www.diabeticretinopathy.org.uk

Diabetic maculopathy
(abbreviations DME & DMO, diabetic macular oedema)

David Kinshuck

 

Introduction

fovea...the yellow dot in the centre of the retina,

Enlarge
The fovea: this is the view of your eye a doctor sees looking,  just like a map. The central area of the retina is the 'macula', shown by the dotted black ring. Light focuses here, so any damage may affect your sight. The very central area, the yellow dot, is the the fovea.

 

The macula is the central area of your retina. It is responsible for all your sharp vision, such as used for watching TV or reading. It can become damaged in diabetes, with leaks developing (oedema).

Generally, if the diabetes is not well controlled, without treatment, this a progressive condition, as described below.

But now new anti-VEGF eye injections can be very effective in reducing the leakage (oedema) and keeping good sight, and nearly all patients will keep good sight.

Treatment includes

macular oedema causes patchy central vision

Side view of the eye:
light enters the eye from the left and focuses on the macula, the central area of the retina. Damage to the macula affects your central vision.

Remember the 'targets' for good control

By keeping to these levels as much as possible (or lower still) you will be doing your best to stop your eyes getting worse. Occasionally by sticking to these targets your retinopathy will improve, even without laser. Review BMJ17   

 

lifestyle

blood pressure

HbA1c

sudden decrease in HbA1c

cholesterol and statins

smoking

insulin

education

Diabetes education courses

sleep apnoea etc

glucose level

Glitazones

hypoglycaemia

neuropathy

issues

compliance

type 2 at diagnosis

Early Maculopathy & laser

early maculopathy, sight still good

Enlarge   A small area of leakage developing in the macula, near to the central area, as indicated by the black pointer. Laser is needed to prevent the leakage spreading out, like a growing tree trunk. As the fovea is not affected, sight will be good. But without laser the leak will spread to the fovea and reduce sight.

 

 

Laser was previously the main treatment, but this has largely been replaced with anti-VEGF injections below.    DCRnet T

Areas of leakage develop in retina, and the retina can become boggy like a sponge. The leak can progress, causing more and more damage. If there is a small area of leakage, laser can seal or reduce the leakage and prevent it going on to cause more damage.

Your ophthalmologist can see the leaks by examining your eye on a 'slit lamp' in the clinic or using an OCT.

Laser is a very bright light that is very focused so it makes tiny burns on the retina. The burns are so tiny they cause very little damage when treating this type of maculopathy.

Once again, controlling your blood pressure, sugar, and fat levels (see Prevention) can help to stop this condition getting worse.

Laser for this type of retinopathy is not painful, and is moderately effective (see evidence).

Sometimes the leak needs more than one laser treatment or injection treatment. More often than not more leaks develop over the next few years, again needing laser, as below. See photo, another

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The leaks in the macular area can be sealed with laser treatment.

laser for early diabetic maculopathy

These leaks are called 'macular oedema', that is areas of thickened spongy retina. Most patients with macular oedema need laser.

Mild oedema may settle without laser AJO 08. On the other hand, an OCT photograph may measure an increase in oedema and vision may deteriorate.

The leakage is much more likely to reduce if glucose, blood pressure, smoking, and cholesterol levels etc are controlled.

Macula is thickened an all diabetic retinopathy patients (Retina 14).

 

 

 

 

Enlarge 

Laser shown as black specs.

 

Moderate Maculopathy (macular oedema) and anti-VEGF drugs such as Avastin and Lucentis and Eylea (Aflibercept)

focalmaculopathy...a leak in one area

Enlarge Moderate or focal maculopathy with one main leaky area: your sight would be good as the centre... the yellow spot in this picture.. remains healthy.

pioglitazone macular oedema

an OCT scan showing macula oedema
enlarge

 

Diabetic maculopathy treatment pathway

As leaky areas develop, anti-VEGF injection treatment is needed, otherwise the condition will become severe. See photo tour.  Laser can help a little if injections are not available.

The water-logging takes 4-6 months to disappear. Because of this, you may not know whether the treatment has been successful until then.

As long as the very centre of the macular area remains healthy, the fovea, your vision will remain good.

Remember a low blood pressure is helpful, as in the table above. See photo.

Treatment should include not smoking, control of the glucose/HbA1c and BP and lipids.

VEGF (vascular endothelial growth factor) is the chemical released by a damaged retina, and this chemical makes nearby parts of the retina leak more.

