Background diabetic retinopathy (mild none-proliferative retinopathy)
enlarge This is the view a doctor sees looking into your eye. The small red dots are 'microaneurysms', tiny damaged capillaries.
The bigger red blobs are small haemorrhages, little flecks of blood. The white dots are exudates (leakage). Your sight is not affected at this stage.This is the term given to early damage of the retina in diabetes. Your sight should be perfectly good at this stage. A doctor examining your eye will notice tiny abnormalities.
The tiny blood vessels in the retina, the capillaries, become damaged, from the diabetes.
Blood vessel damage is generally visible on photographs. In the UK, nearly every person with diabetes should have yearly photos taken. In Birmingham these are taken by about 40 optometrists across the city, but in other places technicians take the photos, often with mobile cameras.
The photographs are examined by the optometrist or photographer, (or computer), and patients with significant damage are referred to hospital clinics. Your pupils have to be dilated for this examination, and you are often advised not to drive until the pupils have returned to their normal size. See
A doctor or optometrist may see 'dots' and 'blots'. The dots are some capillaries that have enlarged, that is the the tiny blood vessels enlarge to form microaneruysms. See photo tour and photo and photo. The blots are tiny haemorrhages, that is tiny spots of blood, on the surface of the retina. There are also leaky areas, called exudates. See photo.
The number of microaneurysms, the little red dots the doctor sees, indicate the likelihood of more severe problems in the years to come. See photo. As the damage is mild at this stage, your sight will be nearly perfect. However, the condition does progress.
This condition is now often called mild none-proliferative retinopathy. If it gets worse the term severe none-proliferative or preproliferative retinopathy is used.
It occasionally progresses quickly, but usually changes slowly. If your diabetes and blood pressure are well controlled, and have been all the time you have had diabetes, changes should be very slow (prevention) are controlled. Unfortunately for many people with diabetes the retinal damage increases, and maculopathy or proliferative retinopathy develop over a few years.
Background retinopathy generally means your diabetes is not controlled as well as it might be. If you have been diabetic 30 years, even with the best control, these may develop. But most people who have background retinopathy have not been diabetic that long, and need better control as per these targets.
Retinopathy progression appears to follow different patterns. Some patients develop leakage (such as macular oedema), and others develop more severe capillary closure (which also causes loss of sight, see proliferative and pre-proliferative). See.
The number of haemorrhages and microaneurysms indicate progression. If they increase in number the retinopathy is getting worse. Dropping blood pressure to the targets below will slow down progression right away.
But if there is significant retinopathy, it takes 3 years of low blood sugars (eg HbA1c <58mmol/l 7.5%, the lower the better) before good control helps.
This photograph shows 'circinate' retinopathy. Laser treatment is needed (early maculopathy). Good diabetic control is needed. Circinates further from the macula would be classified as 'background' or early none-proliferative retinopathy.
Circinate retinopathy...good control is needed to prevent serious eye problems in 3-5 years. There is a circle of exudates surrounding a leaky area, with a dot haemorrhage or microaneurysm in the middle. (Case 54)
Once background retinopathy is discovered,
- If you have had diabetes for many years and are well controlled, and your background retinopathy is not severe, you may be reviewed in a year by your local diabetic retinopathy screening program.
- If your diabetes is not controlled see targets below, (essentially low glucose levels, blood pressure and not smoking) , the condition will get worse and you may need to be reviewed 4-12 months in the Eye Clinic in case injections or laser are needed.
By keeping to these levels as much as possible (or lower still) you will be doing your best to stop your eyes getting worse. Occasionally by sticking to these targets your retinopathy will improve, even without laser. Review BMJ17
- 30-120 minutes exercise a day ,
- moderate alcohol consumption only,
- avoid obesity if possible,
- balanced diet including
- 9 portions of vegetables or fruit a day (9 for men, 7 for women), Lowers BP
- minimal of animal or 'hard' vegetable fats,
salt, see the evidence
Alcohol should be limited to one drink or unit a day, six days a week (Mukamal 2004). More than this leads to brain damage.
- Oily fish such as sardine, salmon, tuna, trout, at least twice a week (small amounts are fine...not a whole salmon!).
- Fibre and healthy fats in the diet slows down retinopathy. No transfats and minimal saturated fat.
