With the improvement of people’s living standard and the change of diet structure, the incidence of diabetes has greatly increased. The number of diabetics in China has reached 50 million, accounting for 1/5 of the total number of diabetics in the world, with the second highest prevalence rate in the world, and is increasing at a rate of at least 3,000 per day. Although the use of insulin and glucose-lowering drugs has extended the life expectancy of diabetics, diabetic retinopathy (glycoretinopathy), a microvascular complication of diabetes, has become the second leading contributor to vision loss and blindness worldwide.
What is glucose retinopathy all about?
Glucose retinopathy is a fundus disease that develops when the walls of the retinal vessels are eroded due to chronic hyperglycemia, with small intraretinal hemorrhages and exudates appearing first; later, the vessels become thin and occluded, and large areas of the retina become ischemic and hypoxic, thus stimulating the creation of new blood vessels. This neovascularization, which grows in a hypoxic environment, is very fragile and is prone to spontaneous rupture, with a large amount of blood flowing into the vitreous and retina, resulting in severe vision loss. The fibrous tissue surrounding the neovascularization also contracts and pulls on the retina, causing it to detach and cause blindness. Secondary neovascular glaucoma also causes blindness.
The probability and extent of developing diabetic retinopathy is related to the duration of diabetes, the degree of metabolic disorders, the age of onset of diabetes, the duration of the disease, genetic factors and the control of diabetes. According to statistics, the probability of retinopathy in Chinese patients with diabetes is: 5-9 years, about 10%; after 15 years, about 50%; after 25 years, 80%-90% of retinopathy occurs. In economically developed countries in Europe and the United States, retinopathy has become the leading cause of blindness in people aged 20 to 60 years. In the United States, diabetic retinopathy accounts for 25% of blindness in adults over the age of 40, and in China, it has risen to the fourth leading cause of blindness in the eye.
Why do many diabetics end up blind?
Nearly 90% of patients who are diagnosed with diabetes in internal medicine do not have regular eye exams as ordered by their doctors, and many of them may already have retinopathy and be in advanced stages of the disease. There are no symptoms in the early stages of glucose retinopathy, the eyes are not red or painful, and vision is normal, so it is often overlooked by patients until the neovascularization ruptures and bleeds or causes a traction retinal detachment and a sudden and severe loss of vision, and the patient does not think to come to the ophthalmology office. At this time, most patients with hemorrhage and retinal detachment and neovascular glaucoma, patients will again see it as an “incurable disease”, no hope of recovery; in the past, vitrectomy requires expensive equipment, many hospitals can not be equipped; its requirements are very high operating techniques, this surgery includes vitrectomy, intraocular electrocoagulation, gas-liquid In the past, vitrectomy required expensive instruments that many hospitals could not equip; it required very high operating techniques, including vitrectomy, intraocular electrocoagulation, gas-liquid exchange, intraocular laser coagulation and intravitreal injection of inert gas. These conditions have limited the widespread availability and application of vitrectomy surgery.
Is there any hope of regaining my sight if I have glycosuria?
The prognosis of advanced diabetic retinopathy cannot be generalized. Patients should undergo a detailed examination at the earliest possible time at a hospital that has the means to fully assess the extent of the lesion and the functional status of the retina, weigh the pros and cons, and decide whether to have surgery. When the lesion is severe, the doctor will recommend that the patient undergo fundus fluorescence angiography (FFA), the results of which are important for the doctor to determine the severity of the lesion and guide the next step of treatment. In some patients, although central vision may still not be restored after surgery, the visual field may expand, which is still important for patients with severe lesions in both eyes or those who are already blind in one eye.
Timely laser and surgical treatment is possible to save most diabetic patients from blindness. Retinal laser photocoagulation can be performed on an outpatient basis based on strict glycemic control. In severe cases of vitreous hemorrhage and retinal detachment, the patient must be hospitalized for a “vitrectomy” combined with complex retinal repair surgery.
Modern vitrectomy has now made it possible to cure many “incurable diseases” and has enabled thousands of blind people to see again. After surgery, patients can usually see very well and walk freely on their own. Sometimes, the eye regains enough vision after surgery to allow the patient to read or drive again.
What is vitrectomy surgery?
Vitrectomy surgery originated in the early 1970s and is performed using a special trocar needle that punctures directly into the white eye, creating the required access to the vitreous cavity through three needle eyes. Initially the vitrectomy tip used was a 17G (1.5mm diameter) This instrument required an optical fiber cuff to make a 2.3mm size scleral incision.
In 1974, a smaller 0.9mm diameter (20G) biosurgical tip was designed, and the system has been in use since then, because the incisions were large and required sutures to close the incisions. 2001 saw the creation of the 25G (0.5mm diameter) biosurgical tip microsurgical system, which uses a trocar needle to directly puncture the bulbar conjunctiva and sclera into the vitreous cavity, quickly creating the necessary The 25G irrigation tube is inserted into the eye through the trocar, which has a higher cutting frequency and suction force, and the conjunctival and scleral wounds can be closed by themselves after trocar removal, avoiding sutures, with a mild postoperative inflammatory response and rapid recovery. It simplifies the operation, reduces the trauma caused by the surgery and saves the operation time. The biosurgery has made a breakthrough and has reached minimally invasive.
