As people with diabetes, we’ve been hearing about the threat that diabetes poses to our eyes since shortly after diagnosis.
In fact, sometimes those lectures and warnings feel constant, leaving you feeling as though diabetes eye complications are inevitable.
While the threat is real, there’s far more to the story than that. The most important part is what you can do to prevent, reduce, and manage any signs of diabetes-related complications in your own eyes.
In this article, we’ll look at how to prevent eye complications, what happens during your annual eye exam, the most common diabetes-related eye complications, and what treatment options are available today.
Preventing diabetes eye complications
The first and foremost thing anyone with diabetes can do to prevent diabetes eye complications is to manage their blood sugar levels as healthily as possible.
While this is easier said than done, the damage that occurs to the small yet critical blood vessels in your eyes when your blood sugars are high can lead to a significant number of conditions, some of which include severe vision loss or blindness.
The American Diabetes Association’s HbA1c guidelines recommend maintaining an A1c at or below 7.0 percent for the best possible prevention of diabetes-related eye complications. A 2016 research study also showed that adolescents with lower A1c levels had a significantly lower risk of developing retinopathy.
You can also talk to your healthcare team about taking a vitamin supplement containing lutein, vitamin A, E, C and others that support healthy eye function. Do keep in mind that a vitamin supplement cannot protect your eyes from nerve damage resulting from persistent high blood sugar levels.
Learn how to lower your A1c in Diabetes Strong’s A1c Guide.
Your annual diabetes eye exam
Here’s the thing about your eyes: it’s just too darn easy for these common diabetes eye complications to develop and worsen without it becoming obvious in your day-to-day life until it’s too late.
However, there are a few key signs the American Optometric Association (AOA) says should cause anyone with diabetes to schedule an appointment with their optometrist or ophthalmologist quickly, including:
- Sudden blurred or double vision
- Trouble reading or focusing on near-work
- Eye pain or pressure
- A noticeable aura or dark ring around lights or illuminated objects
- Visible dark spots in vision or images of flashing lights
Getting your eyes thoroughly examined each year by an optometrist is critical to diagnosing and treating diabetes-related eye conditions in their earliest stages in order to protect and keep your eyesight.
Let’s take a closer look at the four exams conducted during your annual eye check-up.
Visual acuity testing
This eye chart test measures a person’s ability to see at various distances. Nothing you haven’t already done year after year for your pediatrician!
This test measures pressure inside the eye. In those of us with diabetes, eye pressure is critical because other outside strains — like weightlifting or childbirth — could exacerbate the blood vessels in an already struggling eye. If your eyes are generally healthy, those activities that increase the pressure on your eyes are not a concern.
Optical coherence tomography (OCT)
This technique is similar to ultrasound but uses light waves instead of sound waves to capture images of tissues inside the body. OCT provides detailed images of tissues that can be penetrated by light, such as the eye.
Dilated eye exam
Dilation may sound scary, but it’s actually painless and definitely essential to seeing the most vital areas of your eyes.
At some point during your appointment, after testing your vision, your doctor will drip a few drops of Tropicamide (an “antimuscarinic” drug) that simply causes your pupils to enlarge so areas of your eyes can be seen in greater detail — especially your retina, which includes your optic nerve and macula.
You’ll then be asked to wait for about 15 minutes while your eyes “dilate” before the next part of the examination.
Once dilated, your optometrist will examine your eye for:
- Blood vessel changes in each eye
- Any signs of leaking blood vessels in each eye
- Swelling of your macula (DME) in each eye
- Any changes in the lens of each eye
- Any damage to the nerves in each eye
By the way, don’t forget to bring sunglasses to your appointment! You’ll need to wear them when you leave because it can take a few hours for the dilation drug to wear off. With enlarged pupils, you’ll feel like you’re standing 7 feet in front of the sun! Too bright!
For women considering pregnancy or currently pregnant
For women with diabetes considering pregnancy, a dilated eye exam should be performed to identify any existing signs of retinopathy because the stress and pressure of pregnancy and childbirth are known to worsen existing retinopathy.
This doesn’t mean women with retinopathy shouldn’t pursue pregnancy, but it does mean they will need to visit their eye doctor regularly during their pregnancy and perhaps avoid a vaginal birth because of the extreme pressure it puts on the blood vessels in the eyes.
If your pregnancy is a surprise, it’s still important to schedule with your eye doctor immediately upon learning you’re pregnant to assess your current eye health.
Common diabetes eye complications
There is a common theme among all of these diabetes-related eye conditions: blood sugar management.
While not all conditions are necessarily a result of persistent high blood glucose levels — and people with very healthy blood sugar levels can develop diabetic retinopathy, for example — your blood sugar management absolutely plays a starring role in the development and progression of diabetic eye complications.
Here are the most common diabetes-related eye complications and their symptoms.
