Diabetic retinopathy is a complication of diabetes that affects the eyes. Specifically, it affects blood vessels in the retina, the light-sensitive layer at the back of the eye.

Diabetes-related eye problems occur when blockages develop in the tiny blood vessels in the retina as a result of high blood glucose levels. This results in bulging and leaking blood vessels and the growth of abnormal new blood vessels, thus preventing the retina from getting nourishment, and leading to scar tissue formation.

Diabetic Retinopathy: Impact on Vision and Eye Health

In the early stages, diabetic retinopathy may not cause any symptoms. However, as the abnormal blood vessels grow and the condition progresses, it can result in vision problems. Undiagnosed and untreated diabetic retinopathy can lead to vision loss (blindness). A comprehensive dilated eye exam can lead to the diagnosis and early treatment of diabetic retinopathy.

People with both type 1 and type 2 diabetes can develop diabetic retinopathy. This eye condition occurs when high blood sugar levels cause blockages in the retinal blood vessels, cutting off oxygen-rich and nutrient-rich blood flow. The retina responds by growing new blood vessels, but these new blood vessels are abnormal and leak fluid.

Types of Diabetic Eye Disease

Non-Proliferative Diabetic Retinopathy (NPDR)

Non-proliferative diabetic retinopathy (NPDR) is the more common type. It is an early stage of the condition in which new blood vessels are not proliferating (forming).
However, the walls of existing retinal blood vessels develop microaneurysms (small bulges and areas of weakness). These damaged blood vessels in the retina leak fluid and blood.

Diabetic Macular Edema

As more blood vessels become blocked and start bulging, the condition progresses. This leads to swelling of the macula (the central part of the retina responsible for sharp, central vision), which is called macular edema. A buildup of fluid in the macula can lead to decreased vision. People with macular edema need to be treated to prevent permanent loss of vision.

Proliferative Diabetic Retinopathy

Proliferative diabetic retinopathy is the less common but more severe neovascular type. People with this type of advanced diabetic retinopathy have completely blocked retinal blood vessels (retinal ischemia). This triggers the retina to make new blood vessels — this is called neovascularization. But these blood vessels are abnormal. They are fragile and leak a clear, gel-like substance (vitreous) which collects in the central part of the eye.

Over time, scar tissue formation occurs at the sites of abnormal blood vessel growth. This can lead to retinal detachment (separation of the retina from the back of the eye). Sometimes, the abnormal blood vessels prevent the normal flow of fluid out of the eye. This can lead to buildup of pressure inside the eye. Increased intraocular pressure can damage the optic nerve — this is called glaucoma.

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Symptoms of Diabetic Retinopathy

Early Symptoms: What Are The Warning Signs of Diabetic Retinopathy?

Early-stage diabetes eye symptoms may include:

Floaters (objects like strings or spots floating in your vision)
Blurry vision or hazy vision
Colors appearing faded or washed out
Patchy vision or dark spots in vision
Fluctuations in vision
Gradually worsening visual acuity (eyesight)
Sudden or severe vision loss
Eye pain or redness
Difficulty seeing in the dark

Progression of Diabetic Retinopathy Symptoms

Typically, people develop diabetic retinopathy 3-5 years after receiving a diagnosis of diabetes. In the beginning, diabetic eye disease does not usually not cause any symptoms. However, as the condition progresses, it can affect eyesight. The longer you have diabetes and the higher your average blood sugar level, the higher the risk of developing diabetic retinopathy.

Vision Changes and Complications

People with diabetic retinopathy have damaged blood vessels in their retina that leak blood. They also have growth of abnormal small blood vessels that form scar tissue. These changes in the retina can lead to serious vision problems and complications which are described below.

Vitreous Hemorrhage

The vitreous humor is a clear, jellylike substance in the middle of the eye. Leaking blood vessels in the vitreous can cause floaters to appear in the visual field if the amount of bleeding is small. Severe bleeding can completely fill the vitreous cavity in the center of the eye and cause complete vision loss. However, this is not usually permanent vision loss. Vision is regained when the blood clears (this can take several weeks to months). Unless there is other damage to the retina, vision returns to baseline clarity after a vitreous hemorrhage.

Retinal Detachment

As mentioned, abnormal blood vessels in diabetic retinopathy patients stimulate formation of scar tissue. This can cause the retina to detach (pull away) from the back of the eye. It is called tractional retinal detachment and is a medical emergency. Symptoms may include floaters, flashes of light, and severe vision loss.

Glaucoma

The abnormal new blood vessels in the eye that form in people with diabetic eye problems can prevent the normal outflow of fluid from the eye. This can lead to increased intraocular pressure in the eye, which in turn can cause optic nerve damage and loss of vision. This condition is called glaucoma.

Permanent Vision Loss

Complications of diabetic retinopathy, such as macular edema and glaucoma, can lead to complete and permanent vision loss if they are not treated or managed.

