Diabetes affects an estimated 425 million adults aged between 20 and 79 worldwide. By 2045, 628 million people, or 1 in 10 adults across the globe will live with diabetes. As the numbers increase, more and more people are also living with complications that result directly from diabetes. Some of these are so serious that they are life-threatening, while others are sufficiently debilitating to curtail daily activities and quality of life.
Diabetic retinopathy is a complication of diabetes that may be unnoticeable in its early stages but can lead to vision impairment and blindness. It affects an estimated one in three people living with diabetes and is a primary cause of loss of vision and blindness in those aged between 20 and 65.
Chronic hyperglycemia (high blood sugar levels) causes damage to retinal capillaries (small blood vessels) and the risk is exacerbated by hypertension (high blood pressure) and dyslipidemia (deranged cholesterol and lipid levels).
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According to “DR Barometer Report”, 79% of diabetic patients who had impaired vision due to DR said their sight problems made everyday activities difficult, and in some cases impossible. These everyday activities include driving, working and cooking or cleaning their home.
Severity of Diabetic Retinopathy
The severity of DR can range from very mild, i.e., Non-proliferative type to very severe i.e., Proliferative type in which there is growth of abnormal new blood vessels in the retina.
NPDR, i.e. Non-Proliferative Diabetic Retinopathy is the early stage where the small blood vessels in retina leak, making the retina swell. Center of the retina i.e., “Macula”, the center of which is called “Fovea” is responsible for a sharp vision in human eye. When the center of the retina, i.e., the Macula swells, it is called Macular edema.
Macular edema is the most common reason for diminution of vision in diabetic patients. Sometimes tiny particles made of protein and lipids called ‘exudates’ can form within the retinal layers. These can affect the vision too. Also, in NPDR, blood vessels can close off. This is called “Macular Ischemia”. In macular ischemia, blood cannot reach the macula, thus affecting the vision permanently.
PDR, i.e., Proliferative Diabetic Retinopathy is the severe form of diabetic eye disease. It happens when abnormal new blood vessels start growing in the retina. This is called Neovascularisation. These new blood vessels are fragile and often bleed easily. They bleed into the vitreous cavity. This condition is called Vitreous Hemorrhage (VH). VH can be mild to severe. Mild VH causes floaters and severe VH can block all the vision.
These abnormal new blood vessels can also form scar tissue, Scar tissue can cause a pull on the retina leading to its detachment. This condition is called Tractional Retinal Detachment. PDR is very serious condition which can destroy both central and peripheral (side) vision.
Vitrectomy in Diabetics
Vitrectomy is a surgery that removes the clear jelly-like substance called vitreous that fills the eye. The first successful vitrectomy for VH secondary to diabetes was done in 1970. Since then, advances in instrumentation, wide-angle viewing systems, smaller instruments, use of heavy liquids and more sophisticated software have enabled the role of Vitrectomy in diabetic eyes to evolve and it is now integral to managing late complications of diabetic eye disease.
Who is it performed on?
Vitrectomy is necessary in cases of
- Long-standing unresolved vitreous hemorrhage where visualization of the status of retina is too difficult
- Tractional retinal detachments
- Combined retinal detachments
Vitrectomy is also indicated in refractory Diabetic Macular Edema which is resistant to treatment with injections and LASER. More uncommon indications include Epiretinal Membrane formations and macular dragging.
Epiretinal Membrane (ERM) means abnormal growth of an extra layer over the retina causing wrinkling of retinal surface. Thicker membranes also pull the retinal layers apart giving rise to fluid collection i.e., tractional macular edema.
Are there any non-surgical options?
The answer is no. The conditions mentioned above should be managed surgically only. Although Intra-vitreal injection of Anti VEGFs (Vascular endothelial growth factors) and LASER treatment act as adjuncts, the definitive management would be surgery i.e., Vitrectomy. The intra-vitreal Anti VEGF administration few days before surgery is also useful to reduce intra operative bleeding in eyes with extensive new vessels.
What is New?
Separation of vitreous gel from its attachment with retina is called Posterior Vitreous Detachment (PVD). It has been shown that partial PVD promotes progression of PDR while a complete PVD reduces vulnerability to developing PDR.
A promising future intervention to prevent the onset of PDR in susceptible or high-risk eyes is Pharmacological Vitreolysis, in which drugs rather than surgery are used to induce complete vitreous separation from the inner most layer of retina i.e., Internal Limiting Membrane.
What happens if those symptoms are ignored?
Diabetic retinopathy if ignored and left untreated, may aggravate and can eventually lead to permanent blindness.
Diabetic Retinopathy Management
A strict control of blood sugars and correction of associated conditions are mandatory to reduce the incidence of surgery in diabetic retinopathy, also to provide better anatomical and functional results after surgery in cases requiring surgical management.
A standard follow-up protocol has an important role in the early diagnosis and prevention of complications in the eye. Prompt LASER should be immediately performed in proliferative and severe non-proliferative types of DR.
Vitrectomy has proved to be a standard of care for complications of advanced diabetic eye disease in the last few decades. The development of minimally invasive vitrectomy techniques using thinner and finer instruments have led to a much efficient, quicker and safer surgery.
The suture-less approach provides a reduced postoperative inflammation which has spectacularly improved patient’s comfort and recovery. Studies have confirmed the benefits of early vitrectomy. The proper time of surgery is established individually according to the status of fellow eye, degree of visual loss, presence of associated findings and lifestyle of the patient.
Vitrectomy also has risk of some intra-operative and postoperative complications. Most frequent intraoperative complications would be retinal breaks and bleeding. Most frequent post-operative complications would be cataract, recurrent bleeds and development of Glaucoma. (Glaucoma means weakness of the eye nerve due to raised eye pressure)
Although many complications of DR are now medically treated, the most severe ones still require the surgeon’s skills and state-of-the-art equipment.
What is Shekar eye Hospital’s specialization?
Our hospital’s Operating Room for Retinal surgeries is equipped with standard and state of the art instruments. The operating microscope used is ‘Leica’ with an option for BIOM attachment, BIOM is an abbreviation for Binocular Indirect Ophthalmo-Microscope. It is an advanced technology of viewing systems used in vitreo-retinal surgeries. We also have ‘Stellaris PC’vitrectomy machine and Iridex Endolaser machine for Vitrectomy surgery in patients with advanced diabetic disease requiring surgical management.
Shekar Eye Hospital’s record of helping patients with vitrectomy, number of surgeries performed.
Why Shekar Eye Hospital for Diabetic Eye Care?
Our well-trained retina specialists at Shekar Eye Hospital use the appropriate and advanced technologies available here to diagnose and treat patients with diabetic retinopathy. The specialists here are empathic and believe in transparency. They work together to treat the patient in an overall perspective.
Here, on an average we perform 8-10 vitrectomies in a month, added together will be about 100-120 vitrectomies in a year. With the help of our experienced and well-trained surgeons, approximately 80-85% of operated patients have had successful outcome with a useful vision.
