Today, diabetic retinopathy does not take more than surprise and you can stop by optimizing glycemic control, lipid and blood pressure by acting on the lifestyles and making use of laser, medication or surgery. The doctor has more weapons available to stop diabetic retinopathy, but we need to know how to use promptly and correctly. In fact, more and more people fall ill with diabetes and more early. This means that a person with type 2 diabetes in seven (and one with type 1 diabetes in four) is in danger, in the course of his life, to develop ocular complications, and the risk is greater the longer the duration of the disease and the worst hand glycometabolic.

The prospective, controlled studies have shown with certainty that the chronic hyperglycemia is a necessary condition for the development of diabetic microangiopathy, although contributing factors in determining it gentici. The toxicity of hyperglycemia is due mainly to an extent the processes of glycation and the subsequent oxidation of various protein molecules (basement membranes, proteins circulating etc..) Undergoing irreversible denaturation processes. The glucose itself gives rise to oxidation with formation of free radicals. Although the activation of the polyol pathway is stress ossidativi.Un 'glucotoxicity important mechanism has been recognized in the activation of protein kinase C.



Diabetic retinopathy begins when the capillaries that supply the retina, the back of the eye, as a result of prolonged exposure to hyperglycemia is occluded, or gaping, letting out the liquid and material lipoprotein that accumulates in the thickness of the retina.



Retinopathy is therefore the consequence of three fundamental alteration of retinal capillaries:

Capillary occlusion
Hyperpermeability wall
Proliferation of newly formed vessels


We distinguish different degrees of retinal damage that are the basis of classification:



basic or background retinopathy
preproliferante
proliferative


The phase, known as "non-proliferative retinopathy" or "background" is characterized by microaneurysms, haemorrhages and hard exudates and cotton, hard exudates are due to extravasation of plasma proteins, especially lipoproteins.

retinopathy may progress to "proliferating" when new capillaries to replace those damaged or blocked, they grow in a disorderly manner, forming the balls' of vessels that can cause more serious complications of the disease, such as bleeding inside the eye or detachment of retina 'traditional' When the patient as well as diabetes, is also hypertensive or have an excess of fats in the blood, the risk of retinal damage increases.

The retinopathy may involve the periphery of the eye and also the central ark, the macula, the part of the retina Members at the most important visual functions.



The person with diabetes should therefore always check the fundus of the eye, at least every 3-6 or 12 months.



Among the many things that a person with diabetes can do to 'save the view, to undergo a periodic review is by far the simplest. Yet the everyday experience confirms that too many people, especially those who only occasionally attend services of diabetes, 'jump' periodic inspections recommended by the guidelines.

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An examination of the 'fundus' should be done at defined intervals, every 3, 6 or 12 months, the limit every two years, depending on the type of diabetes, duration of illness, level of glycemic control, presence of other complications especially to the kidney (see diabetic nephropathy), blood pressure and blood fat levels.



It is therefore necessary to check the eye and assess the state of the retina and possibly choose the best treatment.

Examination of the fundus should always be done in mydriasis, ie with a prior dilation of the pupil, in order to assess accurately both the central and all the peripheral retina. In case of injury may be useful to take pictures (so-called retinal) to the back of the eye, so you have an image to be compared with images, before or after, and assess the progression or regression of disease or response to different treatments '. If the lesions are more advanced and useful to the photographs of the fundus with the help of a contrast medium. This examination, fluorescein angiography, it is crucial for a correct square on the damage and decide whether and where to perform laser treatments. The fluorescein angiography should be reserved for patients with larger lesions and at the discretion of the specialist, in terms of absence of injury, initial lesions and drink or regression phase (after complete treatment) is sufficient to follow the patient in an examination of the fundus,



Glycemic control.



Once diagnosed with diabetic retinopathy, the first thing to do is improve glycemic control. We know with certainty that diabetic retinopathy is due, in type 1 diabetes and almost exclusively in type 2 diabetes along with other elements, a high blood sugar too often, it must therefore take action to improve nutrition in diabetes, increasing ' exercise and drug therapy using a more aggressive and above all even closer upon blood sugar levels in the patient. This is the high road: a good glycemic control delays the onset of retinopathy and slows the progression.





Fee pressure and lipids.



