DIABETIC RETINOPATHY

It is a complication stemming from prolonged exposure to elevated

blood sugar levels in individuals with diabetes. Itis the leading cause of
blindness among people between 20 and 74 years of age in the United States;
it occurs in both type 1 and type 2 diabetes. People with diabetes are subject
to many visual complications. The pathology referred to as diabetic retinopathy
is caused by changes in the small blood vessels in the retina, which is the area
of the eye that receives images and sends information about the images to the
brain. The retina is richly supplied with blood vessels of all kinds: small arteries
and veins, arterioles, venules, and capillaries.

The pathophysiology of diabetic retinopathy involves a cascade of events

initiated by microvascular changes in the retinal blood vessels. Persistent high
blood sugar leads to ischemia, a condition where reduced blood flow causes
oxygen deprivation in the retina. In response to this, the body releases growth
factors, triggering abnormal neovascularization, or the formation of new blood
vessels. These vessels are often fragile and prone to leakage, increasing the risk
of hemorrhage and potentially leading to complications such as retinal
detachment. Retinopathy has three main stages: non-proliferative
(background), pre-proliferative, and proliferative.

1. Non-proliferative Diabetic Retinopathy (NPDR): In this early stage, the

blood vessels in the retina weaken and may leak fluid or blood.
Microaneurysms, small bulges in the blood vessels, may also develop.
NPDR often has no noticeable symptoms, but it can progress to a more
severe stage. A complication of non-proliferative retinopathy macular
edema occurs in approximately 10% of people with type 1 or type 2
diabetes and may lead to visual distortion and loss of central vision.

2. An advanced form of background retinopathy pre-proliferative

retinopathy is considered to be a precursor to the more serious
proliferative retinopathy. In pre-proliferative retinopathy, there are more
widespread vascular changes and loss of nerve fibers. Epidemiologic
evidence suggests that 10% to 50% of patients with pre-proliferative
 retinopathy will develop proliferative retinopathy within a short time
(possibly as little as 1 year). As with background retinopathy, if visual
changes occur during the pre-proliferative stage, they are usually caused
by macular edema.

3. Proliferative Diabetic Retinopathy (PDR): represents the greatest threat

to vision and is characterized by the proliferation of new blood vessels
growing from the retina into the vitreous. These new vessels are prone
to bleeding. Scar tissue may develop, leading to complications like retinal
detachment. PDR is more severe and can result in significant vision loss if
not managed promptly. The visual loss associated with proliferative
retinopathy is caused by this vitreous hemorrhage, retinal detachment,
or both. The vitreous is normally clear, allowing light to be transmitted to
the retina. When there is hemorrhage, the vitreous becomes clouded
and cannot transmit light, resulting in loss of vision. Another
consequence of vitreous hemorrhage is that resorption of the blood in
the vitreous leads to the formation of fibrous scar tissue. This scar tissue
may place traction on the retina, resulting in retinal detachment and
subsequent visual loss.

CLINICAL MANIFESTATIONS:
Retinopathy is a painless process. In non- and pre-proliferative
retinopathy, blurry vision secondary to macular edema occurs in some patients,
although many patients are asymptomatic. Even patients with a significant
degree of proliferative retinopathy and some hemorrhaging may not
experience major visual changes. However, symptoms indicative of
hemorrhaging includes floaters or cobwebs in the visual field, sudden visual
changes including spotty or hazy vision, or complete loss of vision.

• Blurred Vision: Individuals may experience blurry or fluctuating vision,

impacting their ability to see clearly.
 • Floaters: Floating specks or dark spots in the visual field may occur due
to bleeding into the vitreous humor.
• Impaired Color Vision: Difficulty distinguishing colors or changes in color
perception may be observed.
• Vision Loss: In advanced stages, diabetic retinopathy can lead to partial
or complete vision loss.
• Fluctuating Vision: Vision may vary throughout the day, especially in
cases of macular edema.

