Maintain Your Eye and Vision Health with Diabetes – Latest ADA Standards of Care
By Hope Warshaw
Having diabetes puts you at risk for problems with your eyes and vision. Learn about the steps you can take, as recommended in the latest ADA Standards of Care, to maintain the health of your eyes and prevent damage.
People with diabetes are at increased risk compared to the general population of developing eye problems including: retinopathy, macular edema, cataracts and glaucoma. And diabetes continues to be the leading cause of new-onset blindness in people aged 18 to 64 years of age.
Learn how to maintain the health of your eyes based on guidance from the American Diabetes Association’s Standards of Care.
Diabetes-related eye problems
Four common eye problems:
-
Retinopathy:
-
What is it? Retinopathy can occur when high glucose levels over years damage the small blood vessels of the retina (the inner lining of the eye located at the back). Over time these injured blood vessels can weaken, bulge, or leak fluid into the gel-like middle of the eye (called the vitreous). There are different types of retinopathy. Nonproliferative retinopathy occurs when the blood vessels of the retina have been damaged. Fluids, fats and proteins can leak out of the abnormal blood vessels. In proliferative retinopathy, new unstable blood vessels begin to grow on the surface of the retina. These unstable blood vessels cause frequent minor bleeding which causes local irritation and scarring.
-
How is it treated? Laser treatments, known also as panretinal laser photocoagulation therapy, makes very small burns inside the eye cavity with a beam of light (laser). It is used to treat both nonproliferative and proliferative retinopathy to prevent further growth of unstable blood vessels. Anti-VEGF (Vascular Endothelial Growth Factor) medication (see more under macular edema), a newer treatment, can be an alternative to laser treatment. Common categories of medications to manage high blood pressure – ACE inhibitors and ARBs – also help prevent or slow development of retinopathy as well as diabetes related kidney disease.
-
-
Macular edema:
-
What is it? In macular edema, many years of high glucose levels from diabetes can damage the macula (the part of the retina that is responsible for our central vision, most of our color vision, and the fine detail of what we see) and cause swelling or edema. Macular edema typically develops when people with diabetes also have signs of retinopathy. Aging can also cause edema of the macula.
-
How is it treated? Use of an anti-VEGF medicine, such as aflibercept (Eylea), bevacizumab (Avastin), or ranibizumab (Lucentis), can stop further vision loss and may even improve vision. The medicine is injected into the eye during an office visit. Treatment requires several injections into the eye. Anti-VEGF injections block the growth of abnormal blood vessels in the eye and can stop fluid leaks. Laser treatment (as described above) may be used instead of anti-VEGF injections.
-
-
Cataracts:
-
What is it? A cataract is a cloudy area in the lens of the eye. The development of cataracts is very common as people age. However, people with high glucose levels from diabetes can develop cataracts at an earlier age.
-
How is it treated? Surgery is done to remove the cloudy lens covered by the cataract and to put in an artificial replacement lens. Typically, this requires outpatient surgery. Recovery of vision is rapid but treatment after surgery requires days of putting drops into the eye.
-
-
Glaucoma:
-
What is it? Glaucoma is an eye disease that ultimately affects the main bundle of nerves in the eye called the optic nerve. Usually, early-stage glaucoma causes few or no symptoms, however, it can be detected through a dilated eye exam. People with diabetes have a greater risk of developing glaucoma and if not treated, it can lead to loss of vision and eventually blindness.
-
How is it treated? There is no cure for glaucoma but early treatment can often stop or slow the damage. Prescription eye drops are used daily to lower the eye pressure and prevent damage to the optic nerve. Laser treatment or surgery may be necessary if the drops don’t stop the progression.
-
What does it mean if I have temporary blurry vision?
A common, but most often short-lived, eye problem is blurry vision. If your glucose levels have been high for a while, they can cause blurry vision. It is a common symptom when diabetes is diagnosed, or if a person stops taking their diabetes medications for a longer period of time. The blurry vision usually resolves when glucose levels come back down into a desirable range. If you wear glasses, experts recommend that you do NOT get a new prescription for glasses at this time. Your vision will likely slowly return to your prior status as your glucose levels improve.
How to prevent, reverse, and/or delay diabetes-related eye problems
-
Keep your glucose levels, blood pressure and blood lipids in the recommended target range as much as possible.
-
If you believe you have an eye problem or have sudden changes in your vision, see an eye specialist (optometrist or ophthalmologist) as soon as possible. The eye specialist should check your vision, do a complete eye exam that includes dilating your retinas, and measuring the pressure in your eyes (glaucoma). When they conclude the exam, they will let you know if your eyes are healthy and/or provide you with treatment options. Be sure to take the next steps. Eye problems can progress or worsen without timely treatment. Act quickly, don’t delay.
