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Types

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Background or non-proliferative diabetic retinopathy

The most common form of diabetic retinopathy is called background or non-proliferative disease.

In this form of the disease, high blood sugar levels create weak spots in the walls of the retinal capillaries. The weak spots can cause the walls of the capillaries to break and create tiny hemorrhages. These damaged capillaries leak fluid causing swelling in the surrounding retinal cells. The higher your blood pressure, the faster the fluid is forced out of the leaky vessels. The damaged capillaries also become clogged and are unable to deliver sufficient nutrients to the retinal cells. When capillary damage occurs in the center of your retina (the macula), your vision blurs. Visual blurring caused by non-proliferative retinopathy can't be corrected with glasses and long-term swelling can permanently reduce your central vision.

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Proliferative diabetic retinopathy

Proliferative retinopathy can occur in any diabetic but is most common in diabetics who develop the disease as children (known as type 1 or juvenile onset diabetics). It can occur alone or at the same time as non-proliferative disease.

In this advanced stage of the disease, the retinal cells do not receive enough oxygen which triggers the growth of abnormal blood vessels that grow into the vitreous gel in the center of the eye. These abnormal blood vessels may break, filling the vitreous gel with blood. A hemorrhage of this type can rapidly reduce vision and may take weeks or months to clear.

Over time, these blood vessels contract forming fibrous bands that can tear the retina and detach it from the back wall of the eye. A retinal detachment of this type can severely affect your vision.

Causes, Symptoms and Screening

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Causes

Diabetic retinopathy is caused by elevated blood sugar levels. Too much sugar in your blood damages the tiny blood vessels (capillaries) that supply the retina. Other factors that may increase your risk of developing diabetic retinopathy include high blood pressure, pregnancy, a family history of retinopathy, kidney disease, high cholesterol, and a history of smoking.

Symptoms

Most of the time, there are no symptoms until the disease starts to change your vision. When this happens, diabetic retinopathy is usually already severe. Changes in vision can be a sign of severe damage to your eye. Changes can include:

• Seeing floaters, cobwebs, or spots in your field of vision
• Blurry vision
• Sudden vision loss

Screening

We diagnose diabetic retinopathy by reviewing your medical and family history and performing a comprehensive eye exam that may include a photograph of your eye.

• We will look for diabetic retinopathy during your exam.
• If you have diabetes you should be screened regularly for the presence of diabetic retinopathy. This will ensure that the disease is diagnosed early, when treatment is most effective.
• The disease can make significant progress before you notice any symptoms. Once vision changes occur, additional loss can be both rapid and permanent.
• At your exam, we might have to dilate your pupil. The drops take 15 to 30 minutes to work and your vision will be affected for a few hours afterwards. We recommend bringing someone with you who can drive you home after your test.

Prevention

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You can help prevent or slow the progression of diabetic retinopathy. Even if you have vision loss, it is important for you to be an active participant in your daily diabetes care. The following steps can help you retain good vision:

Control your blood sugar levels

• If you can keep your blood sugar (your fasting blood sugar and your Hemoglobin A1C) in the normal range you will probably be able to maintain good vision throughout your life.
• Keep blood sugar levels near normal by eating a diet that spreads carbohydrate intake throughout the day.
• Monitor your blood sugar levels frequently.
• Get regular physical exercise.
• Take your diabetic medications as prescribed.

Have your eyes examined regularly

• Screening for diabetic retinopathy and other eye problems will not prevent diabetic eye disease, but it can help you avoid vision loss by allowing for early detection and treatment.
• We recommend that you get screened every two years if your last exam was free of retinopathy and within one year if there are signs of mild disease. More severe disease will require more frequent monitoring.
• Changes in vision, such as floaters, blurry vision, or new vision loss, may be symptoms of serious damage to your retina. In most cases, the sooner the problem can be treated, the more effective the treatment will be.

Treatments

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Treatment strategies include:

• Controlling the blood sugar as soon as possible before too much vision is lost.
• Reducing the chance of vision loss by treating swelling of the retina (retinal edema).
• Preventing blindness and potential loss of the eye which can occur when proliferative disease is left untreated.