Anti-VEGF injection  drugs often reduce the leakage, but don't improve sight if there is retinal damage JAMA 14

Mild damage with reasonably controlled diabetes (BP, Hba1c, not smoking) does not get worse and does not need treatment.  JAMA19 

Chronic cysts MR19: sometimes the 'bump' on the Oct. photograph is not fresh leakage but a type of cyst. This does not usually get worse, and is best accepted.  It is usually unnecessary but possible to drain with very major surgery.

Start anti-VEGF whilst vision good Eye 20   as the outcomes are better. Chronic cmo with good vision does not get worse often Eye 20 . These 2 papers are therefore slightly contradictory. However, if the patient does not smoke, if the BP is good <130-140mmHg, if there are no retinal haemorrhages, and if the diabetes has been controlled for years, may be the condition is stable and no treatment is needed.
But if the patients smokes, the BP high, of if the diabetes has not been controlled in the last 3 years, and there are retinal haemorrhages I would suggest treatment would be helpful to prevent deterioration, or at least slow it down, and start whilst vision good.

Injections best BJO 20.

 

Injections of anti-VEGF drugs and steroid injections

The anti-VEGF drugs:

Intravitreal steroid injections

different types of diabetic macular oedema respond differently to anti-VEGF

subretinal fluid..little improvement in vision

spongy /diffuse oedema...best result, some improvement in vision often

cystoid oedema..poor response...little improvement in vision

 
 

 

different types of diabetic macular oedema respond differently to anti-VEGF enlarge

 

A patient

Below is a patient 2006 (left photo larger) treated with laser, lowered glucose levels, lost weight, and lowered blood pressure. The right photo (larger) is after treatment in 2007.

exudates disappear after laser

 

Circinate retinopathy

circinate retinopathy Enlarge
Circinate retinopathy..exudates are in a 'ring' or partial ring.

If the exudate forms a ring this is termed 'circinate' retinopathy as opposite. Laser to the central area of the ring is very helpful, see case 42. and  case 54.

Usually the leakage dries up after the laser.
Laser cannot be carried out if the centre is the fovea, as otherwise the central vision would be damaged.

 

Diffuse maculopathy

diffuse diabetic maculopathy

Enlarge Here there is oedema (leakage), shown as the grey patch here. The very centre of the vision can be affected as the fovea is affected (the yellow spot).

 

Here the waterlogging affects the very central of the vision, and will reduce sight.

In the very early stages your sight may be good, but usually, without laser, the leakage increases and your sight will be reduced so reading and watching TV may become more difficult. photo  

Anti-VEGF injections  should be standard treatment.

 

    

 

grid laser for diabetic maculopathy

 

Laser is may help needed, and may need to be repeated several times.

Enlarge

A 'C' pattern of laser is often applied as above (shown in black).

 

 

 

Severe or ischaemic maculopathy

severe diabetic maculopathy

Enlarge There is considerable water logging in the central area of the retina, and your vision may be very poor.

 

If the macular oedema has not been present long, intravitreal steroids or Anti-VEGF injections will help.

Laser is usually needed also. The leak is shown as a dark area in the centre of the macula with a fluorescein angiogram. This is called 'ischaemia' or 'ischemia' or 'ischaemic maculopathy'.

The sight can be badly affected. Your doctors will have tried to have prevented this severe condition developing, but sometimes this is not possible even with the best treatment. See photo.

We hope fewer people will reach this stage.

Sometimes the tiny capillaries are permanently damaged and treatment will not restore your sight.

See Coping with Poor Vision if this has happened to you.

 

Photos: severe maculopathy and pre-proliferative retinopathy

Here laser and injections are needs, but sight will not improve: the treatment is only to prevent or slow down deterioration.

severe retinopathy..presenting in 2007

enlarge left eye

 

Glitazones may increase macular oedema

Glitazones (pioglitazone) may increase macular oedema. If there is retinopathy they drugs should be stopped, and may be replaced in some patients with Exenatide or Sitagliptin. Case 49. If there is no retinopathy they will not have an effect on the retina so are safe from the eye point of view.

 

pioglitazone macular oedema

left eye, mild macular oedema, good vision
enlarge

pioglitazone macular oedema

right eye, foveal oedema, good vision. The oedema resolved when the pioglitazone was stopped enlarge

 

 

Cataract surgery

This frequently increases macular oedema in patients with diabetes BJO 17  . This can be treated with injections (but also see)

 

 

Abbreviations