- Diabetic retinopathy
- Diabetic macular edema
- Dry eye syndrome
Let’s take a closer look at each of these conditions and how they can be treated.
What is diabetic retinopathy?
The most common issue that can develop in the eyes of a person with diabetes is retinopathy–and it’s probably the one you’ve heard the most about, too.
There are actually four stages of diabetic retinopathy (DR), and of course, the earlier its detected, the better your chances are of stopping its progression and preventing further damage to the health and function of your eyes.
The four stages of diabetic retinopathy, defined by the National Eye Institute (NEI), are:
Stage 1 – mild non-proliferative retinopathy (NPDR): This early form of DR is identified by “small areas of balloon-like swelling in the retina’s tiny blood vessels, called microaneurysms,” explains the NEI.” The fluid from these microaneurysms can then leak into the retina of your eye. This early stage of DR is detectable during your annual visit to the optometrist, and is a very good reason to get your eyes dilated and thoroughly examined each year!
Stage 2 – moderate non-proliferative retinopathy (NPDR): The second stage of DR is when the blood vessels that are key to “nourishing” the retina begin to swell and distort, explains the NEI. “They may also lose their ability to transport blood. Both conditions cause characteristic changes to the appearance of the retina and may contribute to diabetic macular edema (DME).”
Stage 3 – severe non-proliferative retinopathy (NPDR): This next stage of DR is when a significantly large number of the blood vessels in your retina have become “blocked,” which means the retina is severely deprived of adequate blood supply. The fluid that continues to leak from the microaneurisms also contains growth factors that tell the retina to grow new blood vessels.
Stage 4 – proliferative diabetic retinopathy (PDR): “At this advanced stage, growth factors secreted by the retina trigger the proliferation of new blood vessels, which grow along the inside surface of the retina and into the vitreous gel, the fluid that fills the eye,” explains the NEI. However, those new blood vessels are very compromised and fragile, which means that although they are new, they are very vulnerable to leaking and bleeding.
Additionally, any evolving scar tissue from the multitude of microaneurisms can cause the retina to contract and pull away, known as a “detached retina.” A detached retina requires immediate care, often surgery, and can lead to permanent vision loss if it able to be repaired.
Vision loss related to diabetic retinopathy: For many, vision loss in diabetic retinopathy is irreversible but the NEI says early detection and proper treatment can reduce your risk of vision loss by 95 percent.
Additionally, anyone with existing retinopathy may need to see theiroptometrist or ophthalmologist more than once a year.
Diabetic retinopathy signs & symptoms
The only way to catch retinopathy in its earliest stages is by visiting your eye doctor for an annual exam.
Otherwise, like most diabetes eye complications, there are no obvious signs and symptoms that would let you know during your everyday life that retinopathy has developed and is progressing.
At a certain point in its progression, long after you could’ve detected it during an eye exam, bleeding from blood vessels in the retina can cause “floating spots” in your eyes. Sometimes they seem to go away on their own but that doesn’t mean the health of your eye has improved.
The longer these floating spots are ignored and left untreated, the more likely you’ll experience permanent vision loss and develop other related conditions like diabetic macular edema (DME).
“Today’s treatment options for retinopathy keep getting better and are constantly evolving,” explains Angela Bevels, OD, and founder of the Elite Dry Eye Spa in Tucson, Arizona.
“Retinopathy should be treated by a retinal specialist,” adds Bevels, because the overall issue of retinopathy can lead to irreversible vision loss and each stage of retinopathy needs to be treated with great care.
Most importantly, newer treatment options for retinopathy are often able to stop the progression of the disease — saving your vision — which is why it’s so important to catch it early during your annual eye exam.
There are several treatment options available today for retinopathy based on the progression and condition of your eyes.
Scatter laser surgery: “For decades, PDR has been treated with scatter laser surgery, sometimes called pan-retinal laser surgery or pan-retinal photocoagulation,” explains the NEI. “Treatment involves making 1,000 to 2,000 tiny laser burns in areas of the retina away from the macula. These laser burns are intended to cause abnormal blood vessels to shrink.”
Surprisingly, this laser treatment can be completed within just one session, but some patients may need two or more sessions depending on the severity of their retinopathy.
The NEI also explains that while this treatment can preserve central vision, it can actually result in varying degrees of loss in your peripheral vision, color vision, and night vision.
Anti-VEGF injections: Also used to treat DME, anti-VEGF injections that work by blocking a protein called ‘vascular endothelial growth factor’ (VEGF). This unhelpful protein is what stimulates abnormal blood vessels to grow and leak fluid, contributing to DME and retinopathy.
Through these injections, abnormal blood vessel growth is reversed and the fluid in the retina decreases, too. While it sounds intimidating and uncomfortable, anti-VEGF injections are very effective and considered a first-line of treatment for patients diagnosed with retinopathy.
Common FDA-approved pharmaceutical brands of anti-VEGF injections include Lucentis, Avastin, and Eylea.
Vitrectomy surgery: “A vitrectomy is the surgical removal of the vitreous gel in the center of the eye,” explains the NEI. “The procedure is used to treat severe bleeding into the vitreous and is performed under local or general anesthesia.”
During surgery, explains the NEI, “ports (temporary water-tight openings) are placed in the eye to allow the surgeon to insert and remove instruments, such as a tiny light or a small vacuum called a vitrector. A clear salt solution is gently pumped into the eye through one of the ports to maintain eye pressure during surgery and to replace the removed vitreous. The same instruments used during vitrectomy also may be used to remove scar tissue or to repair a detached retina.”
For some patients, this is an outpatient procedure, but for others who need more post-operative observation and support, it can require a single night stay in the hospital.
“After treatment, the eye may be covered with a patch for days to weeks and may be red and sore,” explains the NEI. “Drops may be applied to the eye to reduce inflammation and the risk of infection. If both eyes require vitrectomy, the second eye usually will be treated after the first eye has recovered.”
What is diabetic macular edema?
This common diabetes eye complication is a direct consequence of diabetic retinopathy — affecting about 50 percent of people with retinopathy.
Diabetic macular edema (DME) is the result of fluid building up and swelling in the macula of your eye. The macula is the part of your eye that’s responsible for clear, straight-ahead vision. You use your macula for things like recognizing faces, driving your car, and reading.
DME is actually the number one most common cause of blindness in people with diabetic retinopathy.
It’s often thought of as something that occurs during the most severe stages of retinopathy, but it can actually develop at any point during the progression of retinopathy.
Diabetic macular edema signs & symptoms
Like retinopathy, diabetic macular edema is most easily detected during your annual eye exam. Issues with your vision, however, can be a sign of DME, but waiting until there are obvious symptoms will only reduce your chances of successfully treating it and preventing its progression. Regular eye exams are a must when it comes to stopping DME in its tracks.
Diabetic macular edema treatment options
Anti-VEGF injections: As explained earlier in treating retinopathy, anti-VEGF injections are considered the primary treatment for DME, too. They work by blocking a protein called ‘vascular endothelial growth factor’ (VEGF). This unhelpful protein is what stimulates abnormal blood vessels to grow and leak fluid, contributing to DME and retinopathy.
Through these injections, abnormal blood vessel growth is reversed and the fluid in the retina decreases, too. Common FDA-approved pharmaceutical brands of anti-VEGF injections include Lucentis, Avastin, and Eylea.
Focal/grid macular laser surgery: This surgery involves a few or hundreds of small laser burns to the blood vessels that are leaking fluid near the edema. Through these laser burns, the leaking of fluid is quickly slowed which reduces the swelling in the retina.
“The procedure is usually completed in one session,” explains the NEI, “but some people may need more than one treatment. Focal/grid laser is sometimes applied before anti-VEGF injections, sometimes on the same day or a few days after an anti-VEGF injection, and sometimes only when DME fails to improve adequately after six months of anti-VEGF therapy.”
Corticosteroids: These steroids are injected or actually implanted into the eye, and can be used alone or in combination with other treatment options.
“The Ozurdex (dexamethasone) implant is for short-term use, while the Iluvien (fluocinolone acetonide) implant is longer lasting,” explains the NEI. “Both are biodegradable and release a sustained dose of corticosteroids to suppress DME.”
However, using this type of steroid in the eye does increase a patient’s risk of developing cataracts and glaucoma. This means any patient with DME using corticosteroids will also need to be monitored closely for any signs of increased pressure in their eye, and for signs of glaucoma.
What is glaucoma?
“Glaucoma is a group of diseases that can damage the eye’s optic nerve and result in vision loss and blindness,” explains the NEI. “It is one of the main causes of blindness in the United States. However, with early treatment, you can often protect your eyes against serious vision loss.”
In other words: having your eyes properly examined by an optometrist or ophthalmologist every year can save your vision if it means detecting and treating glaucoma before it has progressed too far.
The AOA estimates that people with diabetes are 40 percent more likely to develop glaucoma than non-diabetics.
The most common type of glaucoma is “open-angle glaucoma” versus “acute-angle glaucoma.”
“You are at increased risk of glaucoma if your parents or siblings have the disease, if you are African-American or Latino, and possibly if you are diabetic or have cardiovascular disease,” adds Doreen Fazio, MD, from the Glaucoma Research Foundation (GRF). “The risk of glaucoma also increases with age.”
Glaucoma signs and symptoms
Glaucoma can have no obvious symptoms for many patients until it’s too late. For others, later stages of the disease can result in blurred vision, distorted vision, or varying degrees of vision loss.