Control of Blood Sugars

The best treatment for diabetic eye disease is the maintenance of excellent blood sugar and blood pressure control. If you already have diabetic retinopathy, establishing good blood sugar control will help to stabilize your vision loss and in some cases improve your vision. However, it may take some months of good control before vision is stabilized.

Laser Treatment

• If the non-proliferative disease is severe enough that it is threatening your vision, we may recommend a treatment called focal laser photocoagulation.
• This procedure can stop the abnormal leakage of blood and fluid in your eye and keep your vision from getting worse.
• These treatments usually take about 10 to 20 minutes and may be a little uncomfortable.
• Some additional diagnostic tests, including a fluorescein angiogram, may be performed prior to this treatment.

Panretinal Photocoagulation

• Proliferative diabetic retinopathy can be treated with panretinal photocoagulation, another type of procedure performed with a laser.
• We use the laser to intentionally destroy the peripheral unhealthy tissue that is stimulating abnormal blood vessel growth.
• The procedure helps to preserve and protect your central vision and has been proven to reduce the likelihood of blindness. 
• After the procedure your vision will be blurry for about a day and some loss of peripheral or night vision may occur.

Vitrectomy

• If you have blood trapped in your vitreous gel or if bands of abnormal blood vessels are threatening to tear or detach the retina, we may suggest a vitrectomy.
• This procedure is performed by skilled retina/vitreous surgeons and is most appropriate for patients who are experiencing, or are at risk for, severe vision loss.
• During the procedure, the surgeon cuts and removes any fibrous bands that may be pulling the retina out of its normal position. In addition, any abnormal blood or hemorrhage trapped in the vitreous gel is also removed.

Lifestyle Changes and Management

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Glasses

Your blood sugar levels fluctuate over the course of the day. Some very sensitive diabetics experience fluctuations in the sharpness of their vision during these changes even with the best pair of glasses. Here are some guidelines to help you receive the best possible pair of glasses:

• Make sure that your blood sugars are in their typical range on the day you are measured for your glasses.
• If your sugars are not in your usual range, we recommend that you reschedule your Optometry appointment.
• Your eye's lenses tend to enlarge when your blood sugar levels are elevated. If you have just started treatment to reduce your blood sugar, you may notice your vision blurring as your blood sugar drops. As the lenses return to their normal shape, you may need a new prescription for glasses that are powered to match your lenses' new shape.
• Even if your blood sugars are well controlled, a minor illness like a cold or the flu can cause your blood sugars to go out of control for a few days. During these periods you may experience more blurred vision. When you recover from the illness, your blood sugars and your vision should return to their previous levels.

Vision loss

It is important to find ways to adapt so that you can use your remaining eyesight to its greatest potential and identify the kinds of vision aids that are most helpful for you. Here are some recommendations.

• If your visual acuity is 20/70 or worse with glasses or contact lenses we can provide a low-vision evaluation to help you use your remaining vision.
• Obtain a copy of Coping with Sight Loss in Northern California by the non-profit organization Prevent Blindness.
• Make adjustments in your daily activities. You can continue to do most - if not all - of your daily diabetes care and other activities even though your eyesight is reduced or fluctuates. 
• Use felt-tip markers to label your medicines and diabetic supplies.
• Acquire vision aids if diabetic retinopathy has severely damaged your vision. We have resources in our Health Education Department and the organization Prevent Blindness Northern California can help you as well.
• Some of our Kaiser Permanente Optical shops offer low vision aides such as magnifiers designed to assist you in performing specific visual tasks. Ask us to schedule a low vision evaluation for you if you would like assistance in selecting low vision aides.

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Your Care with Me

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If you have diabetes, your personal physician will automatically make an appointment for you to come in every 2 years to be screened for diabetic retinopathy. This screening will be included in the list of preventive services that we recommend for you.

After you come in for your screening, we will review the results. If there is evidence of retinopathy on the screening test, we will schedule an appointment for you to come in and see me or one of my colleagues in the Ophthalmology department.

I will examine one or both of your eyes to assess the severity of your retinopathy. I will administer eyedrops to dilate your pupil so that I can clearly see the structures in your eyes, including the retina. Your pupils will remain dilated for several hours, so you may wish to bring someone who can drive you home after your exam.

We will discuss potential lifestyle changes and therapies, and together we will create a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the "After Visit Summary" that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If surgery or a procedure is a treatment option

I will recommend you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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