During the operation, the doctor controls the light-guiding fiber illumination with one hand and the biosurgical head with the other hand, and controls the cutting frequency with one foot switch and the operating microscope with the other foot switch. The biosurgery head enters the vitreous cavity to remove intravitreal blood clots and fibrous membranes and to reduce retinal pulling and peeling to facilitate retinal repositioning. If the retinal wrinkles are too severe to be repositioned, retinopexy may be required. After removing the heavy water, inert gas or silicone oil can be used to fill the vitreous cavity and then perform retinal laser photocoagulation to strengthen the fibrous adhesion between the retina and adjacent tissues, inhibit the deterioration of blood vessels in the lesioned area, and stop the development of retinal lesions, thus saving the visual function of most patients.
If the patient has severe cataract, cataract ultrasonic emulsion resection combined with trans-flat vitrectomy, cataract extraction plus IOL implantation combined with trans-flat vitrectomy and retinal repositioning can be performed in combination.
What level of diabetic retinopathy should receive surgical treatment?
1. Severe vitreous accumulation of blood that does not absorb in 6 to 8 weeks, and the growth of new blood vessels into the vitreous cavity should be operated as early as possible.
2, retinal detachment with early macular traction should be operated as early as possible.
3, mixed retinal detachment.
4, dense pre-retinal hemorrhage and pre-macular fibrous membrane.
5, severe progressive retinal fibrovascular proliferation.
6, vitreous hemosiderosis combined with early iris neovascularization.
7, cataract combined with vitreous hemorrhage: Currently, cataract extraction, vitrectomy and IOL implantation are mostly advocated in one operation, which is conducive to postoperative vision recovery. Intraoperative or postoperative total retinal photocoagulation.
8. Hemolytic glaucoma: Hemolytic glaucoma often occurs after vitrectomy for diabetic retinopathy with vitreous rebleeding, especially in lens-less eyes. Vitreous cavity lavage or vitreous re-excision is performed when pharmacological treatment fails to control IOP.
What preparations should be made before surgery?
1. Systemic examination: Ask the endocrinologist or internist to help control blood sugar before surgery, and give corresponding treatment for combined hypertension and cardiovascular disease. Patients who have been on hemodialysis should seek the advice of a nephrologist for the surgery schedule. Young patients often need to use insulin to prevent ketosis. Those with blood sugar higher than 300 mg% or combined with ketosis are not able to undergo surgery.
2. Eye examination:A detailed eye examination should be performed before surgery, including visual acuity, intraocular pressure, atrial angle, lens, iris, vitreous and retina. Fluorescein fundus angiography can understand the extent of retinal neovascularization. If the vitreous is cloudy and the fundus cannot be seen clearly, ultrasound and electrophysiological examinations should be performed to assist in determining retinal function and morphology.
What should I do after surgery?
For simple removal of vitreous hemorrhage, postoperative prone position is not required and the patient can be discharged from the hospital in a few days. However, immediate exercise and physical work should be avoided to avoid rebleeding.
Patients injected with inert gas or silicone oil should lie on their stomachs after surgery to allow the gas or silicone oil to float and hold the retina to facilitate its repositioning, although it is unbearable for patients to lie on their stomachs for 24 hours a day, which is impossible to do without great endurance and perseverance.
All patients should strictly follow the doctor’s orders for regular postoperative review and, if necessary, laser supplemental photocoagulation. Sometimes after 1 to 3 months of gas absorption, the retina may hemorrhage or detach again, and the ophthalmologist may recommend reoperation, including simpler blood-gas replacement, intravitreal injection of anti-vascular endothelial growth factor, or more complex vitrectomy.
Conclusion
In summary, when you discover diabetic retinopathy, it is important to take it seriously. Blood glucose control is essential and, in addition, regular eye examinations should be performed for early detection and treatment of diabetic eye lesions, with or without vision changes. Do not wait until your vision has deteriorated and the degree of retinopathy may be severe before seeking medical attention. Currently, many patients with advanced diabetic retinopathy who were previously considered incurable can still recover some of their vision due to the continuous improvement and refinement of laser and surgical treatment methods and equipment. Therefore, both doctors and patients should build up confidence and strive for early treatment and the best possible outcome.
The possible surgical treatment of diabetic retinopathy requires close cooperation between the patient and the physician, and mutual trust and patience are necessary to achieve a better outcome. This is a process that may take one to six months to fight the disease and requires the cooperation of the patient and the physician. If the surgery is successful (the general success rate is about 70% to 80%), most patients can regain their vision to cope with daily life, return to work and enjoy the beautiful world, which is the best return that the ophthalmologist and the patient can expect.