Diabetic retinopathy – the specific angiopatiya striking vessels of a mesh cover of an eye and developing against the background of the long course of diabetes. The diabetic retinopathy has the progressing current: in initial stages blurring of sight, a veil and floating spots before eyes is noted; in late – sharp decrease or loss of sight. Diagnostics includes carrying out consultations of the ophthalmologist and a diabetolog, oftalmoskopiya, biomicroscopy, a vizometriya and perimetry, an angiography of vessels of a retina, biochemical blood test. Treatment of a diabetic retinopathy demands system maintaining diabetes, correction of metabolic violations; at complications – intravitrealny introduction of medicines, carrying out a lazerkoagulyation of a retina or a vitrektomiya.
The diabetic retinopathy is a high-specific late complication of diabetes, both insulin-dependent, and insulinnezavisimy type. In ophthalmology the diabetic retinopathy acts as the disability reason on sight at patients with diabetes in 80-90% of cases. At the persons having diabetes, the blindness develops in 25 times more often than at other representatives of the general population. Along with a diabetic retinopathy, the people having diabetes have the increased risk of emergence of IBS, diabetic nephropathy and polyneuropathy, cataract, glaucoma, occlusion of TsAS and TsVS, diabetic foot and gangrene of extremities. Therefore questions of treatment of diabetes demand the multidisciplinary approach including participation of experts of endocrinologists (diabetolog), ophthalmologists, cardiologists, chiropodists.
Reasons and risk factors
The mechanism of development of a diabetic retinopathy is connected with damage of retinalny vessels (blood vessels of a retina): their increased permeability, occlusion of capillaries, emergence of neogenic vessels and development of proliferative (cicatricial) fabric.
Most of patients with the long course of diabetes have these or those signs of defeat of an eye bottom. With duration of a course of diabetes up to 2 years the diabetic retinopathy in a varying degree comes to light at 15% of patients; up to 5 years – at 28% of patients; up to 10-15 years – at 44-50%; about 20-30 years – at 90-100%.
Carry duration of a course of diabetes, hyperglycemia level, arterial hypertension, a chronic renal failure, a dislipidemiya, a metabolic syndrome, obesity to the major factors of risk influencing the frequency and speed of progressing of a diabetic retinopathy. Development and progressing of a retinopathy can be promoted by pubertatny age, pregnancy, hereditary predisposition, smoking.
Taking into account the changes developing at an eye bottom distinguish not proliferative, preproliferativny and proliferative diabetic retinopathy.
The increased, badly controlled level of sugar of blood leads to damage of vessels of various bodies, including retinas. In not proliferative stage of a diabetic retinopathy of a wall of retinalny vessels become permeable and fragile that leads to dot hemorrhages, formation of microaneurisms - to local meshotchaty expansion of arteries. Through semipermeable walls from vessels the liquid fraction of blood filters into a retina, leading to retinalny hypostasis. In case of involvement in process of the central area of a retina makulyarny hypostasis develops that can lead to decrease in sight.
In a preproliferativny stage the progressing retina ischemia caused by occlusion , hemorrhagic heart attacks, venous violations develops.
The Preproliferativny diabetic retinopathy precedes the following, proliferative stage which is diagnosed for 5-10% of patients with diabetes. Carry to the promoting factors of development of a proliferative diabetic retinopathy short-sightedness of high degree, occlusion of carotids, a back otsloyka of a vitreous body, an atrophy of an optic nerve. In this stage owing to the oxygen insufficiency tested by a retina in it for support of adequate level of oxygen new vessels begin to be formed. Process of a neovaskulyarization of a retina leads to the repeating preretinalny and retrovitrealny hemorrhages.
In most cases insignificant hemorrhages in layers of a retina and a vitreous body resolve independently. However at massive hemorrhages in an eye cavity (gemoftalma) there is an irreversible fibrous proliferation in a vitreous body which is characterized by fibrovaskulyarny unions and scarring that as a result leads to a traction otsloyka of a retina. When blocking ways of outflow of VGZh secondary neovascular glaucoma develops.
Symptoms of a diabetic retinopathy
The disease develops and progresses without serious consequences and malosimptomno – her main insidiousness consists in it. In not proliferative stage decrease in sight subjectively is not felt. Makulyarny hypostasis can cause a feeling of blurring of visible objects, difficulty of reading or performance of work at a short distance.
In a proliferative stage of a diabetic retinopathy, when developing intraocular hemorrhages before eyes there are floating dark stains and a veil which disappear independently after a while. At massive hemorrhages in a vitreous body sharply there occurs decrease or total loss of sight.
