Diabetes, a well-known disease deeply rooted in human history, can be traced back to 250-300 B.C., when urine was unusually sweet. In 1889, Mering and Minkowski experimentally removed the canine pancreas, which led to severe diabetes in experimental dogs, thus revealing the key role of the pancreas in the pathogenesis of diabetes. Since then, the medical community has made significant progress in understanding and understanding diabetes, with a variety of innovative drugs and methods emerging.
Diabetes not only affects multiple systems in the body, but it can also cause a range of serious complications. Diabetic retinopathy (DR) is a serious complication of diabetes, especially in China, where it has become the leading cause of blindness in people aged 40 to 60 years.
Diabetic retinopathy is an important complication caused by diabetes, it mainly affects the retina of the eye, in diabetic patients, due to the long-term high blood sugar environment, the microvessels on the retina are damaged, so that the retinal ischemia condition continues to worsen, like a long-term lack of water and gradually withered trees, resulting in loss of retinal function, thereby affecting vision.
Diabetic retinopathy can be understood by a simple analogy: if the eye is compared to a camera, the retina is equivalent to the negative in the camera. Retinopathy caused by diabetes is like a problem with the negative, which prevents the camera from imaging clearly, and similarly, the eye's vision will be reduced.
Diabetic retinopathy is a manifestation of microvascular end-organ damage caused by diabetes. Its course can progress from nonproliferative diabetic retinopathy (NPDR) to proliferative diabetic retinopathy (PDR). As the disease progresses, it may be accompanied by the development of diabetic macular edema (DME). Diabetic retinopathy is one of the leading causes of vision loss worldwide in patient populations between the ages of 25 and 74.
Today, diabetes remains one of the most common noncommunicable diseases worldwide. It is estimated that more than 34 million adults in the United States had diabetes in 2018. This situation is even more prevalent in China, where there are not only up to 600 million people with myopia, nearly half of whom are highly myopia, but also nearly 1300 million diabetics. About 30% of them, or about 39 million patients, also have diabetic retinopathy, and more than 12 million of them are at risk of blindness.
In the future, the impact of diabetic retinopathy will be further amplified. According to **, by 2030, there will be about 19.1 billion people have diabetic retinopathy, of which about 56.3 million may face sight-threatening diabetic retinopathy. Especially in patients who have had diabetes for 20 years, certain studies have shown that almost all patients with type 1 diabetes (99%) and most people with type 2 diabetes (60%) will develop retinopathy of varying severity. This data highlights the prevalence and severity of diabetic retinopathy as a long-term complication. Therefore, diabetes and its complications, especially the prevention and prevention of diabetic retinopathy, have become a major challenge for ophthalmologists and public health workers.
Influencing factors. The development of diabetic retinopathy is influenced by a variety of factors. The occurrence of diabetic retinopathy is not only related to poor blood sugar control, but also affected by a variety of other factors, such as hypertension and hyperlipidemia.
At the same time, in addition to diabetes itself, elevated hemoglobin A1c (HbA1C) levels and blood pressure are also strongly associated with an increased risk of diabetic retinopathy. This means that in order to prevent and slow the progression of diabetic retinopathy, patients need to control their blood sugar and blood pressure in a comprehensive manner and maintain a healthy lifestyle.
In our daily lives, while health risks cannot be completely avoided, just as trees wilt when water is scarce, we can take proactive measures as guardians of our own health. Getting regular eye exams to stay up-to-date on the health of your eyes is like listening to your eyes' needs and helping them cope with challenges and regain their sight. This is especially important for people with diabetes.
*。The science of diabetic retinopathy reveals how this complication develops from different types of diabetes. Type 1 diabetes (T1DM) is usually caused by the destruction of pancreatic cells by autoimmune mechanisms, while type 2 diabetes (T2DM) is more related to lifestyle and genetic factors. Although the two are different, they both can lead to retinopathy, the end-organ manifestation of diabetes.
Type 2 diabetes is strongly associated with genetic factors, and a variety of genetic factors have been identified that influence its development, such as TCF7L2, Notch2, KCNQ1, JAZF1, and Mody, among others. Type 1 diabetes is characterized by the presence of antibodies against specific pancreatic cell proteins in more than 90% of newly diagnosed patients, resulting in gradual cell loss and reduced insulin release, resulting in the development of diabetes.
The main factor in the development of diabetic retinopathy is retinal microvascular damage caused by long-term hyperglycemic states. This is similar to the situation where a riverbed is damaged due to pollution, in which case the microvessels may occlude, causing the retina to be in a state of ischemia and hypoxia, which in turn causes lesions.
Risks: Who is more likely to develop diabetic retinopathy?
So, which populations are more likely to develop this complication? Why did it happen?
People with type 1 diabetes diagnosed with diabetes before the age of 30 have a 50% chance of developing retinopathy after 10 years, and this rises to 90% after 30 years. For patients with type 2 diabetes, fundus lesions occur in more than 50% of patients with a duration of more than 5 to 10 years, especially if blood sugar control is poor.
