Diabetic retinopathy (DR) is the most important manifestation of diabetic microangiopathy, which is a kind of fundus lesion with specific changes and is one of the serious complications of diabetes mellitus. Diabetic retinopathy without retinal neovascularization is called nonproliferative diabetic retinopathy (NPDR) (or simple or background type), while diabetic retinopathy with retinal neovascularization is called proliferative diabetic retinopathy (PDR). retinopathy (PDR).
Staging of diabetic retinopathy.
Depending on the degree of retinopathy in the patient’s eye, diabetic retinopathy is clinically classified into 2 types: background retinopathy and proliferative retinopathy. Background retinopathy is divided into 3 stages: ①Stage I: Microangiomas the size of small grains of rice appear in the fundus. This is a unique fundus change in diabetic patients and can be used by experienced ophthalmologists to diagnose patients with diabetes mellitus. Stage II: White spots with clear edges and irregular shapes appear in the fundus. The formation of this white spot is related to the accumulation of fatty tissue caused by retinal neuropathy. (③) Stage III: Cotton wool-like white spots appear in the fundus. The formation of this white spot is related to focal ischemia and necrosis of nerve tissue.
If the background retinopathy is further aggravated, it may develop into proliferative retinopathy. Patients with proliferative retinopathy may develop serious lesions such as fibrous tissue hyperplasia, vitreous hemorrhage, and retinal detachment in the fundus of the eye.
Prevention of diabetic retinopathy.
Because of the irreversible nature of lesion damage, prevention is the most important aspect, and early prevention is far less expensive and more effective than late treatment.
The most important measure to prevent diabetic retinopathy is strict glycemic control. For type 1 diabetic patients, insulin pumps need to be implanted to reduce large fluctuations in blood glucose, but most type 1 diabetic patients are not yet in a position to have an insulin pump implanted; and for type 2 diabetic patients, because they are asymptomatic and undetected, or have mild symptoms and incomplete treatment, or can only do intermittent treatment, less than 20% of patients can control their blood glucose in the target range, and most diabetic patients are There is a potential threat of retinopathy.
Patients with type 1 diabetes should be examined annually after 5 years of onset, and patients with type 2 diabetes should be examined annually from the onset. If you have abnormal eye sensations, you should shorten the duration of ophthalmologic follow-up, for example, every 3 or 6 months. At the same time, strict control of blood glucose and blood pressure and regulation of blood lipids are needed to delay the onset of diabetic retinopathy as much as possible.
Treatment of diabetic retinopathy.
Intensive blood glucose control Blood glucose control can slow the progression of diabetic retinopathy and is beneficial in reducing the disease. When blood glucose is elevated, the affinity of glycated hemoglobin to oxygen is increased and not easily released. Blood glucose control at normal level can play a role in relieving retinal hypoxia, so controlling blood glucose can prevent and reverse early retinopathy. If blood glucose can be controlled at normal level, the occurrence and development of diabetic retinopathy can be effectively prevented. Thus, blood glucose control is the most important measure to prevent and treat diabetic retinopathy. If a patient’s retinopathy develops rapidly, he or she should be promptly switched to insulin therapy.
Blood pressure control Hypertension is an important trigger for the development of fundus hemorrhage in patients with diabetic retinopathy. Hypertension can also directly cause retinopathy. Therefore, antihypertensive therapy is especially important for patients with diabetic retinopathy. Hypertension can contribute to both the development and progression of diabetic retinopathy and significantly increases the risk of fundus hemorrhage, for example. Therefore, diabetic patients need to use antihypertensive drugs that do not affect their metabolism, such as angiotensin-converting enzyme inhibitors, calcium antagonists, and alpha-blockers.
According to the study of early treatment of diabetic retinopathy, retinal lipid leakage is closely related to blood cholesterol and low-density lipoprotein, and regulation of lipid levels can help improve retinal status.
Other medications Clinically, the disease is divided into two main stages of development, non-proliferative and proliferative lesions, depending on whether neovascularization is present in the retina. In the nonproliferative phase, the patient’s retina shows microangiomas, hemorrhagic spots, hard exudates, and cotton wool spots. The main hazard of this stage is the leakage of plasma components into the retinal tissue due to the disruption of the blood-retinal barrier, resulting in retinal edema, and when the edema occurs in the macula, it causes central visual impairment. At this time, it is still an early stage of diabetic retinopathy, and drug therapy is mostly used, such as some drugs to improve blood viscosity.
Pancreatic kininogenase This drug has the effect of dilating microvessels, activating fibrin in blood and preventing thrombosis. It is administered as 10 U/time, 3 times/day. This drug is contraindicated in patients suffering from tumor or heart failure.
