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Early diagnosis is key to treating diabetes-related vision loss

Early diagnosis is key to treating diabetes-related vision loss
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Diabetic retinopathy

Common eye problems

About the Buhler Eye Care Centre

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for Manitoba

BY LIZ KATYNSKI
Winnipeg Health Region
Wave, May / June 2012

Shelly Laninga did not assume the worst when she started to experience blurred vision in her left eye in the fall of 2011.

After all, it wasn't the first time she had trouble with her vision. In 2009, the 46-year-old mother of two had been diagnosed with cataracts in both eyes and underwent surgery to correct the problem. Her vision had been crystal clear ever since.

So when her left eye started acting up again, she thought it was probably a relatively minor issue, one that could be easily addressed. She was only partly correct.

As it turned out, Laninga's latest eye problem was a bit more complicated than she initially thought. Instead of a minor irritation, Laninga was diagnosed with diabetic retinopathy - a microvascular complication of diabetes that can lead to vision loss and blindness.

But Laninga was right about one thing. The staff at the Winnipeg Health Region's Buhler Eye Care Centre would be able to help her, just as they did when she developed cataracts in 2009.

Located at Misericordia Health Centre, the Buhler Eye Care Centre is the largest surgical and eye treatment clinic in Western Canada. With 26 surgical ophthalmologists on staff, the centre serves patients from Manitoba, Northwestern Ontario, the Territories and Nunavut, and performs about 10,000 eye surgeries each year.

Diabetic retinopathy is not an uncommon condition, according to Dr. Frank Stockl, an ophthalmologist at the Buhler Eye Care Centre. In fact, this condition is the leading cause of blindness in working-age people in North Amercia, and affects about 500,000 Canadians, the vast majority of whom have diabetes and are over the age of 45. And that number is expected to grow as Canada's population ages and the diabetes rates continue to rise. "Three to five per cent of the population worldwide is affected by diabetic retinopathy, and this number will increase as the population ages," says Stockl, who is also an assistant professor in the Department of Ophthalmology, Faculty of Medicine at the University of Manitoba. "By 2031, the diabetic population in Canada is expected to increase by 61 per cent."

The problem arises when high blood sugar levels caused by diabetes damage blood vessels in the eye. Over time, the blood vessels may weaken and leak fluid or become blocked, causing damage to the retina, which contains the cells that allow you to see clearly.

"They (blood vessels) are like a sealed garden hose," explains Stockl. "Diabetes can damage the inner-lining of these vessels and fluid can leak out. It's sort of like poking holes in a garden hose."

Fluid leaks can also occur if the blood vessels are "pulled." As Stockl explains, once the blood vessels become severely damaged, the eye starts building new ones. The problem is that the new blood vessels create scar tissue, which can then pull on the retina. "So you can think of them as being a really delicate garden hose being stretched or pulled. If you pull hard enough on those vessels, they'll start to leak." Eventually, all this leakage of fluid damages the cells within the retina, causing blurred vision and possible blindness.

Diabetic retinopathy is diagnosed just like many other retinal conditions affecting the eye. The pupils are dilated with drops and the eye is examined with lenses that magnify the view of the retina to see if there have been any changes, such as fluid in the retina or growth of abnormal vessels. Those living in remote northern areas of the province can be screened through the Manitoba Retinal Screening Vision Program. Nurses dilate the eye and take photos that are uploaded to a server and read by an ophthalmologist at the Buhler Eye Care Centre.

There are four stages of diabetic retinopathy, ranging from mild non-proliferative to proliferative disease, which is the most advanced stage of the condition and means the eye is producing abnormal blood vessels.

By the time Stockl had examined Laninga, her condition had progressed to proliferative diabetic retinopathy. Essentially, the blood vessels in her eye had become blocked or damaged to the extent that new blood vessels were growing. The new blood vessels were causing pulling on the retina, which in turn was causing her own blood vessels to leak fluid. The leakage had progressed to the point that it was affecting the function of the macula (which is the part of the retina where our central and most important vision occurs), causing Laninga to lose her vision.

