The Eyes Have It Too: Dealing with the Vision Problems Associated with Type-2 Diabetes

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With seriously impaired vision and blindness in the offing down the line, eye care for people with type-2 diabetes goes far beyond getting regular checkups.

It’s common knowledge that eye and vision problems are both an indicator and a symptom of type-2 diabetes. Given the seemingly greater severity of the condition’s other symptoms, eye care and attention to the eyes tend to recede from people's field of vision until those problems, too, are severe enough to require medical intervention.

Who in 2018 doesn’t get eye fatigue from the hours spent staring into computers and other bright-light, back-lit devices? Who, with age, does not experience a degradation of vision? Who has time to deal with the hazards of the first, and who can stop time to delay the second?

The message of both diabetes and vision specialists is that there are in fact things people with type-2 diabetes can do to monitor and safeguard their vision. What it comes down to fundamentally is—no surprise here—dealing constructively with your type-2 diabetes. But beyond that, there are some salient particulars to consider.

Visual signs and symptoms of type-2 diabetes

Blurred vision, double vision, reduced vision, impaired night vision, and “floaters” are all phenomena that could have other etiologies but are common to people with T2D. They’re symptoms, to be sure, but not infrequently they’re also indicators of T2D that an individual may be unaware of, or is in denial about. Until they become medical emergencies, these problems are often laughed off as “old age” or not spoken of at all.

Annual eye checks by a licensed professional, in most cases an ophthalmologist or an optometrist (though many practitioners of family medicine are fully qualified to conduct basic tests), are an important part of any responsible individual’s preventive health measures. They’re also often one of the first elements of the check-ups to be put off, sometimes under the guise of the difficulty of getting to yet another doctor in yet another location.

Still, the words of the American Diabetes Association are apt here: “With regular checkups, you can keep minor problems minor. And if you do develop a major problem, there are treatments that often work well if you begin them right away.” Not to be alarmist, so are those of the National Institutes of Health: “All forms of diabetic eye disease have the potential to cause severe vision loss and blindness.”

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What are the main diabetic-caused or -related eye diseases?

The ones with common names, that most lay people know at least something about, are cataracts and glaucoma. Cataracts are a clouding of the eyes’ lenses, and people with diabetes are 3-5 times more likely to get them. “Glaucoma” refers to an array of eye diseases that cause damage to the optic nerve, the “bundle” of nerves that connect the eye to the brain. Diabetes doubles the risk of glaucoma. It bears noting that both conditions afflict the non-diabetic general population too.

The two rather more serious eye conditions are specific to people with diabetes (of both types). The most common is diabetic retinopathy, which affects the blood vessels in the tissue at the back of the eye. Diabetic macular edema (DME), a complication of diabetic retinopathy, refers to the swelling in an area of the retina called the macula, near the optic nerve bundle.

Both are the leading causes of blindness among people with diabetes who are of working age.

Diabetic retinopathy

The principal cause of diabetic retinopathy is the chronic high blood pressure associated with diabetes. It can cause the blood vessels in the retina to bleed or “leak” fluid, both of which distort vision. The National Eye Institute (NEI) lists its four stages:

  1. Mild nonproliferative retinopathy. Small areas of balloon-like swelling appear in the blood vessels of the retina.
  2. Moderate nonproliferative retinopathy. Blood vessels feeding the retina swell and distort, and lose their ability to transport blood.
  3. Severe nonproliferative retinopathy. More blood vessels bloat and lose their blood-bearing capacity. The blood-deprived areas of the retina secrete factors to grow new blood vessels.
  4. Proliferative diabetic retinopathy (PDR). The growth factors trigger a proliferation of blood vessels along the inside of the retina and into the vitreous gel, the fluid that fills the eye. Fragile, the new vessels are prone to breaking, and accompanying scar tissue can cause retinal detachment.

Diabetic retinal edema (DRE)

This swelling of the retina is the result of #2 above. The eye's macula makes possible the clear, straight-ahead vision necessary for activities from reading to driving. As the NEI explains, “About half of all people with diabetic retinopathy will develop DME. Although it is more likely to occur as diabetic retinopathy worsens, DME can happen at any stage of the disease.”

With respect to the two linked conditions, the NEI says this:

“People with all types of diabetes (type 1, type 2, and gestational) are at risk for diabetic retinopathy. Risk increases the longer a person has diabetes. Between 40 and 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy, although only about half are aware of it. Women who develop or have diabetes during pregnancy may have rapid onset or worsening of diabetic retinopathy.”