- no (ultra) processed food Cell Metab 19 as this puts weight on and leads to inflamation throughout the body.
- generally 130/80 (see graph) or preferably less BMJ 16. Even less if well <120 BMJ17
- (120/75 ..home monitoring)
- 125/75 or less if protein in urine present (115/70.. home monitor)
- ACE inhibitors or Angiotensin Receptor Antagonists unless young/pregnant/very low blood pressure/poorly tolerated
- The lower the better in macular oedema, as long as you feel well.
- An ideal pressure is below 115 (systolic, first number) for healthy people. <120 is is only suitable for new/well diabetes patients 2012. Otherwise slightly higher as above.
- Home monitoring blood pressures should be 10mmHg (systolic) and 5mmHg (diastolic) lower see than these 'clinic' pressures.
- Depression & anxiety increase BP.
- 48-58 mmol/mol (6.5%-7.5%) or less (see graph) with very few or preferably no hypos. These (or slightly lower) levels are the best to prevent complications
- <58 mmol/mol (7.5%) for insulin users; <48 mmol/mol (6.5%) if not using insulin and have good health. Problems with intensive control. Target should be adjusted according to health and age. If you are a type 1 patient and cannot achieve good control, you need to checked for other conditions such as coeliac disease (anti-TTG antibodies), addisons, and thyroid.
- If hypos develop, seek expert advice from your diabetes nurse/doctor.
- if your HbA1c is high (say 97mmol/mol / 11%), then the next step may be to achieve 75 (9%)....in other words, and any improvement is helpful, gradually reaching lower levels above.
sudden decrease in HbA1c
- A sudden improvement in control (HbA1c drop of 33 mmol/mol/3% ) will lead to a temporary rapid increase in progression of retinopathy: laser may be needed.
- Good control is important in the longer term, that is after about 2 years. When people who control their diabetes well will be better off after this period. See
- A temporary increase in retinopathy is most common when starting insulin for the first time, especially if the diabetes is very badly controlled when you start the insulin.
- Individual targets Nice 16
cholesterol and statins
- <4.0mmol/l, and statins recommended for most adult patients with diabetes whatever the cholesterol.
- statins are recommended whatever the cholesterol, if well tolerated age>40y Statins reduce retinopathy EJO 20
- A fibrate such as fenofibrate may help if there a lot or exudates.
- LDL <2
- Avoid if pregnant, GFR <15, pancreatitis
- If GFR low but still >15, need a lower dose.
- smoking 20 a day triples/quadruples retinopathy
- passive smoking may double retinopathy: room-mates inhale at least 25%
- electronic cigarettes are much much safer and probably have a negligible effect on retinopathy debate BMJ 18
- even 'Just one cigarette a day seriously elevates cardiovascular risk ' BMJ18, so it is best to stop completely.
- type 1 patients and ideally type 2 patients using insulin with significant glucuose fluctuations, glucose sensors are ideal : Freestyle or Dexcom.
- Insulin pumps generally produce better control still, but are harder to use.
|Diabetes education courses|
- everyone with diabetes should attend an education course, Primary Care Trusts are obliged to send you on such a course, but very few patients have ever attended one. If you have not been on one, discuss this with your diabetic team.
sleep apnoea etc
- this contributes to macular oedema and loss of sight (Schwartz, 2006), and many serious problems.
- It is common in diabetes, particularly if you are overweight. Do you have sleep apnoea?
- see 15 Retina18 Retina19
- 5.0-7.2 mmol/l before meals
- <10.0 mmol/l after meals
- no serious hypos
- for patients who test their glucose levels and adjust insulin doses, the new glucose sensor is highly recommended and has transformed the lives of many patients. They are provided on the NHS for type 1 patients. I would recommned then for type 2 pateints using mulitple insulin injections, but they are not funded by the NHS (~£30/week)
- Rosiglitazone and pioglitazone should not be used if there is significant retinopathy, and certainly not if macular oedema is present, as they increase macular oedema and fluid retention. Case 49. Lirglutadite and Exenatide are drugs that can be used instead low also lower weight (they are injections.)
- insulin users need to avoid serious hypoglycaemia. Expert help is usually needed if episodes are severe/frequent. See
- 10% compliance if multiple treatment,
? 60% one tablets
type 2 at diagnosis
- need a test for Haemochromatosis