Retinopathy Proliferative

Proliferative retinopathy is an advanced and serious complication of diabetes that can lead to blindness if left untreated, but with early detection and proper treatment, vision loss can often be prevented or slowed.

Table of contents

• What Is Proliferative Retinopathy?
• Who Gets Proliferative Retinopathy?
• Causes and How the Disease Develops
• Symptoms and Vision Effects
• How the Condition Is Diagnosed
• Treatment Options
• Potential Complications
• Prevention and Management

What Is Proliferative Retinopathy?

Proliferative retinopathy is a serious complication of diabetes that affects the eyes. It occurs when abnormal blood vessels grow and spread from the surface of the retina (the light-sensitive tissue at the back of the eye) into the vitreous cavity (the clear, gel-like substance that fills the middle of the eye)^[1][2]. This condition is the advanced stage of diabetic retinopathy, which is why it’s also called proliferative diabetic retinopathy or PDR.

The term “proliferative” describes the growth of these new, abnormal blood vessels^[3]. This process is called neovascularization, and while it might sound like the body is trying to help itself, these new vessels are actually very fragile and cause serious problems. They can break easily and bleed into the eye, or they can grow into bands of scar tissue that pull the retina away from the back wall of the eye^[2][4].

Proliferative retinopathy distinguishes itself from nonproliferative diabetic retinopathy because it involves the actual growth of new blood vessels. During the earlier stages of diabetic retinopathy, blood vessels become weakened and may leak fluid, but new vessels haven’t started growing yet^[3][4].

Who Gets Proliferative Retinopathy?

While proliferative retinopathy is present in less than 5 percent of all individuals with diabetes, it appears in more than 20 percent of younger people with insulin-dependent diabetes^[2]. The condition becomes more common with age, poor blood sugar control, and high blood pressure.

Your risk of developing proliferative retinopathy increases if you have other diabetes-related health problems. People with diabetic non-healing ulcers, diabetic nephropathy (kidney disease), and diabetic neuropathy (nerve damage) are more likely to progress to this advanced stage^[2].

Additional risk factors include having difficult-to-manage diabetes, high cholesterol, heart disease, coronary artery disease, and chronic kidney disease^[4]. The longer you have had diabetes, the higher your risk becomes for developing this eye complication^[1][3].

Causes and How the Disease Develops

Proliferative retinopathy happens because of damage caused by high blood sugar levels over time. When blood sugar levels stay too high, they damage the tiny blood vessels that supply blood to the retina^[1][4]. These damaged vessels weaken, swell, and may leak fluid into the retina.

As the damage gets worse, some of these blood vessels close off completely as your body tries to repair them^[4]. When blood vessels close, parts of the retina don’t get enough fresh oxygen and nutrients. This lack of blood supply is called ischemia^[2].

In response to not getting enough oxygen, the retina releases a chemical signal to grow new blood vessels. This chemical is called vascular endothelial growth factor, or VEGF^[6][7]. The new blood vessels that grow are meant to restore blood flow, but they are very fragile and abnormal.

These abnormal vessels can grow on the surface of the retina or at the optic nerve (the connection between your eye and brain)^[2]. They may bleed suddenly into the vitreous, causing a vitreous hemorrhage. The vessels also produce scar tissue that can pull the retina off the wall of the eye, creating a tractional retinal detachment^[2][5]. New blood vessels may even grow on the colored part of the front of the eye (the iris), leading to a painful rise in eye pressure called neovascular glaucoma^[5].

Symptoms and Vision Effects

Proliferative retinopathy is often without symptoms while the abnormal blood vessels slowly grow over months to years^[2]. Many people with this condition have no symptoms in the early stages and may not realize their vision is at risk^[10]. This is one reason why regular eye examinations are so important for people with diabetes.

When symptoms do appear, they may include^[1][3][4]:

• Blurred or distorted vision
• Spots or dark strings floating in your sight, called floaters
• Changes in vision that may come and go
• Dark or empty areas in your vision
• Difficulty seeing at night
• Colors looking faded or less vivid
• Vision loss

If bleeding occurs from the fragile new blood vessels, the blood may cloud the vitreous and block your vision. This can happen suddenly and may cause you to see many new floaters that look like gray or black specks or strings^[3]. If scar tissue causes a retinal detachment, you will lose vision in the affected area^[2].

It’s important to contact a medical professional right away if your vision changes suddenly or becomes blurry, spotty, or hazy^[1].

How the Condition Is Diagnosed

Proliferative retinopathy is generally diagnosed by an eye care professional during a careful eye examination^[2]. The first step is an exam where both pupils are dilated with eye drops. The drops widen your pupils to give the eye care professional a better view inside your eyes^[8]. These drops can cause your reading vision to blur for several hours.

During the exam, your doctor looks for irregularities in the inside and outside parts of your eyes^[8]. Vascular damage often occurs more in the outer areas of the retina, so patients may go to their eye doctor with little or no symptoms and be surprised to learn they have significant damage^[10].

