Let’s go into each one of these chronic
complications in greater detail.
The topic here, if the diabetes is not controlled
properly, which is unfortunately a leading
cause of blindness in adults in the United
States is diabetic retinopathy; leading cause
of renal failure in the United States, diabetic
You want to make sure you know everything
about these two major chronic, chronic complications.
Remember the chronic complications of type
2 diabetes will take a little bit longer,
but nonetheless could very well occur, unfortunately
does in a type 1 diabetic.
You still would call this chronic complication,
but things have been accelerated quite a bit
because of the variability of insulin control.
Usually asymptomatic and that is what makes
it so scary.
So, you have a patient who is coming in obese,
family history of diabetes, what is your next
step in management?
Well, everything seems to be checking out,
but make sure that you are properly referring
your patient to get an eye check for sure,
optometrist at least; ophthalmologist whatever,
point being is that eye check.
You are checking for cataracts and more importantly,
you are checking for diabetic retinopathy
because this will then cause especially if
the retina is being detached, the retina becomes
detached, that’s it, permanent blindness,
Annual ophthalmology screening starting 5
years after type 1 diabetes and shortly after
initial type 2 diabetes mellitus diagnosis
has been made, no joke, because the patient
doesn’t know any better; asymptomatic on
top of that, you need to be vigilant.
Treat it with laser, photocoagulation to prevent
Literally, we want to make you do everything
in your power to obliterate some of the blood
vessels that have been damaged and make sure
that you are constantly checking for retinal
So, what is happening within the capillaries
here so you do a fundoscopic examination,
you have-you have done one before and you
are looking at the optic disc and sunburst
appearance, you see the retinal blood vessels,
it look orangish and all of a sudden, you
see cotton wool spots, all of a sudden you
see dot blot hemorrhages.
You know what I am referring, don’t you?
Dot blot hemorrhages, meaning to say that
you have micro aneurisms and it ruptured maybe
due to non osmotic glycolation in there, you
Hmm, you see such changes that are taking
place within your retinal blood vessel.
In addition, you start seeing areas in the
retina with neovascularization and that looks
like tortuous blood vessels in your fundoscopic
examination, whoa, now we are getting even
worse, oh my goodness, because now these angiogenesis
that is taking place with the tortured blood
vessels because now remember, if one capillary
has been blocked then another capillary is
being formed, right, both of new blood vessels.
The body doesn’t know any better, it is
trying to compensate for what has been damaged.
So, what it is going to do as new blood vessels
are being formed unbeknownst to the capillary,
it is going to pull the retina off from the
retinal pigment epithelium.
Welcome to retinal detachment.
Photocoagulation, big deal.
May see transient exacerbation during first
year of intensive insulin therapy and perhaps
even during pregnancy.
Talk about the classification of retinopathy.
First, non proliferative, still scary, you
find micro aneurisms; this does not mean we
have hemorrhage yet, but if it ruptures, you
find dot blot hemorrhages.
If you do a fundoscopic examination and you
find areas on the retina which kind of look
like they are white, they are called cotton
This then represents infarction, may result
in the nerves being damaged, there might be
intraretinal hemorrhage, occluded, dilated,
tortuous vessels; nonproliferative so far.
This is not what is going to lead blindness,
but my goodness, we are getting there.
Next classification, proliferative, who is
The new blood vessels, this is called neovascularization
and if you find new blood vessels with the
help of VEGF, vascular endothelial growth
factor, and they might ask you a question
from pharmacology about VGEF inhibitor such
Theoretically, sounds great because then you
inhibit the neovascularization and therefore,
perhaps prevent the retinal detachment.
There is pre-retinal and vitreous hemorrhage,
subsequent fibrosis and tractional retinal
detachment, tractional, literally traction
of pulling the retina off.
Now, macular edema, retinal thickening, edema
involving the macula.
Can you think…
Can you-Can you picture what the macula looks
The dark area, you have heard of the fovea
and such, can occur during nonproliferative
or proliferative retinopathy.
Definitely know the difference between proliferative
and nonproliferative; proliferative one step
closer to absolute retinal detachment and
Let’s go ahead and take a look at the fundoscopic
examination diabetic retinopathy.
On your left is nonproliferative.
The areas in which you find a little bit of
reddening that, in fact, will be retinal hemorrhages
and the area that has been pointed out as
being this little white or cotton wool spots,
nonproliferative versus what you see on the
The optic disc seems to be compromised, can’t
visualize it as clearly as you would like,
that’s because of proliferation, it is proliferative
and that looks like spider web, doesn’t
That’s a non… that’s neovascularization.
Compare that to what you see on the left.
On the left, the optic disc kind of looks
like the sun, bright; it’s what looks like
for the most part being a little bit more
normal, but on the right, my goodness, that’s
neovascularization, do you see the difference?
That’s what you call the proliferative and
if you have such neovascularization taking
place and enough damage with fibrosis and
traction, you might be pulling off the retina.