Calcium hydroxybenzenesulfonate This drug has the effect of inhibiting platelet aggregation, reducing whole blood viscosity and preventing thrombosis. It is administered as 250-500 mg/time, 2-3 times/day.
Both of these drugs have anti-platelet aggregation and prevent thrombosis. Pansentin 50 mg/day and aspirin 300 mg/day can effectively control the progression of the disease in patients with diabetic retinopathy.
In addition, anticoagulant drugs represented by heparin, pro-fibrinolytic drugs represented by urokinase and streptokinase, and aldose reductase inhibitors are effective in a few cases.
Chinese medicine treatment ①Yin deficiency and dry heat type: symptoms include thirst and excessive drinking, elimination of grain and good hunger, red tongue and yellow coating. Fundus examination: retinal hemorrhage, edema and exudation. Treatment is to nourish yin and clear heat. The formula is to add and reduce the amount of liquid and white tiger soup: Sheng Di, Yuan Shen, Mai Dong, Zhi Mu, gypsum, Gu Jing Cao, Mucuna Pruriens, fried gardenia and Dan Pi. ② Blood stasis blocking the ligament type: the disease is prolonged, heat burns the blood, blood stasis in the eye ligament, retinal hemorrhage is seen in the fundus of the eye, which is not absorbed for a long time, or even vitreous hemorrhage, the tongue is purple and dull or there are petechiae and petechiae. The treatment is to cool the blood and invigorate the blood. Kidney yin deficiency: dry mouth and weakness, soreness and weakness of the waist and knees, pale and dull tongue with white or little coating, retinal hemorrhage, exudation, edema or mechanization in the fundus of the eyes. The treatment is to nourish yin and tonify the kidney, with the formula of Zengliang Tang combined with Liuwei Dihuang Tang: Shengdi, YuanShen, MaiDong, ShanYao, ZeDa, FuLing, ShanYuFu, DanPi or Liuwei Dihuang Tang with Radix Rehmanniae, Dry Lotus Grass, ZhiMu and HuangBao.
For retinal lesions and diabetic cataracts, early administration of the Chinese medicines Dendrobium Night Light Pill, Bright Eyes Dihuang Pill and Qiju Dihuang Pill is also effective; for retinal hemorrhage, Yunnan Baiyao can be administered; for fundus hemorrhage that is not absorbed for a long time, sedative drops of Salvia injection are effective.
Laser treatment The purpose of laser treatment is to stop the progression of the lesion and prevent further vision loss. When the lesion develops to a large area of retinal vascular atresia, the lesion has begun to progress to the proliferative stage, and whole retina disseminated photocoagulation should be performed in time. The argon ion laser has a small spot and the green laser is easily absorbed by hemoglobin, so it can directly coagulate and close neovascularization, microvascular tumors and capillaries with fluorescent leakage. It can stop vitreous hemorrhage and retinal edema without affecting the function of the macula. Additional laser treatment is required annually to close the incipient neovascularization.
Cryotherapy The mechanism of treatment is similar to that of laser treatment and is indicated for patients who cannot undergo laser treatment due to cataract or vitreous hemorrhage.
Surgical treatment Vitrectomy, mainly used for complications of proliferative retinopathy, such as intravitreal blood accumulation for a longer period of time without absorption, retinal detachment by traction, severe progressive retinal fibrovascular proliferation, and dense anterior retinal hemorrhage. Surgical removal of the hemorrhagic vitreous and intraocular laser can restore some vision. The purpose of surgery is to remove the accumulated blood, cut off the mechanized membrane, eliminate the scaffold on which the fibrous tissue grows, loosen the pull on the retina, fill the vitreous cavity with silicone oil or gas if necessary, restore the normal retinal anatomical relationship, and perform total retinal photocoagulation during or after surgery. In some patients, although the central vision still cannot be restored after surgery, the visual field may be expanded, which is still important for patients with severe lesions in both eyes or those who are already blind in one eye.
In conclusion, diabetic patients should increase their awareness of their disease and pay high attention to it. As far as possible, dietary control or combined hypoglycemic drugs should be used to control blood glucose in the normal range, and insulin should be applied under the guidance of an endocrinologist if necessary to prevent the occurrence of diabetic ophthalmopathy and other diabetic systemic complications. Ophthalmic treatment should be carried out in stages according to the condition. At present, due to the continuous improvement and perfection of laser and surgical treatment methods and equipment, many patients with advanced diabetic retinopathy that were originally considered incurable can still recover some of their vision.