[Medical Insight No. 62] Symptoms and treatment of "diabetic retinopathy" by an ophthalmologist.

□ Broadcast Date and Time: December 13, 2024 (Fri) 10:20 pm
□ Producer in charge: Lee Siwoo
□ Author in charge: Kim Bae-jeong and Kim Hyun-jung
□ Cast: Moon Yong-seok (Ophthalmologist at Gangnam Sacred Heart Hospital, Hanlim University)
□ Broadcast channel
IPTV - GENIE TV No. 159 / BTV No. 243 / LG Uplus No. 145
SkyLife Number 90
Cable - Delive No. 138 / Hyundai HCN No. 341 / LG HelloVision No. 137 / BTV Cable No. 152

* The text below may differ from the actual broadcast content, so please check the broadcast for more accurate information.


◆ Moon Yong-seok: Hello, I'm Moon Yong-seok, an ophthalmologist. The story I prepared in this time is the symptoms and treatment of diabetic retinopathy, which is as scary as diabetes.

◇ Voice actor Park Sang-hoon: Diabetes, called the national disease. While the number of diabetic patients is increasing due to westernized eating habits and lack of exercise, the number of patients with diabetic retinopathy, a complication of diabetes, is increasing. Diabetic retinopathy is one of the three major blindness diseases that can lead to blindness due to damaged retinal blood vessels, and 6 out of 10 patients with a 15-year history of diabetes suffer from the disease, and 9 out of 10 patients with a 30-year history of diabetes suffer from diabetic retinopathy. Let's take a closer look at the symptoms and treatments of diabetic retinopathy that are as scary as diabetes.

<Understanding Diabetes>
◆ Moon Yong-seok: In modern society, diet, or diet, is becoming an important keyword for health. Among them, the most popular keyword is blood sugar. Blood sugar spike, blood sugar index, insulin resistance I think you've probably heard a lot recently. These words are all related to one big disease. As you might expect, it's diabetes. The fear of diabetes is not in the blood sugar itself. 'High blood sugar' itself is not a problem right now. Diabetes is a problem because of complications, after all. The same goes for blood pressure. Blood pressure itself is not a problem, but complications are a problem, and blood sugar blood pressure is called a surrogate marker and a mutual gate marker that can determine these complications or risks.

<Stypes of Diabetes Complications>
◆ Moon Yong-seok: Then let's look at what complications of diabetes are. There are two major complications of diabetes. One is a major vascular complication and the other is a microvascular complication. It means that the large blood vessels are visible. Cardiovascular disease, angina, myocardial infarction, etc. may be typical to our naked eyes, cerebrovascular diseases such as stroke, and peripheral vascular diseases such as "foot rotting" or "the wound does not heal well and rot again." Second, there may be microvascular complications. There are three major complications of microvascular complications. The first is diabetic nephropathy, the second is diabetic neuropathy, and the third is diabetic retinopathy. You've probably heard of 'I've been dialyzed for diabetes' or 'I've had a kidney transplant' somewhere around me. This is because of diabetic nephropathy. You've also heard from somewhere that 'the tip of your fingertips are numb because of diabetes', or 'the tip of your toes became very dull, so I didn't know well even though I was injured, and the wound was left unattended and there was a problem.' This is because of diabetic neuropathy. And finally, we have diabetic retinopathy to deal with today.