The longer the course of the disease in diabetic patients, the prevalence and blindness of diabetic retinopathy also increase year by year. For example, the incidence of retinopathy is 30% within 5 years, 50% within 10 years, 60% within 15 years, and 80% at 25 years.
In addition to the course of the disease, blood glucose, blood pressure, and lipids are the three important risk factors for diabetic retinopathy. Large fluctuations in blood glucose and poor control can accelerate the progression of diabetic reticulum and increase the morbidity. Other risk factors include proteinuria, pregnancy, body mass index, racial differences, genetic factors, and undesirable habits such as smoking and alcohol consumption.
Understanding these risk factors and making targeted improvements and interventions is key to preventing and slowing down diabetic retinopathy. For patients in high-risk groups, lifestyle modifications, aggressive control of diabetes, blood pressure and lipid levels, and regular eye exams can effectively save vision and reduce the impact of retinopathy.
Pathology. There are two main types of diabetic retinopathy: non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR). The key difference is the presence or absence of abnormal neovascularization: in proliferative diabetic retinopathy**; Nonproliferative diabetic retinopathy does not, also known as simplex or background. This classification helps guide the approach and progression.
During the pathophysiology of diabetic retinopathy, the ischemic retina secretes vascular endothelial growth factor (VEGF), leading to two main problems: (a) increased vascular permeability, which in turn causes retinal swelling or edema; (b) Angiogenesis or neovascularization.
The main factors that affect vision include:
capillary leakage, leading to diabetic macular edema (DME); capillary occlusion; Complications after retinal ischemia such as retinal neovascularization, vitreous hemorrhage, traction retinal detachment, and neovascular glaucoma. The pathological features of diabetic retinopathy reveal how the disease affects the retina and causes visual impairment.
Diagnosis. The diagnostic process of diabetic retinopathy involves symptoms, a physical examination, and a detailed evaluation using specialized equipment.
In terms of symptoms, symptoms of diabetic retinopathy may include decreased or fluctuating vision, the presence of floating objects, loss of visual field, etc. These symptoms may be due to lens or macular edema, vitreous hemorrhage, or traction retinal detachment. Understanding the patient's blood glucose and blood pressure control is also an important part of the diagnosis.
Physical examination and physical examination include slit lamp examination and fundus examination after pupil dilation. Slit-lamp examination is mainly used to observe abnormalities in the anterior part of the eyes, such as iris neovascularization; A dilated fundus examination evaluates the macula and other parts of the retina.
The use of specialized diagnostic tools is key in diagnosing diabetic retinopathy. Fluorescein fundus angiography (FA) can detect microvascular abnormalities such as microaneurysms, retinal edema, and neovascularization; Optical coherence tomography (OCT) can reveal retinal structures, including edema and retinal thickness.
For people with diabetes, regular eye exams, including slit lamp examination, dilated fundus examination, fluorescein angiography, and optical coherence tomography, are essential. In addition, regular testing of hemoglobin A1c levels is also necessary to help assess the degree of glycemic control over the past 3 months. For most patients, the ideal target range for HbA1c is 55%-6.0%, or at least keep it below 7%. For older patients, a slightly higher HbA1c target may be set.
Through these comprehensive diagnostic steps, doctors can accurately diagnose diabetic retinopathy and develop a corresponding plan based on the severity of the condition.
Differential diagnosis. In the diagnosis of diabetic retinopathy, differential diagnosis is crucial because it helps doctors distinguish diabetic retinopathy from other diseases with similar presentations. These include:
For macular edema with retinal hemorrhage:
Radiation retinopathy: Confirmation of whether the patient has been exposed to radiation** is required. Venous occlusion: manifested by vascular occlusion and telangiectasia. **Paraconcave telangiectasia: characterized by telangiectasia. For retinal neovascularization:
Venous occlusion: retinal neovascularization that may result from venous occlusion needs to be considered. Retinal vasculitis: may be accompanied by inflammatory manifestations of retinal neovascularization. Sarcoidosis: retinal neovascularization may occur in some patients. Ocular ischemic syndrome: retinal neovascularization due to ischemic reaction. Sickle cell retinopathy: predominantly peripheral neovascularization. For iris neovascularization:
Vein occlusion: may lead to the formation of new vascularization of the iris. Ocular ischemic syndrome: Iris neovascularization due to ocular ischemia. Through a detailed history, a careful physical examination, and imaging tests, doctors can make an accurate differential diagnosis.
Other ocular complications of diabetes.
Diabetes not only affects the body's blood sugar levels, but can also trigger a range of eye complications. For example, people with diabetes may develop telangiectasias of the conjunctiva and even microangiomas. These symptoms may sound professional, but in simple terms, they are like tiny blood vessels in the eye being "attacked" by diabetes.
In addition, the cornea may be uncomfortable, manifesting as decreased sensation and epithelial exfoliation, iris may develop irisitis, and even neovascular glaucoma may occur. These conditions may sound complicated, but they all point to a common cause – the effects of diabetes on the eyes.