Causes and Risk Factors

Diabetes, High Blood Sugar, and Abnormal Blood Vessels

The cause of diabetic retinopathy is too much sugar in the blood. Diabetic eye problems can, therefore, develop in people with diabetes mellitus type 1, diabetes mellitus type 2, and pregnant women with gestational diabetes.

As mentioned, high blood sugar levels damage tiny blood vessels in the retinal tissue (the light-sensitive tissue at the back of the eye). This causes the blood vessels to leak and causes diabetic macular edema (swelling in the central part of the retina). As the condition progresses, some blood vessels become completely blocked, cutting off the retina’s blood supply. In response, the retina forms new blood vessels (neovascularization). However, these abnormal blood vessels leak and cause scar tissue formation.

Other Contributing Risk Factors and At-Risk Populations

According to the American Diabetes Association, people who are at risk of developing diabetes-related eye problems include:

Those who have had diabetes for many years.
People with poorly controlled blood sugar levels.
Those with other health conditions such as hyperlipidemia (high cholesterol) or hypertension (high blood pressure).
Smokers.
Pregnant people.
African Americans, Hispanics, and Native Americans.

Diagnosing Diabetic Retinopathy

Dilated Eye Exam

An eye doctor can make a diagnosis of diabetic retinopathy with a comprehensive dilated eye exam. This involves placing dilating eye drops in your eyes that widen the pupils. This allows the ophthalmologist to get a better look at your retina and other structures in your eye.

Fluorescein Angiography

Once your eyes are dilated, your eye doctor will inject a contrast agent (dye) called fluorescein into your blood through a vein in your arm. The dye allows your doctor to see the flow of blood in the blood vessels of your eye, identify if any are leaking or blocked, and take pictures.

Optical Coherence Tomography (OCT)

OCT is a non-invasive imaging test that takes cross-sectional 3D pictures of the retina. Eye doctors use this test to measure retinal thickness and assess how much fluid has leaked into retinal tissues. Optical coherence tomography (OCT) is also used to monitor response to treatment for diabetic retinopathy.

Importance of Regular Eye Exams

People with diabetes often do not have any symptoms of eye problems, even though damage is silently occurring in the background. Regular eye exams can help catch diabetic eye problems early and prevent serious complications.

Your diabetes doctor will check your eyes for signs of diabetic eye disease. In addition, every 1-2 years, you should also have a more detailed assessment by a specialist (an eye doctor who provides care to people with diabetes). If you have diabetic eye problems, you may need to see an eye doctor more often.

Understanding The Results of Diagnostic Testing

Diabetic eye screening is a set of eye tests that check for signs of diabetic retinopathy. These tests can help to identify diabetic eye problems before you have any vision changes or symptoms.

Note that it’s important to have regular eye tests to check for eye problems. However, diabetic eye screening is not the same as a regular eye test. Your doctor will recommend diabetic eye screening if you have:

Gestational diabetes (high blood glucose levels during pregnancy)
Type 1 or type 2 diabetes mellitus (every 1-2 years)

Here’s what the results mean:

Results of Diagnostic Tests and Diabetic Eye Screening	What it Means	What Happens Next
No retinopathy	No diabetes-related changes were seen in your eyes	Repeat testing in 1-2 years
Background retinopathy	Small changes were seen in your eyes, but they are not severe enough to affect your vision	Repeat testing in 1 year or sooner
Referable retinopathy	Diabetes-associated damage was seen in your eyes	You will be referred to a specialist to manage diabetic retinopathy

Treatment of Mild to Moderate Nonproliferative Diabetic Retinopathy

You may not need specific treatment if you have early-stage (nonproliferative) diabetic retinopathy. Your doctor will monitor you closely and start treatment if the condition progresses. You should work with your endocrinologist (diabetes care provider) to improve glycemic control (blood glucose levels). This can slow the progression of diabetic eye problems.

Treatment of Advanced Proliferative Diabetic Retinopathy or Macular Edema

In people with advanced diabetic eye disease, prompt treatment is necessary to prevent vision loss. Treatment options include:

Vascular endothelial growth factor (VEGF) inhibitors

VEGF inhibitors, also called anti-VEGF treatments, are drugs that are injected into the vitreous part of the eye under local anesthesia. They prevent the growth of new blood vessels and reduce swelling. The U.S. Food and Drug Administration (FDA) approved the following VEGF inhibitors are FDA-approved for the treatment of diabetic macular edema:

Faricimab-svoa (Vabysmo)
Aflibercept (Eylea)
Ranibizumab (Lucentis)
Bevacizumab (Avastin) - off-label use for diabetic macular edema

Possible side effects of the anti-VEGF injections include mild eye discomfort (pain, watering, burning) for about 24 hours. More serious side effects include infection and increased pressure in the eye. Your eye doctor may recommend a series of four anti-VEGF injections at four-week intervals, followed by a repeat scan to assess response.

Photocoagulation

Photocoagulation is a type of laser treatment (also called focal laser therapy). It can slow or prevent leaking of fluid in the retina by destroying abnormal blood vessels with a laser. This laser surgery is done in an eye doctor’s office. People who already have vision problems before photocoagulation may not regain normal vision, but the treatment can prevent macular edema from worsening.

