Pregnant women with diabetes should have an eye exam within the first trimester and be followed closely throughout the pregnancy because diabetic retinopathy can worsen during pregnancy. And postpartum, women with diabetes should receive eye exams for one year after delivery.6

A comprehensive eye exam should include:

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  • Visual acuity test
  • Dilated eye exam
  • Tonometry, measurement of the pressure inside the eye

In addition to an eye exam, photographs of the fundus, or interior of the eye including the retina, may be helpful in diagnosing vessel damage. However, retinal photography should not replace a comprehensive eye exam.

A diagnosis of diabetic retinopathy and/or macular edema may follow from the following signs:

  • Leaking blood vessels
  • Swelling inside the retina
  • Pale, fatty deposits on the retina
  • Damaged nerve tissue
  • Any changes to the blood vessels

If macular edema is suspected, a fluorescein angiogram should be done to find leaking blood vessels. This is done as part of treatment plan usually involving laser photocoagulation surgery. A solution of sodium fluorescein is intravenously administered into the arm, followed by sequence photographs of the retina to evaluate its circulation.

Managing glucose levels

Since retinopathy is a consequence of the underlying diabetic condition, the most comprehensive means to lower the risk of developing it or to slow its progression is to maintain optimal blood sugar levels. Patients need to be educated on how to keep blood glucose levels in the prescribed target range through medications and diet and exercise, as appropriate.

ADA guidelines recommend that vigorous exercise or strength training should be avoided in patients with proliferative retinopathy or severe nonproliferative diabetic nephropathy to avoid triggering a hemorrhagic event or retinal detachment.

Results from the Diabetes Control and Complications Trial indicate that tight glucose control cut the risk of diabetic retinopathy by 76%. Disease progression slowed by 54% in those people who already had some eye damage at the start of the trial.4

Other trials, including the UK Prospective Diabetes Study (UKPDS), found that stringent glucose control minimized overall microvascular problems in people with type 2 diabetes, including diabetic retinopathy, diabetic kidney disease and diabetic neuropathies by 25%.

Most recently, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye Study, published in 2010, showed that intensive blood glucose control reduced the risk of diabetic retinopathy progression by about one-third compared to standard therapy (7.3% vs. 10.4%).7

These studies look to the levels of glycosylated hemoglobin A1C (HbA1C) as a standard measure of glucose control. HbA1C is used to determine the average blood glucose levels over the previous two to three months. A target HbA1C level of 6.5% or lower is optimally recommended for most adult patients with diabetes to reduce diabetes-related complications.

American Diabetes Association (ADA) guidelines currently recommend testing HbA1C levels twice a year in the diabetic population. Quarterly testing is suggested for patients who have not met treatment target goals or who have changed treatment strategies.

Managing BP and cholesterol

The UKPDS trial results showed that reducing BP also reduced the progression of diabetic retinopathy. However, results of the ACCORD study did not find any benefit in lowering the progression of retinopathy by intensive blood pressure control.

Despite these mixed results, another ACCORD finding provides convincing evidence that lipid management — in the form of a statin and a fibrate medication — does reduce diabetic retinopathy progression. Specifically, the combination reduced disease progression by one-third compared with statin monotherapy (6.5% vs. 10.2%).7 ACCORD was the first clinical study to show that combination therapy with fenofibrate and simvastatin (Zocor, Merck) reduces diabetic eye disease progression.

Treating diabetic retinopathy

During the first three stages of diabetic retinopathy, no specific treatments are available, though health care professionals should continue stressing the importance of adequately managing glucose, BP and cholesterol levels.