<Eye complications of diabetes>
◆ Moon Yong-seok: The eye complications caused by diabetes are not just diabetic retinopathy. There are also diabetic cataracts and diabetic optic neuropathy. However, diabetic retinopathy accounts for the largest portion of clinical practice. Retinal blood vessels are the only blood vessels in our body that can be seen directly with the naked eye. You may have been tested by putting eye drops in your eyes and growing your pupils when you went to the ophthalmologist. This is the sinus examination that examines the retina. Through this acidity test, we can look directly into the blood vessels in the retina, and diabetic retinopathy is a disease in which this blood vessel is damaged, so we can directly observe the extent to which the blood vessels are damaged. In addition, blood vessels are destroyed through other underlying diseases, such as blood pressure and hyperlipidemia, other underlying diseases other than diabetes, and the blood vessels that are destroyed not only the eye vessels, but also other blood vessels throughout the body. In that case, you can evaluate the degree to which the blood vessels in other areas are damaged to the extent that the retinal blood vessels are damaged, so many other doctors request ophthalmologists to examine the retinal blood vessels, which help them a lot. Our eyes are largely composed of various organs from the front of our eyes to the back of our eyes. The front of the eye is a clear glass window called the cornea, behind it is a transparent medium that acts as a very big eyeglass in our eyes, behind it is a space full of jelly-like substances called glass bodies, behind the retina. Diabetic cataracts occur in the large lens that acts as glasses in our eyes as mentioned earlier. Cataract is a disease in which the lens becomes cloudy and the lens, which is originally supposed to be transparent, becomes cloudy, so light can no longer enter properly, and because of this, light does not reach the retina properly, making it appear cloudy. Diabetic optic neuropathy occurs in the optic nerve. In the optic nerve, the retina, which is spread wide like paper behind the eye, gathers in one place and forms a bundle and heads to the brain, and the bundle heading to the brain is the optic nerve. Diabetic optic neuropathy is a problem because blood is not properly supplied to the optic nerve and the optic nerve eventually loses its function. Diabetic retinopathy is a disease in which the blood vessels of the retina, which are spread out like wallpaper behind our eyes, are damaged and eventually the nerves called the retina are damaged together. Diabetic retinopathy is a big problem because it is the leading cause of blindness in the working-age population around the world. The working age population is the age of people who can work directly. If you can work directly, but you can't work due to diabetic retinopathy, not only will the country's productivity decline, but it will also increase socioeconomic costs because you have to take care of the welfare of people who are inactivated due to this decreased visibility. Therefore, diabetic retinopathy is the first cause of blindness in the working-age population, so it can be said to be a very socioeconomic disease. Statistics show that up to 28% and up to 50% of diabetic patients suffer from diabetic retinopathy. Recently, it is also known to be the most common cause of vision damage in people over the age of 25.

<Diabetic Retinopathy>
◆ Moon Yong-seok: When you have diabetic retinopathy, you will see various findings when you perform an acid test. The most representative finding is retinal bleeding. Basically, diabetes is a disease that attacks the blood vessels and the supporting tissues surrounding the blood vessels. In that case, the blood vessels are basically bound to be damaged, and blood is bound to come out of the damaged blood vessels. So, if you do an obstetric test and observe it, bleeding is observed in diabetic retinopathy. Over time, this bleeding is hemolyzed and absorbed and disappears, leaving only the oil component among the plasma components. When you observe this, it looks like a yellow dot, which we call exudate. Bleeding is absorbed, but exudates are not absorbed or lost. If this exudate is formed and the location of the macula is the macula, it is the central part of the retina that is responsible for central vision. It is also where the focus is, but when exudate is generated in this area, it is covered by the exudate, and light cannot reach the retina properly, and the central vision is greatly reduced. In addition to that, there is also a view that it is a cotton bed. Cotton is synonymous with infarction, and infarction refers to tissue that is dead because blood vessels do not supply blood properly. You've heard of myocardial infarction a lot, right? Diabetic retinopathy also occurs in the eyes, and when blood vessels are destroyed, infarction is observed. This is sometimes referred to as cotton.

<Factors influencing the progression of diabetic retinopathy>
◆ Moon Yong-seok: The main factors affecting the progression of diabetic retinopathy are diabetes prevalence period, degree of blood sugar control, degree of blood pressure control, hyperlipidemia, pregnancy, etc. At first glance, I don't think diabetic retinopathy will progress if you just control your blood sugar well, but it's not. Through many large-scale studies, it is known that blood pressure control is very important and hyperlipidemia control is also very important. In addition, even if blood sugar, blood pressure, and hyperlipidemia are all well managed, fine damage will continue to accumulate. If the duration of diabetes, or the duration of diabetes, is long, this minute damage will accumulate, and eventually diabetic retinopathy will appear. In addition, women may go through a process called pregnancy, which is also a factor that worsens diabetic retinopathy very much. So, pregnant diabetics are closely monitored at shorter intervals than non-pregnant diabetics.

<Symptoms of diabetic retinopathy>
◆ Moon Yong-seok: The problem with diabetic retinopathy is that most of them are asymptomatic. As a result, patients do not come to the outpatient clinic. Usually, endocrine physicians recommend going to the ophthalmology clinic immediately after diagnosis of diabetes, but because there are no symptoms, they often do not come to the ophthalmology clinic until it is very advanced. The basic progression of diabetic retinopathy begins around the area and progresses to the eye-centered macula. That's why there are no symptoms in the beginning. Diabetic retinopathy may have progressed so much that it has invaded the center, or it may have developed macular edema diabetic macular edema that is not related to the diabetic retinopathy stage. Also, diabetic retinopathy progresses so much that when a new blood vessel is formed, it can burst, and when it bursts in the eye, blood accumulates in the eye. If this blood floats and you see this floating blood, you may experience visual impairment. Therefore, the detection of diabetic retinopathy must be done through a test that is not necessarily symptomatic, that is, a screening test or screening.

<classification of diabetic retinopathy>
◆ Moon Yong-seok: Diabetic retinopathy can be broadly divided into 0 to 6 stages. It can be said that nothing is level 0, and it can be said that it is level 6 just before the large visual loss that is difficult to reverse. Steps 0 through 4 are usually what we call nonproliferative diabetic retinopathy, and step 5 through step 6 is called proliferative diabetic retinopathy. Proliferation, which means something is forming and growing. In poor vascular medical terms, new blood vessels are being created. The fact that this occurs also means that the prognosis of visual function has already become very poor. In addition, diabetic macular edema can occur independently of the stage of diabetic retinopathy. This is the release of various inflammatory substances from blood vessels and cells damaged by diabetes, which causes the macula, the center of the retina responsible for central vision, to swell. There are four stages of nonproliferative diabetic retinopathy. Stage 1 is mildly non-proliferative diabetic retinopathy, stage 2 is severe non-proliferative diabetic retinopathy, stage 3 is severe non-proliferative diabetic retinopathy, and stage 4 is very serious. In mild diabetic retinopathy, mild retinal bleeding or microvascularization is observed. Microvascular flow is a finding that has emerged because blood vessels are not strong. The second stage, which is moderate, is between this third stage, the severe diabetic retinopathy stage, and the first stage, the mild diabetic retinopathy stage, and we call it moderate diabetic retinopathy. In severe diabetic retinopathy, vascular destruction progresses, making the aperture of the retinal veins inconsistent, and abnormal blood vessel masses are observed in the retina. If they look a lot together in many ways, they are designated as very serious steps. This is step four. Proliferative diabetic retinopathy can be divided into two main categories. It is not a high-risk proliferative diabetic retinopathy and high-risk proliferative diabetic retinopathy. The definition here is actually a little difficult to explain because it is academic and complex, but the key point is that the prognosis of visual function is very poor. As I said earlier, proliferative diabetic retinopathy refers to a stage in which new blood vessels, that is, poor blood vessels, are developed. These defective blood vessels occur here and there, and when these defective blood vessels burst and bleed into the vitreous space, which is the inner space of the eye, vitreous bleeding occurs together, and sometimes this blood vessel forms a strong and very strong pathological film called a fibroblast. In addition, the macula may swell regardless of the stage of diabetic retinopathy. The macula refers to the center of the retina, which is responsible for our central vision. Apart from the stage of diabetic retinopathy, this macular swelling occurs at any stage, which is called diabetic macular edema.

<Treatment of Diabetic Retinopathy>
◆ Moon Yong-seok: How will diabetic retinopathy be treated? When we say treatment, we have some nuance of 'curing the disease by eradicating it', but the treatment of diabetic retinopathy is not. Basically, the pathophysiology of diabetic retinopathy itself is the destruction of blood vessels, and the destroyed blood vessels do not return to normal blood vessels, so of course diabetic retinopathy is difficult to go back to the past. Sometimes outpatients ask if diabetic retinopathy can be cured or eradicated by surgery, but this is why it is impossible. The key to treatment is to prevent it from happening in the end, or to slow down the progression if it does. Basically, if you have non-proliferative diabetic retinopathy, that is, before the development of new blood vessels, you should control sugar, blood pressure, and hyperlipidemia without any treatment to the eyes themselves. However, if you move on to proliferative diabetic retinopathy, you have to start treatment. This is because a factor called neovascularization that occurs in proliferative diabetic retinopathy has a very poor effect on visual function. As we enter this proliferative diabetic retinopathy, the key to treatment is to fade the new blood vessels. Representatively, there is transmembrane laser photocoagulation. Photocoagulation, or light energy, is emitted with the entire retinal laser to support the coagulation retina by converting it into thermal energy. I told you that the blood vessels I mentioned earlier are destroyed, so non-current areas where blood does not flow, where new blood vessels are formed. The high oxygen demand in this area is ultimately secreting defective blood vessels and neovascular-inducing substances such as vascular endothelial growth factors. In the end, when new blood vessels are formed, most of the retina has a non-current area, and if you talk about it easily with a laser, it burns tissue, solidifies oxygen demand, prevents neovascular-inducing substances from coming out and makes existing neovascularization disappear. Since the laser supports all but the macula, the field of view may be slightly narrowed. However, it has to be endured to some extent, but it is a treatment in the direction of preserving the central vision, that is, the macula. Since injections that fit the eyes have the effect of inhibiting the vascular endothelial growth factor mentioned earlier, new blood vessels can also be suppressed. If a new blood vessel bursts and blood collects in your eyes, and the laser is covered by blood, so you can't immediately perform periscope laser photocoagulation, you can try the laser after waiting for the blood to settle down. As I said earlier, vascular endothelial growth factors can also have inflammatory effects, causing the macula to swell, causing diabetic macular edema, so this injection treatment is also used to treat diabetic macular edema. Surgery is now the last thing you consider as you go on, and you can no longer handle it with the previous treatment. It's the vitreous body, a jelly-like substance, that fills the space in the eye, and the blood collection here is called vitreous bleeding. When a defective blood vessel bursts, vitreous bleeding occurs, and if it is not improving during maintenance with injection treatment, you have no choice but to consider performing surgery and removing it yourself. In addition, as I mentioned earlier, if this new blood vessel forms a very strong pathological membrane called a fibroblast, and the strong force of this membrane causes the retina to be pulled up and torn apart, that is, if it causes traction retinal detachment, then you should consider retinal surgery to remove this pathological membrane and traction.