Although hypertension is a major factor in diabetic retinopathy. We need to achieve and maintain very low levels of pressure: 130/85. Needed medications, often more than one, in fact, lowering the pressure, reduce the risk and progression of diabetic nephropathy and cardiovascular risk. Even the lipid requires attention: in people with diabetes are excessive triglycerides and LDL cholesterol. They should therefore be kept under control not only total cholesterol but also its surroundings and the proteins that carry (ApoA and ApoB), returning to normal LDL cholesterol and possibly making it drop below 70 mg / dl.



Laser treatment.



Laser photocoagulation is a procedure of cauterization of the retina sacrificing portions of diseased retina and aims to eliminate vascular abnormalities responsible for edema. The interventions are carried out with the laser on an outpatient basis and usually require only topical anesthesia (anesthetic eyedrops); anesthetic injections are reserved for more complicated cases and for more aggressive treatments. Diagnosis and therapy continue to evolve in gaining precision and efficiency, today laser photocoagulation therapy continues to be validated by large randomized studies to halt the progression of the disease is the tool that has reduced significantly in recent decades blindness in patients diabetics.



Intravitreal drugs.



A1 1aser have been added in recent years, two categories of drugs injected directly into the vitreous Verige: antiVEGF steroids and drugs (such as Ranibizumab, Pegaptanib, bevacizumab), which prevent the formation of new blood vessels or facilitate regression of those already formed. Injection therapy should be combined with those laser and intravitreal drugs still represent a therapeutic option in selected cases, additional or refractory to laser treatment. If the anti-VEGF drugs block angiogenesis (ie formation of new blood vessels), the injection of steroids, as well as having anti-angiogenic effects, spoke on a variety of complex factors involved in the origin of retinopathy. Steroids, however, carry the risk of ocular hypertension (increased pressure in the eye) and cataracts. The problem, common to both groups of drugs, is the need to repeat this injection as the efficacy of the drug is transient and chronic diabetic retinopathy. In the U.S., and soon in Europe, are already available injectable steroids inland endovitreale with sustained release that have shown effectiveness in reducing the complications of vascular diseases of the retina such as retinal thrombosis.

New Therapies
Triamcinolone acetonide (Kenacort) is a steroid in crystalline form that is showing great potential efficacy in conditions such as diabetic macular edema, for which the therapeutic weapons in our possession are not fully effective, the drug has inhibitory activity neovascularization; used by a few years intravitreal thanks to its ability to inhibit neovascularization, anti-inflammatory and anti-edema.
The ruboxistaurin is a specific inhibitor of protein kinase C beta (PKC-β), the first of a new class of molecules being tested for the treatment of diabetic retinopathy, diabetic peripheral neuropathy (nerve damage) and nephropathy diabetica.ascolarizzion01 - 2004 Association
They are currently being tested a number of drugs belonging to the class of monoclonal anti-VEGF (vascular endothelial growth factor) activity with inhibition of neovascularization by which it would seem that it is finally possible to significantly improve the lives and view of many patients with neovascular diseases of the retina. Avastin (bevacizumab) is an anti-VEGF monoclonal antibody that is injected inside the eye. At present, the Avastin is the first anti-VEGF to be used in Italy, the drug is in band H, which can be used by the National Health Service until you have submitted an application to test the local ethics committee , and the only way to use the drug outside the NHS is purchased at a pharmacy in Switzerland or the Vatican.

The other antibodies Macugen (Pegaptanib) and Lucentis (Ranibizumab) are currently not yet commercially available.

While waiting for this to happen, now we have only the Avastin in several pilot studies would seem to have a good effect not only in reducing the risk of further vision loss but also to improve visual function.





Vitreoretinal surgery.



In advanced forms of diabetic retinopathy, retinal bleeding complications or pre-pathological adhesions between the retina and vitreous, vitreo-retinal surgery plays a key role in halting the progression of the disease and preserve vision. Surgical techniques and instrumentation in recent years have seen amazing progress, "continues the ophthalmologist in Milan," the surgery, which until yesterday was considered the last resort is now a treatment option with a good relationship between benefits and risks, even in the dell'ederna traditional management - in this case the intervention, the vitreous separates from the retina - is the retinal detachment and dell'emovitreo. Laser surgery and are not contradictory. "In fact, operating a laser treated eye already gives you the best results in other cases where the laser treatment was performed in a timely fashion can be performed during surgery (endo-laser).
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