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Retinopathy, Diabetic

Retinopathy, Diabetic is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Noninflammatory retinal disorder characterized by retinal capillary closure and microaneurysms. Retinal ischemia leads to release of a vasoproliferative factor, stimulating neovascularization on retina, optic nerve, or iris.
  • Most patients with diabetes mellitus (DM) will develop diabetic retinopathy (DR). It is the leading cause of new cases of legal blindness among residents in the United States between the ages of 20 and 64 years.
  • DR can be divided into three stages.
    • Nonproliferative (background)
    • Severe nonproliferative (preproliferative)
    • Proliferative
  • System(s) affected: nervous

Geriatric Considerations
Prevalence will increase, as population generally ages and patients with diabetes live longer.

Pregnancy Considerations
  • Pregnancy can exacerbate condition.
  • Pregnant diabetic women should be examined in 1st trimester and then every 3 months until delivery.

Epidemiology

Incidence
  • Peak incidence of type 1, juvenile-onset DM is between the ages of 12 and 15 years. In type 1 DM (T1DM), there is beta cell destruction, leading to insulin deficiency.
  • Peak incidence of type 2, adult-onset DM is between the ages of 50 and 70 years. Type 2 DM (T2DM) ranges from a condition characterized by insulin resistance with relative insulin deficiency to one that is predominantly an insulin secretory defect with insulin resistance.
  • Incidence of DR is directly related to the duration of diabetes.
  • <10 years of age, it is unusual to see DR, regardless of DM duration.

Prevalence
  • 6.6% of the U.S. population between ages of 20 and 74 years has DM.
  • ~25% of the diabetic population has some form of DR.
  • Predominant age
    • Risk increases after puberty.
    • 2/3 of juvenile-onset diabetics who have had DM for at least 35 years will develop proliferative DR (PDR), and 1/3 will develop macular edema. Proportions are reversed for adult-onset diabetes.
  • Predominant sex: male = female (type 1, juvenile-onset DM); female > male (type 2)

Etiology and Pathophysiology

  • Related to development of diabetic microaneurysms and microvascular abnormalities
  • Reduction in perifoveal capillary blood flow velocity, perifoveal capillary occlusion, and increased retinal thickness at the central fovea in diabetic patients are associated with visual impairment in patients with diabetic macular edema (DME).
  • Vascular endothelial growth factor (VEGF) is elevated in patients with hypoxic retina. Intraocular levels of VEGF are elevated in patients with retinal or iris neovascularization. Retinal hypoxia also contributes to DME, and VEGF is a major contributor to DME.

Risk Factors

  • Duration of DM (usually >10 years)
  • Poor glycemic control
  • Pregnancy
  • Renal disease
  • Systemic hypertension (HTN)
  • Smoking
  • Elevated lipid levels associated with increased risk of retinal lipid deposits (hard exudates)
  • Myopic eyes (eyes with longer axial length) have a lower risk of DR.

General Prevention

  • See “General Measures.”
  • Monitor and control of blood glucose.
  • Schedule yearly ophthalmologic eye exams.

Commonly Associated Conditions

  • Glaucoma
  • Cataracts
  • Retinal detachment
  • Vitreous hemorrhage (VH)
  • Disc edema (diabetic papillopathy); may occur in T1DM and T2DM

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Citation

Stephens, Mark B., et al., editors. "Retinopathy, Diabetic." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116528/all/Retinopathy__Diabetic.
Retinopathy, Diabetic. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116528/all/Retinopathy__Diabetic. Accessed April 24, 2019.
Retinopathy, Diabetic. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116528/all/Retinopathy__Diabetic
Retinopathy, Diabetic [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 24]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116528/all/Retinopathy__Diabetic.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Retinopathy, Diabetic ID - 116528 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116528/all/Retinopathy__Diabetic PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -