Retinopathy

The retina is the light-sensitive tissue that lines two-thirds of the human eye and is responsible for receiving visual images. Any damage or disease of the retina is known as retinopathy, which might cause visual impairments. There are several different types of retinopathy, which are all caused due to vascular damage/changes in the small retinal blood vessels.

Hence, retinopathy is also called retinal vascular disease. Oftentimes, retinopathy presents as an ocular manifestation of systemic diseases such as diabetes and hypertension. Diabetes is one of the most common causes of retinopathy worldwide. Diabetic retinopathy is a leading cause of blindness in working-age people. The WHO has designated diabetic retinopathy as primary eye disease, and it accounts for almost 5% of blindness worldwide.

Signs and Symptoms

Signs and symptoms of retinopathy include:

Blurred vision
Double vision
“Floaters” or spots in the vision
Pain and redness in the eye that does not resolve
Decreased peripheral vision
Decreased night vision

Types of Retinopathy

For ease of understanding, retinopathy is broadly classified into proliferative and non-proliferative types.

Non-proliferative retinopathy

Non-proliferative retinopathy is often caused by direct damage or remodeling of the small retinal blood vessels. The main mechanisms of damage in non-proliferative retinopathy are a) blood vessel damage or remodeling, b) direct retinal damage, and c) occlusion of the retinal blood vessels. Hypertension, atherosclerosis (hardening or narrowing of blood vessels), radiation, prematurity, etc. are the common causes of non-proliferative retinopathy. Non-proliferative retinopathy is much more common and may not require treatment.

Proliferative retinopathy

Proliferative retinopathy is the result of abnormal blood flow to the retina due to blood vessel overgrowth, or new blood vessel formation. These pathologically overgrown blood vessels are often fragile, weak, and ineffective at supplying blood to the retinal tissues. Such fragile blood vessels are prone to leakage which allows fluids, protein, and other debris direct access to the retina. As these blood vessels are weak, they are at high risk of hemorrhage which increases the risk of vision loss and blindness. Several causes of the non-proliferative retinopathy can lead to proliferative retinopathy as the disease progresses. Diabetes mellitus is the most common cause of proliferative retinopathy.

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Causes

Diabetes mellitus

Hypertension

Atherosclerosis

Radiations

Solar retinopathy

Prematurity

Anemia

Sickle cell disease

There are several different causes of retinopathy. Some of the most common causes are listed below:

1. Diabetes mellitus: Diabetes (diabetes mellitus) is a common disease in which blood-sugar levels are raised for a prolonged time period. Diabetes mellitus has many complications associated with it, and several eye disorders are among those complications. Diabetic retinopathy is the most common eye complication of diabetes. It is also a leading cause of adult blindness.

Diabetic retinopathy occurs when high blood-sugar levels affect the functionality of retinal blood vessels. Initially, the retinal capillaries start to leak blood or fluid which leads to swelling in the retina. Retinal swelling can result in blurring of central vision, and it can leak into the vitreous humor, the fluid surrounding the retina, leading to the formation of floaters or spots in the vision. In the earlier stages, the patient can be asymptomatic as serious vision damage is less likely.

However, as the disease progresses, it may result in a more advanced stage of the disease called proliferative diabetic retinopathy. In this form, blood vessels in the retina get closed off. New blood vessels grow to make up for the lack of blood flow to the retina. The pathologically overgrown new blood vessels are fragile with reduced strength which can then result in scarring and more leakage. This can lead to serious vision loss and blindness.

2. Hypertension: Hypertension (high blood pressure) and vascular (blood vessel) diseases can affect the small blood vessels of the retina just as they can affect other blood vessels. Retinopathy may therefore be an indicator of vascular damage elsewhere in the body. Visual changes sometimes develop because of advanced retinopathy and may be a sign of undiagnosed or poorly controlled hypertension. Although rare, blindness may occur. The high pressures in the circulation lead to the thickening of the artery walls, which in turn reduces the amount of blood flow to the retina. This reduction in flow causes damage to the retinal tissue.

3. Atherosclerosis

4. Radiations

5. Solar retinopathy

6. Prematurity

7. Anemia

8. Sickle cell disease

Diagnosis

Retinopathy is diagnosed by an ophthalmologist or an optometrist during the eye examination. The clinician will have to examine the retina to make this diagnosis. Several ways can be employed to examine the retina. Direct visualization of the retina by looking through the pupil with light after dilating the pupil is one of the ways that clinicians can use to examine the retina. Stereoscopic fundus photography is the gold standard for the diagnosis of retinopathy.

Prevention

Retinopathy occurs often as a manifestation of systemic diseases such as diabetes or hypertension. Controlling blood sugar levels and blood pressure is paramount to effectively reducing the incidence of retinopathy.

Blood sugar control: Individuals wait is important for them to have their blood sugar levels checked. The gold standard blood sugar test is the A1C test. A controlled blood sugar level can effectively reduce the incidence of retinopathy and its impending progression to advanced stages.

Blood pressure control: Controlling blood pressure can also lower the incidence and progression of retinopathy. A primary care physician can help with blood pressure control strategies.

Other: Besides blood sugar and blood pressure control, there are other modifications that can help. Regular exercise may help lower the incidence and progression of retinopathy. If someone has sleep apnea, treatment of sleep apnea may help as well. Regular eye examinations are important to check for the progression of retinopathy from non-proliferative to proliferative stages.

Treatment

Treatment of retinopathy is based on the cause of the retinopathy, nature, and progression of the disease. For advanced-stage disease, ophthalmologists may opt for pan-retinal photocoagulation. Laser photocoagulation therapy has been the standard treatment for many types of retinopathy. The usage of anti-VEGF drugs (antibodies to sequester the growth factor), such as bevacizumab or pegaptanib, have shown promising results in the treatment of proliferative retinopathies.

If the vitreous humor has become clouded by blood leakage, the clouding may disappear spontaneously. However, if clouding persists, vitrectomy, or surgical removal of the vitreous humor, may be necessary. This procedure can restore vision that has been obscured in the vitreous; however, any vision loss due to retinal damage or detachment cannot be restored.

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