-
Prevent, reverse, and/or delay diabetes-related eye problems by having regular eye exams (see below). A complete eye exam includes having your eyes dilated so the provider can see the back of your eyes and examine your retinas.
-
Adults with type 1 diabetes: Have an initial comprehensive eye exam by an ophthalmologist or optometrist within five years of diagnosis.
-
People with type 2 diabetes: Have the same comprehensive eye exam just after being diagnosed because you may have had undiagnosed prediabetes or type 2 diabetes for several years.
-
Of note, retinopathy status should be assessed prior to starting to lower glucose levels or with the addition of another glucose-lowering therapy. Rapidly lowering glucose levels that have been high for a long period of time have been associated with the onset or worsening of retinopathy.
-
Pregnancy: Women who have either type 1 or type 2 diabetes who are planning to get, or are, pregnant (first trimester) should have an eye exam. These women should have knowledge of and be counseled about the risk of development or progression of diabetic retinopathy. They should be monitored every trimester and one year after pregnancy as indicated by their degree of retinopathy.
-
Note: If your eye doctor recommends an eye exam more often than noted above, get it done.
-
-
Regular follow up
-
If there’s no evidence of retinopathy or other problems after one or more exams, then screening should be done every year by an ophthalmologist or optometrist.
-
If you are told you have evidence of retinopathy or other eye problems, you should see a specialist for that problem as often as recommended by the specialist.
-
In closing, the ADA now recommends a comprehensive approach to prevent and/or delay most long-term diabetes complications. Some of the actionable steps you can take to prevent eye problems or other complications includes:
-
Achieve and maintain glucose levels in desirable target ranges.
-
Achieve and maintain blood pressure in target ranges.
-
Achieve and maintain lipid levels in target ranges.
-
Be prescribed and take as prescribed glucose-lowering medications that offer protection to the heart, blood vessels, and kidneys (GLP-1 receptor agonist or SGLT-2 inhibitor).
-
Be referred for and obtain diabetes self-management education and support regularly.
-
Get regular exams to check for any complications such as retinopathy, heart disease, kidney disease, etc.
-
Report any physical changes in your body or symptoms to your diabetes care providers.
-
Take action as soon as possible to get the recommended treatment for a detected problem.
Advice from a person with diabetes on maintaining eye health
To gain insights into the practical and emotional aspects of preventing or managing diabetes-related eye disease, we talked to Sarah Mart, MS, MPH. Mart has had type 1 diabetes for 41 years and is director of operations for DiabetesSisters.
“When it comes to getting that annual eye exam done, I go to the ophthalmologist that my endocrinologist recommended when I first moved to where I live now [in Colorado],” Mart said. “I make my appointment for next year’s exam at the end of the prior year’s exam. I put all of my medical appointments in my phone and online calendar right away. Otherwise, it doesn't happen.”
“If a problem is detected, I ask for the name of a recommended provider that is in the provider network I have to use. I also check on my coverage for these services. If necessary, I talk with the person who handles prior authorizations and/or make plans for how to handle the cost.”
“I've been stressed about eye appointments for 41 years, and the anxiety can increase from year to year. I try to remember to breathe mindfully on my way to the exam and during the appointment. I use my wide network of ‘diabetes-besties’ and text with them before my eyes get too dilated. People in this network are my safe space, because when you know, you know.”
We realize that what works for Mart may not work for you. What’s most important is that you find what does.
View other diaTribe articles about diabetes-related complications:
-
Maintain the Health of your Heart and Blood Vessels – Latest ADA Standards of Care
-
Maintain the Health of Your Liver – Latest ADA Standards of Care
About this series:
Each year the American Diabetes Association (ADA) updates their Standards of Medical Care in Diabetes. These Standards of Care or Standards, are updated by the ADA’s Professional Practice Committee (PPC) reviews of recent research and consultation with subject matter experts. ADA publishes their revised Standards each January as a supplement in their journal as well as online. ADA also maintains, “Living Standards.” These interim updates are published as necessary based on new science, regulatory changes, new medication or technology approvals, etc.
This series of articles translates the what’s and how to’s on diabetes complications based on the ADA Standards. Our goal at diaTribe is to help you be in the know so you may take actions to prevent or slow the progression of any complications as soon as possible. Research shows the central tenets to prevent diabetes complications are to keep your glucose levels, blood pressure, and blood lipids in the recommended target ranges as often as possible. Plus, get the regular recommended diabetes-specific exams, and, if a problem is detected, take the recommended actions to prevent or delay further progression and problems.
