Pre-proliferative /non-proliferative retinopathy
In this condition the retina has been damaged by the higher than normal sugar levels over several years. The condition is called 'pre-proliferative' as it usually progresses to develop proliferative retinopathy, when 'new vessels' develop. It is now generally termed 'non-proliferative'.
In severe forms of pre-proliferative retinopathy there are lot of haemorrhages, as the retina is very ischaemic. This needs laser treatment to prevent new vessel growth. Proliferative retinopathy in one eye is especially likely if the other eye has already developed new vessels. It is rarely asymmetric here here. Anti-VEGF treatment may also help..some clinics now have stopped laser and just use Anti-VEGF injections.
haemorrhages (flecks of blood) and tiny abnormal blood vessels are present.
If there are lots of haemorrhages, more than illustrated here, new vessels
may grow over the next 12 months, and laser will be needed.
There will be damage to the tiny retinal vessels, such as 'IRMAs' (intra-retinal-microvascular abnormalities). There may be cotton wool spots (areas of retinal damage). p110
It is important to control your retinopathy over the long term. However, if your control has been mediocre, and then starts to improve, then the retinopathy may occasionally get worse, and you may need a lot of laser. However, in parts of the world here anti-VEGF injections are available, results are better waiting without laser, and offering injections if macular oedema or proliferation develops.
But after 2-3 years of good control your retinopathy will be better than it would have been otherwise: In the long term good control is crucial, as below. Progression may be rapid, see.
Mild pre-proliferative retinopathy does not need laser/anti-VEGF. If your diabetic
control (sugar, BP, cholesterol,
weight) is good as below, then any progression will be slow. Progression
to a more serious type of retinopathy (macular oedema or proliferation)
will be much quicker if your control is poor, and such a patient should
be examined every 4 months or so.
Also, when a patient with type 2 diabetes changes from tablets to insulin, a rapid improvement in diabetic control may occur, and so such patients may develop a rapid deterioration of their retinopathy.
Moderate or severe pre-proliferative (sometimes called moderate non-proliferative or severe non-proliferative retinopathy) usually needs anti-VEGF (if unavailable) before obvious proliferation develops.
If anti-VEGF injections are not available, PRP laser is indicated. Light subhreshld laser for mild cases is helpful, more severe cases need heavier laser, with slightly greater risk of causing an increase inmacular oedema. (Not all ophthalmologists agre about laser.). There is evidence this reduces the number of vitreous haemorrhages etc later see. Sometimes 2-3 more sessions of laser are needed.
On the other hand, if anti-VEGF injections or laser is delayed, either macular oedema or proliferation develops, and treatment is less likely to prevent visual loss. Sometimes no matter what approach is taken macular oedema develops, but this is much reduced with the anti-VEGF injections or newer laser techniques.
Laser has a 30% chance in increasing in macular oedema, but this risk is much lower if subthreshold laser is used.
Anti-VEGF has not been generally used for pre-proliferative retinopathy, but in future it may be used more often, and will certainly help if there is also macular oedema.
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 Eye 17
- 30-120 minutes exercise a day ,
- moderate alcohol consumption only,
- avoid obesity if possible,
- balanced diet including
- 9 portions of vegetables or fruit a day (9 for men, 7 for women), Lowers BP
- minimal of animal or 'hard' vegetable fats,
salt, see the evidence
Alcohol should be limited to one drink or unit a day, six days a week (Mukamal 2004). More than this leads to brain damage.
- Oily fish such as sardine, salmon, tuna, trout, at least twice a week (small amounts are fine...not a whole salmon!).
- Fibre and healthy fats in the diet slows down retinopathy. No transfats and minimal saturated fat.
- generally 130/80 (see graph) or preferably less BMJ 16. Even less if well <120 BMJ17
- (120/75 ..home monitoring)
- 125/75 or less if protein in urine present (115/70.. home monitor)
- ACE inhibitors or Angiotensin Receptor Antagonists unless young/pregnant/very low blood pressure/poorly tolerated
- The lower the better in macular oedema, as long as you feel well.
- An ideal pressure is below 115 (systolic, first number) for healthy people. <120 is is only suitable for new/well diabetes patients 2012. Otherwise slightly higher as above.
- Home monitoring blood pressures should be 10mmHg (systolic) and 5mmHg (diastolic) lower see than these 'clinic' pressures.
- Depression & anxiety increase BP.
- 48-58 mmol/mol (6.5%-7.5%) or less (see graph) with very few or preferably no hypos. These (or slightly lower) levels are the best to prevent complications
- <58 mmol/mol (7.5%) for insulin users; <48 mmol/mol (6.5%) if not using insulin and have good health. Problems with intensive control. Target should be adjusted according to health and age. If you are a type 1 patient and cannot achieve good control, you need to checked for other conditions such as coeliac disease (anti-TTG antibodies), addisons, and thyroid.
- If hypos develop, seek expert advice from your diabetes nurse/doctor.
- if your HbA1c is high (say 97mmol/mol / 11%), then the next step may be to achieve 75 (9%)....in other words, and any improvement is helpful, gradually reaching lower levels above.
sudden decrease in HbA1c
- A sudden improvement in control (HbA1c drop of 33 mmol/mol/3% ) will lead to a temporary rapid increase in progression of retinopathy: laser may be needed.
- Good control is important in the longer term, that is after about 2 years. When people who control their diabetes well will be better off after this period. See
- A temporary increase in retinopathy is most common when starting insulin for the first time, especially if the diabetes is very badly controlled when you start the insulin.
- Individual targets Nice 16
- <4.0mmol/l, and statins recommended for most adult patients with diabetes whatever the cholesterol.
- statins are recommended whatever the cholesterol, if well tolerated age>40y
- A fibrate such as fenofibrate is advisable in nearly every person with retinopathy. They reduce retinopathy progression 40% (Fenofibrate 200mg od) Field Study. We now recommend these for all adult patients, and they can be used in addition to a statin.
- LDL <2
- Avoid if pregnant, GFR <15, pancreatitis
- If GFR low but still >15, need a lower dose.
- smoking 20 a day triples/quadruples retinopathy
- passive smoking may double retinopathy: room-mates inhale at least 25%
- electronic cigarettes are much much safer and probably have a negligible effect on retinopathy
- even 'Just one cigarette a day seriously elevates cardiovascular risk ' BMJ18, so it is best to stop completely.
- multiple dose insulin, using a protocol such as using lantus (long acting) and rapid acting (novarapid/humalog) is normally superior to twice daily. (This is controversial.)
- Insulin pumps generally produce better control still, but are harder to use.
- everyone with diabetes should attend an education course, such as DAFNE (insulin) , DESMOND (type 2 at diagnosis), or XPERT (type 2). Primary Care Trusts are obliged to send you on such a course, but very few patients have ever attended one. If you have not been on one, discuss this with your diabetic team. Get a diabetes buddy.
- this contributes to macular oedema and loss of sight (Schwartz, 2006), and many serious problems.
- It is common in diabetes, particularly if you are overweight. Do you have sleep apnoea?
- see 15
- 5.0-7.2 mmol/l before meals
- <10.0 mmol/l after meals
- no serious hypos
- for patients who test their glucose levels and adjust insulin doses, the new glucose sensor is highly recommended and has transformed the lives of many patients. The cost is about £30/week).
- Rosiglitazone and pioglitazone should not be used if there is significant retinopathy, and certainly not if macular oedema is present, as they increase macular oedema and fluid retention. Case 49. Lirglutadite and Exenatide are drugs that can be used instead low also lower weight (they are injections.)
- insulin users need to avoid serious hypoglycaemia. Expert help is usually needed if episodes are severe/frequent. See
- many patients receive totally inadequate care BMJ 11. Some call this 'institutionalised neglect'.
- 10% compliance if multiple treatment,
? 60% one tablets
type 2 at diagnosis
- need a test for Haemochromatosis
Photos (details see case 15)