In the earlier stages of diabetic retinopathy, a patient might undergo laser surgery to seal the blood vessels and prevent leakage. But Laninga would require more comprehensive treatment.

Stockl decided the best course of action was to surgically remove the abnormal blood vessels from the eye, a procedure known as a vitrectomy. He then used a laser to seal the leaking blood vessels to prevent further leakage and regrowth of the abnormal vessels.

In addition, Laninga was given a dose of Avastin, a drug that helps keep blood vessels from expanding and leaking, in her left eye. Stockl is hoping to avoid using Avastin for the right eye. "Laser treatment should stop the growth in the vessels in the right eye, but she might (need Avastin), it is possible."

Vitrectomies have been performed since the 1980s, but in the last 10 years, there have been many improvements to techniques and the instruments that are used. One of the major advances is that the incisions used to gain access to the back part of the eye have become much smaller.

While Stockl was able to surgically address Laninga's condition and preserve her eyesight, he says the most important tool in treating diabetic retinopathy is early diagnosis. "The real nightmare in diabetic retinopathy occurs in those people not screened," he says. "Screening is critical. People with diabetes should have their eyes checked at least once a year, but we know that 30 to 50 per cent of them do not receive proper diabetic screening examinations."

Early diagnosis means more effective treatment. While Laninga suffered blurred vision prior to being diagnosed, people with the condition do not always have symptoms. "The condition can advance a lot without the patient knowing it," says Stockl.

While people who have had diabetes for 10 years or more are at high risk of developing some form of diabetic retinopathy, many will be able to limit the severity of the condition by keeping their diabetes in check. That means controlling your blood pressure and blood sugar level. "Those with poor diabetic control are more at risk," says Stockl. "A lot of people with diabetes are unaware of how devastating the disease can be if it progresses to advanced stages. It can rob you of your vision and cause loss of independence. You can lose your driver's license, your employment. The results can be devastating."

One challenge in trying to reduce the damage from diabetic retinopathy is raising awareness about the connection between diabetes and vision loss. "Diabetes is the leading cause of blindness," says Stockl. "Yet many people don't even know they have diabetes."

As a result, one of the best ways to avoid diabetic retinopathy is to reduce your risk by maintaining good blood sugar control. Laninga was diagnosed with Type 1 diabetes at age six months. Type 1 diabetes is unavoidable and means your pancreas stops producing insulin.

In contrast, Type 2 diabetes is much more influenced by lifestyle, which means it can be prevented for many people. Generally speaking, Stockl says, people can reduce their risk of developing or at least slow the progression of the devastating complications of Type 2 diabetes by leading an active lifestyle, maintaining a healthy weight, eating a balanced diet, and watching their cholesterol and hypertension (blood pressure). "Smoking is also a potential risk factor that may make diabetic retinopathy worse, says Stockl.

Following her eye surgery, Laninga took a month off from her job at Academy Dental to recuperate. Today, life is pretty much back to normal. She continues to enjoy working, bowling, gardening, and cheering on her sons Mackenna, 9, and Quinn, 8, as they play hockey.

And, despite the seriousness of her condition, she remains undaunted.

"It's my personality," she says. "I don't get down about things. Worrying and fretting just drives you insane. I know I am in good hands with a good doctor. I just have to be trusting. "It's amazing what they can do now. Dr. Stockl is amazing. I can't believe how many people the clinic sees in a day. Some drive in from Brandon and Ontario to see the specialist," she says.

"There is always something in life. If you don't accept what has happened to you and learn to live healthy, life is way too short to say, 'Why me?' I have a wonderful husband - Greg Lyon - and two beautiful children.

"You just have to go with it. You have always got to look for the good in life."

Liz Katynski is a Winnipeg writer.

Wave: May / June 2012

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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