Several diagnostic tests may be used^[2][8]:

• Fluorescein angiography: An orange dye is injected into a vein in your arm or hand. The dye circulates through your body and into the blood vessels of your eyes. Rapid sequence photos are taken as the dye moves through your eye’s blood vessels. This test can identify areas of new blood vessel growth and regions where blood supply has been lost.
• Optical coherence tomography (OCT): This test uses light beams sent into your eye. The reflected light is processed by a computer to create detailed cross-sectional images of the retina. This shows whether fluid has leaked into retinal tissue.
• Ocular ultrasound: If your eye is too filled with blood to examine directly, a probe is placed on your eyelid. Reflected sound waves produce images on a screen, allowing your doctor to evaluate the eye’s internal structure even when it can’t be seen directly.
• Retinal photography: High-resolution images of your retina are taken to detect any abnormalities.

Your doctor will select the diagnostic tests most appropriate for your particular situation^[2].

Treatment Options

If you have proliferative retinopathy, you will need treatment^[8]. There are several effective treatment options available, and they may be used individually or together^[2]. Treatment is aimed at slowing or stopping the condition from getting worse^[8].

Laser Treatment

Panretinal photocoagulation, or PRP, is one of the most common treatments for proliferative retinopathy and has been used successfully for decades^[2][7]. During this procedure, brief spots of bright light are placed around the outer areas of the retina using a laser. The laser creates hundreds of small burns throughout the peripheral retina^[2][6].

These laser burns reduce the release of VEGF, the chemical signal that stimulates abnormal blood vessel growth. This decreases the stimulus for new blood vessel formation and helps prevent bleeding and retinal detachment^[2][5]. The treatment may be done in one or more sessions. This treatment has saved vision in millions of patients and provides long-term control of proliferative retinopathy^[2].

Anti-VEGF Injections

Injections of anti-VEGF medications into the eye block the signals released by oxygen-starved regions of the retina^[2][6]. These medicines slow the growth of abnormal blood vessels and can cause them to shrink or become inactive very quickly following treatment.

Anti-VEGF medicines that might be used include aflibercept (Eyelea) or ranibizumab (Lucentis)^[6][7]. These injections are highly effective at reversing the growth of abnormal blood vessels. However, the effect of anti-VEGF therapy is usually temporary, lasting months before the abnormal vessel growth resumes, so repeat treatments are needed^[2]. The advantage of anti-VEGF therapy is that it does not affect your side vision like laser treatment might^[2].

Vitrectomy Surgery

If you have very advanced proliferative retinopathy, bleeding that won’t clear on its own, or a retinal detachment, your doctor may recommend surgery called a vitrectomy^[2][6][8]. This procedure is recommended in cases of advanced bleeding or scarring inside the eye.

Vitrectomy surgery is performed in an operating room or surgery center. The surgeon uses a microscope to look into your eye and performs the procedure using tiny needle-sized instruments^[2]. During the surgery, the surgeon removes the blood-filled vitreous and replaces it with saline (salt water). This clears the view and allows additional laser treatment if needed. The surgeon can also remove scar tissue and repair the retina^[2][8].

In particularly severe cases, more than one vitrectomy surgery may be necessary^[5].

Other Treatments

Sometimes steroids may be injected into the eye. An implant, such as Iluvien, may be placed in the eye that releases a small amount of corticosteroid medicine over time^[6].

Many people with proliferative retinopathy need to be treated more than once as the condition can progress over time^[8].

Potential Complications

Untreated proliferative retinopathy can cause blindness^[2]. The condition can progress and lead to vision loss if left untreated, and it is the leading cause of vision loss in adults between 20 and 74 years of age^[3].

Specific complications include^[2][4][5]:

• Vitreous hemorrhage: The fragile abnormal blood vessels can bleed suddenly into the middle of the eye, blocking vision
• Tractional retinal detachment: Scar tissue produced by abnormal vessels can pull the retina off the wall of the eye
• Neovascular glaucoma: New blood vessels may grow on the iris (the colored part of the front of the eye), leading to a painful and blinding rise in eye pressure
• Permanent vision loss and blindness

With proper treatment and control of the underlying diabetes, proliferative retinopathy can be stabilized and vision can often be preserved^[2].

Prevention and Management

While not everyone with diabetes will develop proliferative retinopathy, there are several important steps you can take to protect your vision^[4].

Control Blood Sugar Levels

The most important way to prevent vision loss is proper treatment and control of diabetes^[1]. Keeping your blood sugar levels within your target range helps prevent damage to the blood vessels in your eyes. Good blood sugar control is important even if you’ve already been treated for retinopathy, as it can help keep the condition from getting worse^[6].

Manage Blood Pressure and Cholesterol

High blood pressure and high cholesterol can worsen eye damage^[2]. Monitor your blood pressure and have your cholesterol levels checked regularly, and follow your healthcare provider’s recommendations for controlling these conditions.

Get Regular Eye Exams

Regular eye examinations are critical because proliferative retinopathy is easier to treat the earlier it is identified^[2]. If you have diabetes, a yearly dilated eye exam with an eye care professional is recommended, even if your vision seems fine^[1]. Early detection allows for timely treatment that can slow or prevent vision loss^[4].

Healthy Lifestyle Choices

Additional steps that can help include^[13]:

• Eating a healthy diet filled with leafy greens, whole grains, and lean proteins
• Exercising regularly to help your body use insulin more effectively
• Maintaining a healthy weight
• Quitting smoking, as it can worsen blood vessel damage
• Managing stress through relaxation activities
• Getting quality sleep
• Limiting alcohol consumption

These lifestyle choices, combined with regular medical care and monitoring, can go a long way toward protecting your eyesight and maintaining your quality of life^[4][13].