Panretinal Photocoagulation or Scatter Laser Treatment

Scattered laser burns can be used to shrink abnormal blood vessels in the retina. The laser surgery is done over 1-2 sessions. Side effects include blurred vision for about 24 hours after the procedure. Some people experience decreased night vision or loss of peripheral vision.

Vitrectomy

Vitrectomy is an eye surgery in which the surgeon removes blood and scar tissue from the vitreous cavity through a tiny incision in the eye. This procedure is done under local or general anesthesia in a surgical center or hospital. It can slow or stop the progression of diabetic eye problems but does not cure diabetic retinopathy.

Managing Blood Sugar Levels

Diabetic retinopathy is a complication of diabetes, and it occurs due to high blood glucose levels. Blood sugar control is important for all diabetes patients, especially those who have signs of complications such as diabetic eye disease. Taking your diabetes medications as prescribed and keeping your blood glucose under control is essential to slow the progression of diabetic retinopathy.

In addition to prescribed diabetes medications, a key factor in managing diabetes is lifestyle changes such as eating a healthy diet, exercising regularly, managing stress, and stopping smoking.

Can Diabetic Retinopathy Go Away?

Diabetic retinopathy cannot go away, but it can be managed. There is no cure for diabetic retinopathy, but treatment can help to slow the progression and prevent further damage to the eye. Remember, diabetes is a lifelong condition, and even with treatment for diabetic retinopathy, future damage to the retina is still possible.

Preventing Diabetic Retinopathy

It may not always be possible to prevent diabetic retinopathy, but you can lower your risk by doing the following:

Get regular eye exams. Early detection and treatment can prevent serious eye complications in individuals with diabetes.
Seek medical care without delay if you notice any changes in vision, such as blurred vision, hazy vision, or floaters.
Monitor and maintain blood glucose levels in a healthy range. Try to keep your hemoglobin A1c (HbA1c or glycosylated hemoglobin) below 7%.
Follow your doctor’s treatment plan for high blood pressure and high cholesterol, which are associated with an increased risk of diabetic eye problems.
Quit smoking, if you smoke.

Managing Diabetic Retinopathy

If you have been diagnosed with diabetes or diabetic eye disease, keep all your healthcare appointments. This will ensure minor problems remain minor, and if major problems develop, they are caught and treated early.

Here are some resources from the National Eye Institute:

Further information about diabetic eye disease
Webinars and videos on diabetic eye problems

FAQs on Diabetic Retinopathy

Can You Drive With Diabetic Retinopathy?

It depends. If you have mild diabetic eye changes and your vision is not affected, you may be able to continue driving. However, some people with diabetic eye disease have to stop driving due to problems with night vision or reduced peripheral (side) vision.

What Does Diabetic Blurred Vision Look Like?

Diabetic blurred vision can look like blurry, hazy, or wavy vision with colors appearing washed out or faded. You may also notice floaters (objects like spots or lines floating in your field of vision).

What Are The 4 Stages of Diabetic Retinopathy?

The 4 stages of diabetic retinopathy are:

Mild non-proliferative retinopathy
Moderate to severe non-proliferative retinopathy
Diabetic macular edema
Proliferative retinopathy

What Triggers Diabetic Retinopathy?

High blood glucose levels trigger diabetic retinopathy by causing damage to tiny blood vessels in the retina of the eye. This damage can progress and can lead to complications like vitreous hemorrhage (bleeding) and retinal detachment and eye diseases like glaucoma and cataracts.

What Is The Life Expectancy of a Diabetic Retinopathy Patient?

The life expectancy of a diabetic retinopathy patient depends on many factors, including the severity of diabetes, blood glucose control, and other health conditions.

Researchers have, however, found that people with mild, moderate, and severe diabetes-related retinopathy are at an increased risk of all-cause mortality (death from any cause).

Studies show that the 5-year survival rate after vitreous surgery for proliferative diabetic retinopathy is 68%. The presence or absence of heart disease is an important factor in predicting survival — 50% of patients with diabetic retinopathy and heart disease die within 3.5 years of vitreous eye surgery, whereas patients who don’t have heart disease have a 5-year survival rate of 90%.

Your doctor will discuss with you the best treatment approach to manage your diabetic retinopathy based on your medical history and other medications.

In addition to following your prescribed medications and attending follow-up appointments, adopting a healthy lifestyle is essential for your long-term well-being. Your care team can provide recommendations on suitable physical activities and dietary choices that are best for your health.

What Foods Should Someone With Diabetic Retinopathy Avoid?

Someone with diabetic retinopathy should avoid foods that can lead to worsening glycemic control (poor control of blood glucose levels). This includes processed foods, trans fats, foods, and beverages with added sugar, and high-salt foods.

You should consult your doctor if you have questions about your diet. A referral to a registered dietitian may be helpful, as they can provide valuable resources for a diet that best fits your health needs.

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