“There are typically no early warning signs or symptoms of open-angle glaucoma,” explains the GRF. “It develops slowly and sometimes without noticeable sight loss for many years.”
“Most people who have open-angle glaucoma feel fine and do not notice a change in their vision at first because the initial loss of vision is of side or peripheral vision, and the visual acuity or sharpness of vision is maintained until late in the disease.”
For the less common acute-angle glaucoma, symptoms according to the GRF include:
- Hazy or blurred vision
- The appearance of rainbow-colored circles around bright lights
- Severe eye and head pain
- Nausea or vomiting (accompanying severe eye pain)
- Sudden sight loss
Glaucoma treatment options
“Currently, in the US, eye drops are often the first choice for treating patients,” explains the GRF. “For many people, a combination of medications and laser treatment can safely control eye pressure for years.”
Eye drops used to treat glaucoma decrease eye pressure by helping to drain excess fluid from the amount and decrease the amount of fluid produced by the eye.
Types of eyedrop medications to treat glaucoma include:
- Prostaglandin analogs
- Alpha agonists
- Carbonic anhydrase inhibitors (CAIs)
- Rho khinase inhibitors
Many patients will need a combination of medications to manage their glaucoma.
“Glaucoma is a treatable eye disease until it isn’t,” explains Bevels. “The best advice is to use your prescription drops for intraocular pressure control as directed by your eye care provider. There is nothing scary about eye drops, but they are an issue for older patients with dexterity issues, and sometimes surgery is the best option.”
What are cataracts?
A cataract is the result of cloudiness in the lens of your eye. They can be small, only interfering with your vision slightly, and they can become much large enough that the interference with your vision is significant and impossible to ignore.
While people with diabetes — especially those who smoke cigarettes — are at a greater risk for developing cataracts, they can also develop in otherwise healthy individuals, too.
“Cataracts most often develop in persons over the age of 55,” explains the AOA, “but they are also occasionally found in younger people, including newborns.”
Cataracts signs and symptoms
Unlike most other diabetes eye complications, cataracts have considerably more significant symptoms, including:
- a “cloud” visible when looking at your eye in the mirror
- blurred vision or cloudy spots in some parts of your vision
- seeing double (when you see two of something, instead of one)
- increased sensitivity to light
- difficulty seeing at night or needing more light when you read
- see normally bright colors as somewhat faded and less vibrant
Cataracts treatment options
Some cataracts never worsen enough to require treatment, but for many, surgery is essential to improving and restoring your vision.
“If a cataract develops to a point that your daily activities are affected, you will be referred to an eye surgeon who may recommend the surgical removal of the cataract,” says the AOA. “
While surgery always sounds intimidating, cataract surgery is fairly simple and can be performed in a relatively short outpatient procedure in your surgeon’s office (rather than an operating room in a hospital).
“Using a small incision, the surgeon will remove the clouded lens and, in most cases, replace it with an intraocular lens implant,” explains the AOA. “A medication is generally placed in the eye after surgery and the eye may be patched.”
What is dry eye syndrome?
Dry eye syndrome (DES) or dry eye disease (DED) or “keratoconjunctivitis sicca” can be found in over 50 percent of all patients with diabetes, explains Bevels, making it a common diabetes eye complication.
“Many patients are asymptomatic, but still have the disease or the beginning process of the disease developing,” says Bevels, whose clinic, Elite Dry Eye Spa, specializes in dry eye syndrome.
“Chronic use of any topical eye medication can lead to a dry eye diagnosis,” adds Bevels. This means that patients who require long-term medications for their eyes should be on the lookout for signs of dry eye syndrome, get a proper diagnosis, and follow-through with treatment quickly to prevent any further issues.
Dry eye syndrome signs and symptoms
The most common include a stinging, burning, or scratchy feeling on and around your eyes. You may also find a thin mucus around your eyes, as well as frequent redness in the whites of your eyes, and a greater sensitivity to the sun.
Dry eye syndrome treatment options
For some patients, a daily application of artificial tears will be enough in addition to improving blood sugar levels. But other patients with more advanced stages of retinopathy or DME may require a “Meibomian gland analysis” and consistent treatments to prevent the loss of the outermost oil tear layer, explains Bevels.
“There will be some patients who also suffer from evaporative dry eye disease,” adds Bevels, “and this may require a treatment of ‘punctal plugs,’ autologous tears, and possibly a prescribed anti-inflammatory eye drop, depending on the severity of the patient’s symptoms and overall condition of their eye.”
Take good care of your eyes — you need them!
Our eyes are vital to our everyday experience of being alive — so taking good care of them, which means taking good care of our diabetes, is a must.
“Other simple things you can to protect your eyes,” adds Bevels, “is to wear UV sunglasses outdoors, and consider ocular supplements with high levels of zinc, lutein, and carotene.”