Regular survey of the ophthalmologist for the purpose of identification of initial changes of a retina and prevention of a proliferating diabetic retinopathy is necessary for patients with diabetes.
For the purpose of screening of a diabetic retinopathy to patients the vizometriya, perimetry, biomicroscopy of a forward piece of an eye, eye biomicroscopy with Goldman's lens, a diafanoskopiya of structures of an eye, a tonometriya across Maklakov, an oftalmoskopiya under midriazy is carried out.
For definition of a stage of a diabetic retinopathy the oftalmoskopichesky picture has the greatest value. In not proliferative stage of an oftalmoskopicheska microaneurisms, "soft" and "solid" exudates, hemorrhages are found. In a proliferative stage the picture of an eye bottom is characterized by intraretinalny microvascular anomalies (arterial shunts, expansion and an izvitost of veins), preretinalny and endoviteralny hemorrhages, a neovaskulyarizatsiy retina and DZN, fibrous proliferation. For documenting of changes on a retina a series of photos of an eye bottom by means of the fundus-camera is carried out.
At pomutneniye of a crystalline lens and a vitreous body instead of an oftalmoskopiya resort to performing ultrasonography of an eye. For the purpose of assessment of safety or violation of functions of a retina and an optic nerve electrophysiological researches are conducted (an elektroretinografiya, definition of KChSM, an elektrookulografiya, etc.). For detection of neovascular glaucoma the gonioskopiya is carried out.
The fluorescent angiography allowing to register a blood-groove in horeoretinalny vessels acts as the most important method of visualization of vessels of a retina. The optical coherent and laser scanning retina tomography can serve as an alternative of an angiography.
For definition of risk factors of progressing of a diabetic retinopathy the research of level of glucose of blood and urine, insulin, glikozilirovanny hemoglobin, a lipidic profile, etc. indicators is conducted; UZDG of kidney vessels, EhoKG, ECG, daily monitoring HELL.
In the course of screening and diagnostics identification of the changes indicating progressing of a retinopathy and need of performing treatment for the purpose of the prevention of decrease or loss of sight is necessary earlier.
Treatment of a diabetic retinopathy
Along with the general principles of treatment of retinopathies therapy includes correction of metabolic violations, optimization of control of glycemia level, HELL, lipidic exchange. Therefore at this stage the main therapy is appointed by the endocrinologist-diabetologom and the cardiologist.
Careful control of level of a glycemia and glucosuria, selection of adequate insulin therapy of diabetes is exercised; purpose of vasoprotectives, hypotensive means, antiagregant, etc. is made. For the purpose of treatment of makulyarny hypostasis intravitrealny injections of steroids are carried out.
Carrying out laser coagulation of a retina is shown to patients with the progressing diabetic retinopathy. Lazerkoagulyation allows to suppress process of a neovaskulyarization, to achieve an obliteration of vessels with the increased fragility and permeability, to prevent risk of an otsloyka of a retina.
In laser surgery of a retina at a diabetic retinopathy several main methods are used. The barrier lazerkoagulyation of a retina assumes drawing paramakulyarny coagulates as "lattice", in several rows and is shown at not proliferative form of a retinopathy with makulyarny hypostasis. Focal laser coagulation is applied to cauterization of microaneurisms, exudates, the small gemorragiya revealed during an angiography. In the course of panretinalny laser coagulation coagulates are put on all zone of a retina, except for makulyarny area; this method is generally applied at a preproliferativny stage to the prevention of its further progressing.
At turbidity of optical environments of an eye as an alternative of a lazerkoagulyation serves the transskleralny krioretinopeksiya based on Holodova of destruction of pathological sites of a retina.
In case of heavy proliferative the diabetic retinopathy complicated gemoftalmy, traction of a makula or an otsloyky retina, resort to performance of a vitrektomiya during which blood, a vitreous body is removed, soyedinitelnotkanny tyazh are cut, the bleeding vessels are cauterized.
Forecast and prevention
Secondary glaucoma, cataract, otsloyka of a retina, , considerable decrease in sight, a total blindness can become heavy complications of a diabetic retinopathy. All this demands constant observation of patients with diabetes by the endocrinologist and the ophthalmologist.
The large role in prevention of progressing of a diabetic retinopathy is played by correctly organized control of level of sugar of blood and arterial pressure, timely reception of antihyperglycemic and hypotensive medicines. Timely carrying out a preventive lazerkoagulyation of a retina promotes suspension and regress of changes at an eye bottom.