NURSING MANAGEMENT
Nursing management of patients with diabetic retinopathy or other eye
disorders involves implementing the individual plan of care and providing
patient education. Education focuses on prevention through regular
ophthalmologic examinations, blood glucose control, and self-management of
eye care regimens. The effectiveness of early diagnosis and prompt treatment
is emphasized in educating the patient and family.
If vision loss occurs, nursing care must also address the patient's
adjustment to impaired vision and the use of adaptive devices for diabetes self-
care as well as activities of daily living.

• Regular Monitoring: Conduct routine assessments of visual acuity,

intraocular pressure, and fundus exams to detect any changes in the eye.

• Blood Sugar Control: Emphasize the importance of tight glycemic control

to minimize vascular damage and slow the progression of retinopathy.

• Blood Pressure Management: Monitor and control hypertension, as

elevated blood pressure can exacerbate retinal complications.

• Lifestyle Education: Educate patients on adopting a healthy lifestyle,

including a balanced diet, regular exercise, and smoking cessation, to
support overall vascular health.
 • Medication Adherence: Ensure patients adhere to prescribed
medications.

• Patient Education: Provide comprehensive education about the

condition, its progression, and the importance of regular eye
examinations to encourage proactive management and early
intervention.

• Emotional Support: Offer emotional support and address any concerns

or anxieties patients may have about their vision and the impact of
diabetic retinopathy on their daily life.

MEDICAL MANAGEMENT
For advanced cases of diabetic retinopathy, the main treatment is argon
laser photocoagulation. The laser treatment destroys leaking blood vessels and
areas of neovascularization. For patients who are at increased risk for
hemorrhage, pan-retinal photocoagulation may significantly reduce the rate of
progression to blindness. Pan-retinal photocoagulation involves the systematic
application of multiple (more than 1000) laser burns throughout the retina
(except in the macular region). This stops the widespread growth of new
vessels and hemorrhaging of damaged vessels. The role of "mild" pan-retinal
photocoagulation (with only one third to one half as many laser burns) in the
early stages of proliferative retinopathy or in patients with pre-proliferative
changes is being investigated.

For patients with macular edema, focal photocoagulation is used to

apply smaller laser burns to specific areas of microaneurysms in the macular
region. This may reduce the rate of visual loss from macular edema.
Photocoagulation treatments are usually performed on an outpatient basis,
and most patients can return to their usual activities by the next day.
Limitations may be placed on activities involving weight bearing or bearing
down. In most cases, the treatment does not cause intense pain, although
patients may report varying degrees of discomfort such as a headache.

Usually, an anesthetic eye drop is all that is needed during the

treatment. A few patients may experience slight visual loss, loss of peripheral
vision, or impairments in adaptation to the dark. However, the risk of slight
visual changes from the laser treatment itself is much less than the potential
for loss of vision from progression of retinopathy.

A major hemorrhage into the vitreous may occur, with the vitreous fluid
becoming mixed with blood, preventing light from passing through the eye; this
can cause blindness. A vitrectomy is a surgical procedure in which vitreous
humor filled with blood or fibrous tissue is removed with a special drill-like
instrument and replaced with saline or another liquid. A vitrectomy is
performed for patients who already have visual loss and in whom the vitreous
hemorrhage has not cleared on its own after 6 months. The purpose is to
restore useful vision; recovery to near-normal vision is not usually expected.

• Vitrectomy: This surgical procedure involves removing blood and scar

tissue from the vitreous humor of the eye, improving visual acuity and
reducing the risk of complications like retinal detachment.

• Laser Photocoagulation: Utilizing laser technology, this procedure aims

to seal leaking blood vessels and reduce abnormal vessel growth, helping
to stabilize and protect the retina.

• Intravitreal Injections: Administration of anti-VEGF drugs through

injections into the vitreous humor can inhibit the growth of abnormal
blood vessels, preventing further damage.