medications; monitoring your blood sugar levels; keeping regular appointments with the doctor; taking regular exercise; and maintaining a healthy body weight will all help to achieve this.

Control your blood pressure and lipids (fats, including cholesterol)

Go for regular eye screening examinations

Do not wait until you experience vision problems. Getting regular eye screening examinations will allow any dangerous diabetic retinopathy to be detected and treated before further damage occurs.

See an eye doctor (ophthalmologist)

See an eye doctor (ophthalmologist) without delay if you notice any eye sight problems such as blurriness and floaters. Treatment is more effective when the problem is detected early.

Do not smoke

Smoking damages small blood vessels and worsens many of the health problems that affect people with diabetes.

Treatment for Diabetic Retinopathy

Patients with early stages of retinopathy do not need treatment but they must be followed up regularly in case treatment becomes necessary.

Treatment is needed when patients have more severe retinopathy and are at risk of losing their sight. Various treatments are available to stop blood vessels from leaking; reverse the growth of abnormal new vessels; and remove blood or scar tissue in the eye.

Injections of anti-VEGF medications into the eye

Patients usually need a few injections, given about 1 month apart. The doctor will numb the eye with eye drops before doing the injection. These medications include Aflibercept, Ranibizumab and Bevacizumab (off-label).

Laser photocoagulation of the retina

This clinic procedure is an important treatment for proliferative diabetic retinopathy. It involves applying very tiny burns to the retina using laser light, usually over 2 or 3 sessions. Patients may need more sessions if blood in the vitreous gel prevents the laser from reaching the retina effectively.

Vitrectomy

Vitrectomy is an operation that is done for more advanced disease. The eye surgeon makes tiny cuts on the eye in order to remove blood from the vitreous gel and scar tissue from the retina. This is performed in the operating theatre, either with patient awake (local anaesthesia) or unconscious (general anesthesia). He/she is usually in hospital for only half a day, but sometimes overnight.

It is important to know that damage from diabetic retinopathy cannot be completely reversed, and successful treatment only slows or stops it from getting worse. Patients will have some degree of permanently blurry eyesight if they receive treatment late.

If all treatments fail, as can happen in very late stages of diabetic retinopathy, the eye will go blind. Early detection and timely treatment of diabetic retinopathy reduces the risk of blindness by 95 percent.

FAQ

1. What is a Diabetic Eye Examination?

A diabetic eye examination involves an examination of the retina (the light-sensitive nerve layer inside the eye).
It is not only a test of how well you can see, or a test to see if you need to wear glasses.

There are two kinds of diabetic eye examination:

1. Screening test

Screening tests are done to detect diabetic retinopathy before patients themselves notice any problems with their vision.

It involves using a special camera to take photographs of the retinae. Apart from seeing a bright flash of light, you will experience no discomfort at all. This test may not be possible if your pupils are too small or if your eye tissues are not clear.

Some centres may put an eye drop into your eyes to dilate your pupils for the test. If this is done, you will experience slightly blurry vision for up to several hours.

Retinal Photography

2. Detailed eye examination

An eye doctor reviews your medical history and does a detailed eye examination, checking for diabetic retinopathy and other conditions like cataract and glaucoma.

This takes longer than a screening test and usually involves dilating your pupils with eye drops. You will experience slightly blurry vision for several hours until the eye drop wears off. In the meantime, sunglasses will help to reduce any glare. You may wish to arrange for someone to drive you home after the test.

2. How Can I Get a Diabetic Eye Examination?

If you live in Malaysia, these are the ways you can get a diabetic retinal examination:

1. Ask the doctor who is treating you for diabetes to check your vision and retina once a year.

If he/she is does not perform these tests, he/she can advise you on how to get the test.

2. See an eye specialist doctor (ophthalmologist) in any private eye clinic or hospital.

This is a good option if you have a problem with your eyesight as you can get to see a specialist very quickly. Depending on where you go and what tests you need, a visit to a private clinic usually costs RM100 and above.

3. See an eye doctor in a government hospital.

If you have eyesight problems, you may ask your regular doctor to refer you to a government eye doctor. Bring the referral letter to the eye clinic to get an appointment. You may have to wait a few weeks for an appointment if your condition is not urgent, since government clinics have many patients to look after. The charges are nominal.

4. Get a screening test at a government clinic.

If you are a diabetes patient of a government clinic, you can get screening with retinal photography every year at a Klinik Kesihatan or government eye clinic. You will be given an appointment to see an eye doctor if your photographs are abnormal or if your eyesight is poor.

If you are not a patient of a government clinic, you could see a Medical Officer in a Klinik Kesihatan and ask for a diabetic eye examination. The charges are nominal but getting an appointment may take time.

5. Get a screening test using retinal photography at a private facility.

There are very few places that have this service. You may choose this option if you do not have any eyesight symptoms. However, if you already have symptoms, you should go directly to see an eye doctor instead of doing this screening test.

The few available services include:

Eye Photo, Petaling Jaya, by the Malaysian Society of Ophthalmology
This is a free community service for diabetic retinopathy screening using a camera donated by Bank Simpanan Nasional (BSN). The non-medical office staff will capture and print the pictures for you; you will need to ask your own doctor to interpret the pictures.
Sau Seng Lum Diabetes Clinic, Petaling Jaya
This Buddhist organization runs a charitable diabetic clinic that offers diabetic retinopathy screening. It accepts walk in patients as well as referrals from medical doctors. The charges are low or nominal.
Sunway Medical Centre (Eye Centre), Petaling Jaya
This is a commercial service using a wide-field retinal camera that captures a wide view of the retina. An optometrist takes the retinal photographs and gives a report for your own doctor to review. The pictures are not printed and you do not see an eye doctor. The charge is RM50 (correct as at August 2016).

You may find other retinal photography services by making local inquiries. If you know of any other services available, please contact us for listing.

3. When Should I Have a Diabetic Eye Examination?*

Most people with type 2 diabetes or non-insulin dependent diabetes mellitus (NIDDM) should have their first eye examination as soon as they are diagnosed, and then once a year.

Children with type 1 diabetes or insulin-dependent diabetes mellitus (IDDM) may have their first eye examination within 2 - 5 years after diagnosis, and then once a year.

Pregnancy can seriously worsen diabetic retinopathy. Women with diabetes are recommended to have their eyes checked and treated for any diabetic retinopathy before, or as soon as possible after, getting pregnant. The check should be repeated every 3 months throughout the pregnancy. This recommendation also applies to women with gestational diabetes in their first trimester of pregnancy. Generally, women who develop gestational diabetes after the first trimester do not need an eye examination.

You will need more frequent eye examinations once diabetic retinopathy has developed.

* Adapted from the Clinical Practice Guidelines for the Screening of Diabetic Retinopathy, Malaysian Ministry of Health, 2011.