There are usually no symptoms in the early stages, and the disease(s) usually “progress unnoticed until it affects vision…. Bleeding from abnormal retinal blood vessels can cause the appearance of ‘floating’ spots. These spots sometimes clear on their own. But without prompt treatment, bleeding often recurs, increasing the risk of permanent vision loss. If DME occurs, it can cause blurred vision.”

Diabetic retinopathy is detected by

  • Visual acuity testing
  • Tonometry, which measures pressure within the eye
  • Pupil dilation, to enhance the examination of the retina and optic nerves
  • Optical coherence tomography (OCT), an ultrasound-like procedure that use light waves to provide images of tissue that can be penetrated by light
  • Further, a fluorescein angiogram can be performed to look for damaged or leaky blood vessels if there is a suspicion of severe damage.

Treatment

Several therapies, sometimes used in combination, are used to treat DME:

  • Anti-VEGF Injection Therapy. Drugs are injected into the eye’s vitreous gel to block the protein vascular endothelial growth factor. Typically injections are monthly for the first six months.
  • Focal/grid mascular laser surgery. Leasers burn leaking blood vessels in the edema.
  • Corticosteroids. Often in combination with other therapies, corticosteroids are injected or implanted into the eye.

Treatment of proliferative diabetic retinopathy (PDR) has long involved more aggressive laser surgery, sometimes in a single session. Loss of peripheral vision is a not infrequent complication. Recently, anti-VEGF injection therapy is also being used, usually as a front-line treatment. It has shown effectiveness at slowing the progression of diabetic retinopathy.

Vitrectomy, the surgical removal of the vitreous gel in the eye, is used to treat severe bleeding into the vitreous gel. It is performed both inpatient and outpatient and may cause soreness or inflammation.

How you can affect diabetes-related eye disease

The factor you cannot control is the length of time you have had diabetes, the longer the greater the risk of developing eye and vision problems. Except, of course, that you can control that by doing your part in prevention and early detection of T2D. Diabetes is high on the list of diseases of denial, often leading to pre-mature, even sudden death.

While there is evidence of a genetic disposition to retinopathy, other causal factors include high blood sugar and high blood pressure. In the (last) ounce of prevention model, if you are recently diagnosed with type-2 diabetes, get an eye examination as soon as possible.

If your information about type-2 diabetes is up to date, the rest you know. Exercise and diet diet diet. The folks at Diabetes Self-management make some specific dietary recommendations:

  • Leafy green vegetables (the usual suspects, e.g., kale and broccoli)
  • For prevention of AMD and cataracts: corn, kiwifruit, red grapes, spinach, zucchini, yellow squash, orange peppers, orange juice, egg yolks, and Vitamin E
  • Brightly and deeply colored fruits and vegetables
  • Fatty fish (e.g., salmon) three times a week
  • Vitamin C-rich foods including cantaloupe, strawberries, citrus fruits, kiwifruit, mango, papaya, broccoli, Brussels sprouts, sweet peppers, tomatoes, and cauliflower.
  • Very low to no alcohol and tobacco

There is also a general recommendation to wear sunglasses outdoors. It is very important that they be ultraviolet ray protective. This generally means that they will cost more, and make sure what you buy is what it says it is. Sticky paper labels saying “UVP” are highly cost-effective for off-brand sunglass makers, so beware of any you buy in bargain markets.

One last word

Seeing is believing. People are alarmingly attached to the bad lifestyle habits that reliably lead to type-2 diabetes, and willing to stay in denial or take risks with the “understanding” that there are medical solutions. Faced with the idea of severely impaired vision or blindness, some of them find new enthusiasm for preventing type-2 diabetes or treating it appropriately and aggressively.  

Sources/Reading:

http://www.diabetes.org/living-with-diabetes/complications/eye-complications/?referrer=https://www.google.co.th/

https://nei.nih.gov/health/diabetic/retinopathy

https://www.diabetes.co.uk/symptoms/blurred-vision.html

https://www.diabetesaustralia.com.au/eye-health

https://wa.kaiserpermanente.org/healthAndWellness/index.jhtml?item=/common/healthAndWellness/conditions/diabetes/eyes.html

http://www.allaboutvision.com/askdoc/diabetes.htm

https://www.diabetesselfmanagement.com/blog/diabetes-and-your-eyes-more-than-retinopathy/

https://www.healthline.com/health/diabetes/blurry-vision

https://www.mayoclinic.org/diseases-conditions/diabetic-retinopathy/symptoms-causes/syc-20371611

https://www.medicinenet.com/diabetes_and_eye_problems/article.htm

 

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