<Prevention of Diabetic Retinopathy>
◆ Moon Yong-seok: There is nothing special about preventing diabetic retinopathy. If I'm good at controlling my blood sugar and I have hypertension hyperlipidemia, I'm good at controlling hypertension hyperlipidemia. So if it's slowed down the time of occurrence, all you have to do is slow down the progress. It's very simple, but it's hard to keep. But the effect is very powerful. And more importantly, make sure to come to the ophthalmologist regularly for screening. As I said earlier, diabetic retinopathy may be progressing even if there are no symptoms. That's why you must check it regularly and come when your ophthalmologist tells you to come. Otherwise, you may miss the progressive diabetic retinopathy and damage your visual function.

<Medical AI Q&A>
◆ Moon Yong-seok: Viewers sent me questions about diabetic retinopathy. Let's check it out together.

◇ Y-ON (AI Anchor): underwent laser treatment for diabetic retinopathy. After the procedure, my eyes ache and I feel a foreign body sensation. Is it a side effect of the procedure?

◆ Moon Yong-seok : It is less likely to be a side effect of the procedure, but it may be related to the procedure. Basically, diabetic patients do not have strong corneas, but when we laser, we put laser contact lenses on the cornea. In the process of putting this laser contact lens on and removing it, the non-strong cornea may have been damaged. Usually, the average person feels very severe pain when the cornea is damaged, but diabetic patients often do not feel the pain itself. So, there are cases where you only think of it as a feeling of foreign matter. Therefore, it is recommended to visit the ophthalmologist to check if the corneal surface is okay.

◇ Y-GO (AI Anchor): Three months ago, there was nothing wrong with the diabetes test, but when I went to the hospital because my eyes were drooping, it was diabetic retinopathy. Can diabetic retinopathy occur without diabetes?

◆ Moon Yong-seok: The premise that diabetic retinopathy can develop even without diabetes is wrong in itself if it's a very suspected situation. You'll have diabetes. However, it is highly likely that the diabetes test three months ago simply checked fasting blood sugar, not glycated hemoglobin or such reliable diabetes test indicators. This is because fasting blood sugar is highly volatile and there are quite a few affected areas, so diabetes is sometimes not found through this fasting blood sugar measurement. Therefore, if you heard that these findings were suspected of diabetic retinopathy, I recommend you not to rely on the diabetes test you received three months ago, but to go to an internal medicine such as endocrinology once again to test for diabetes.

◇ Y-ON (AI Anchor): Are nutritional supplements like lutein and beta carotene helpful for diabetic retinopathy?

◆ Moon Yong-seok: There's a lot of misunderstanding about this now, and the commercially available macular degeneration adjuvant called lutein is actually a combination of high concentrations of vitamins and minerals that are known to be effective in age-related macular degeneration. Therefore, there is basically no evidence that it is 'helpful for diabetic retinopathy'.

◇ Y-GO (AI Anchor): I've been diagnosed with diabetes for about 10 years and I decided to have surgery a week later for diabetic retinopathy. Is there a case of recurrence after surgery?

◆ Moon Yong-seok: First of all, the question you asked about 'reoccurrence after surgery' was, for example, whether another vitreous hemorrhage could occur or not, whether other diabetes complications could occur, and whether you should continue to receive additional treatment. That's quite possible. Because there is no treatment to eradicate diabetic retinopathy. In order to completely eliminate it, all normal blood vessels must be restored, but that cannot be done. Therefore, diabetic macular edema can occur again at any time, and new blood vessels can occur in areas that do not receive perineal laser photocoagulation, resulting in bleeding or problems.

<Let's just remember this>
◆ Moon Yong-seok: In the old saying, if your body is a thousand nyangs, your eyes are 900 nyangs. Eyes are very important organs for keeping your quality of life high. And diabetes is also a scary disease that can take away these eyes in an instant. If you have diabetes, always be alert and control your sugar, and at the same time, don't forget to visit the ophthalmologist for a screening test. I hope my story today helped you to have a healthy and happy life. Thank you.