Diabetes can also cause cataracts, ophthalmoplegia, changes in refraction, and even affect the optic nerve, causing vitreous hemorrhage. Among these complications, the most serious is diabetic retinopathy, especially macular edema, which is the most common complication. Macular edema may sound professional, but it is actually the ** area of the eye that is "edematous", which seriously affects vision.
Be wary: diabetic retinopathy is likely to lead to blindness! It is also one of the leading causes of blindness in adults. When diabetic retinopathy progresses to a certain level, it can lead to macular edema, vitreous hemorrhage, and even retinal detachment. The most severe cases are traction retinal detachment and neovascular glaucoma, when patients may experience extreme pain and blindness at the same time.
*。Can diabetic retinopathy be a**?
The answer is yes. However, the protocol needs to be customized according to the different stages and severity of the lesion. Different stages and severity of illness mean different prognosis. For example, panretinal photocoagulation** is often considered when diabetic retinopathy enters a severe non-proliferative phase or early proliferative phase. This stage is when neovascularization is just beginning to appear, but there are no fibroproliferative changes. Once the lesion enters the proliferative phase, surgery** becomes an option.
When it comes to diabetic retinopathy, we need to take a holistic approach:
System control: comprehensive control of diabetes, hypertension, dyslipidemia, etc., which is the basis of the best.
*and follow-up: Different methods are selected for different symptoms.
Diabetic macular edema**: Retinal edema can be stabilized with a laser** to reduce edema, or retinal edema can be reduced by injecting anti-VEGF drugs or corticosteroids. The choice of drug is essential to improve the effect. Proliferative diabetic retinopathy**: Laser photocoagulation** is used in the peripheral part of the retina to reduce the formation of new blood vessels. In some cases, injections of anti-VEGF drugs can be used as an alternative or adjunct to laser**. In severe cases, vitrectomy may be required. Surgery** does manage the progression of diabetic retinopathy to some extent and may help improve vision in some cases. The main goals of surgery include removal of vitreous hemorrhage, release of vitreoretinal traction, retinal reduction, and, if necessary, completion of laser**. Surgery can include retinal photocoagulation, removal of fibrous membranes, intraocular filling with silicone oil or inert gas, etc., to help retinal replacement. For early diabetic retinopathy, the success rate of surgery is usually high, exceeding 90%, which is effective in controlling the progression of the disease and potentially improving vision. However, in advanced stages of the disease, the success rate of surgery** and vision recovery may be reduced. Purpose of surgery: Removal of blood and scar tissue from the eye, laser if necessary**. Risks of complications from surgery: These include the risk of infection and the possibility of accelerating the development of cataracts. The management of the whole body condition is very important throughout the process. This includes effective control of diabetes, hypertension, hyperlipidemia, etc. Postoperative follow-up focuses on recovery, risk of complications, and prognosis. Changes in the patient's condition need to be closely monitored during the process and measures adjusted according to the patient's specific needs.
Prophylaxis. The above may sound worrying, but here's what the general public needs to know: Blindness due to diabetic retinopathy is preventable with strict blood sugar control, early detection and**.
To prevent diabetic retinopathy, patients need to work hard to control their blood sugar and blood pressure. Studies have shown that a 1% reduction in mean HbA1c significantly reduces multiple risks associated with diabetes, including endpoint risk, mortality and myocardial infarction, and the risk of microvascular complications.
Diabetic retinopathy is often undetectable in the early stages because patients often have no obvious symptoms of discomfort. But once the lesion progresses to a later stage, the visual impairment is often irreversible and may even lead to blindness. Fortunately, more than 90% of blindness can be avoided through regular fundus screening and early diagnostic intervention.
However, fundus lesion screening still faces many challenges, such as patient neglect, shortage of professional ophthalmologists, and imbalance of medical resources between urban and rural areas. In this context, the application of artificial intelligence technology in the medical field shows great potential. Especially in the field of ophthalmology, there is already artificial intelligence software that can automate diagnosis. These software use deep learning of medical images to make diagnoses quickly and accurately, which is a boon especially for patients in low-resource settings.
However, even with the assistance of artificial intelligence, early screening and intervention of diabetes complications still require the support of professional ophthalmologists and medical resources. The field of ophthalmic medicine is undergoing a revolution brought about by AI technology, which is not only the advancement of medical technology, but also the far-reaching care for the health of patients.
For people with diabetes, it is important to know when to perform fundus screening. For patients with type 1 diabetes, fundus examination is recommended starting after puberty and following up once a year. For people with type 2 diabetes, screening should be started at the time of diagnosis and annually thereafter. Patients with gestational diabetes should be screened before or 3 months into pregnancy.
Finally, by controlling blood sugar, blood lipids, and blood pressure, diabetic patients can effectively reduce or delay the occurrence of retinopathy. This is not only responsible for one's own health, but also caring for one's family.
Diabetes