Vision Loss: Retinopathy
Guest: Dr. Esther Bowie - Ophthalmology/Storm Eye Institute
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Esther Bowie, who is Assistant Professor of Ophthalmology here at the Medical University of South Carolina. Dr. Bowie is a specialist in diseases of the vitreous and retina, which are two structures in the eye. Dr. Bowie, let’s start by talking about a very common problem that you’re quite an expert in, which is diabetic eye disease, or retinopathy. What are the eye problems; visual problems, that people with diabetes develop?
Dr. Esther Bowie: Diseases that can affect the retina in patients who have diabetes include what we call nonproliferative changes; meaning, hemorrhages, fluid leakage. And in the more advanced form, they can start forming abnormal blood vessels, which can lead to bleeding, and ultimately retinal detachment.
Dr. Linda Austin: So, these are diseases of the tiny little blood vessels in the eye? Now, could you explain exactly where those blood vessels are? Most people would think of blood vessels as being in the white part of the eye, but you’re really talking about the back side of the eye.
Dr. Esther Bowie: Right. These are blood vessels that are located in the layer of the eye that’s called the retina, which can be sort of imagined, or thought about, as the film of the camera, and this is what really helps you to see. These are blood vessels that actually supply the retina. When diabetes affects you, and if it affects you severely, it can affect these blood vessels, and they become abnormal, so they start bleeding or leaking fluid. And if they affect the supply to the retina significantly enough, you can start, actually, growing blood vessels that are abnormal. That’s when we say that you have proliferative diabetic retinopathy.
Dr. Linda Austin: Proliferative, meaning that they’re growing?
Dr. Esther Bowie: Right. It means that they’re growing abnormal blood vessels, or growing in the retina, which should not happen after birth.
Dr. Linda Austin: So, when a doctor, then, takes their ophthalmoscope; that instrument, and they tell you to look at the wall behind them, they’re peering into the back of the eyeball, the back surface, one of the things they’re looking at are those blood vessels? How common is it for people with diabetes to have diseases of the blood vessels of the eye?
Dr. Esther Bowie: It’s actually very common. The key thing for diabetes, though, is your control. If you have good blood sugar control, you’re less likely to have changes of diabetic retinopathy. However, if you have diabetes long enough, most patients will have some changes. There are really two types of diabetes. There’s the noninsulin-dependent, which is the one that develops later on. These patients, at the time of diagnosis, can actually have changes, because they have had diabetes for some time beforehand. They need to have their eyes examined immediately.
For patients with insulin-dependent diabetes; developed at a younger age, as a kid, it takes awhile, usually, for them to develop the changes in their retina.
Dr. Linda Austin: So, it’s another reason, since the noninsulin-dependent diabetes develops later in life, and is often associated with overweight and lack of exercise, to really attend to those issues and try to keep yourself in good physical condition to begin with. People don’t think of blindness as a result of letting their weight go, but it can be, can’t it?
Dr. Esther Bowie: Yes, that’s correct.
Dr. Linda Austin: Now, let’s imagine that someone has been unfortunate enough to actually have these eye changes, and they come to you, what are some of the first symptoms that they might be aware of that they’re having?
Dr. Esther Bowie: Unfortunately, in the early stages, you may be asymptomatic; there will be no symptoms. A patient may not realize this. So, it’s really important that once you have the diagnosis you get your eyes examined at least once a year. However, if you’re asymptomatic, other changes can occur. Your vision can be blurred. This can be your central vision, or it can be just all over, or you may notice that you have floaters; little black spots, or red spots, floating around in your vision. And that’s if you should have a vitreous hemorrhage, or a bleed, because of abnormal blood vessel growth.
Dr. Linda Austin: And that would be a hemorrhage into the fluid that’s within the middle part of the eye itself?
Dr. Esther Bowie: Right. That would be a hemorrhage, or bleed, in the fluid or vitreous.
Dr. Linda Austin: Now, what can you, as an ophthalmologist, do to help people who have diabetic retinopathy, or eye disease?
Dr. Esther Bowie: The first thing is actually prevention; reminding the patient that it’s important to have good blood sugar control. There’s a level called the hemoglobin A1c, which really needs to be less be than 7. Patients with less than 7 are less likely to develop diabetic retinopathy.
At the next level; so you’ve now developed changes from diabetes, we have options such as laser, for fluid leakage, or laser for abnormal blood vessel growth. As of recently, we now have medicines that we can inject into the eye, which do not prevent it, but it does control the amount of fluid leakage or growth of abnormal blood vessels. These are not cures, but they help to delay the progression of retinopathy.
Dr. Linda Austin: So, once you’ve lost ground, then, right now, at least with current technology, you can’t regain what you’ve lost? Is that true?
Dr. Esther Bowie: Generally, you can regain to a certain extent, but you can never get back to normal; so it will never be 100 percent.
Dr. Linda Austin: But you can definitely slow down the progression?
Dr. Esther Bowie: Right. Exactly.
Dr. Linda Austin: I would imagine that for you, as an ophthalmologist, the use of that laser, that must be very delicate surgery. Tell us how that procedure is actually done.
Dr. Esther Bowie: The laser is actually pretty straight forward. We do it very often. It’s an in-office procedure. The patient sits at a laser machine. We apply a little numbing, or anesthetic, medicine to the eye and place special lenses on the eye, and we treat it. And, generally, it’s pain-free. They’re usually not required to use any medications after eye drops. The follow-up is scheduled according to each patient’s condition.
Dr. Linda Austin: And then you follow the patient from that point on?
Dr. Esther Bowie: Right. Correct.
Dr. Linda Austin: What are some of the other procedures that you sometimes do for patients with diabetic eye disease?
Dr. Esther Bowie: If the diabetic eye disease is severe enough where they have vitreous hemorrhage, or a bleed in they jelly, or the vitreous; in the middle of the eye, we may need to do surgery. This is called a vitrectomy. We make three small incisions in the eye and remove the jelly and the blood and apply additional laser. This usually works pretty well to remove the blood and improve a patient’s vision.
In the more advanced cases, where they have retinal detachment, we may also need to peel scar tissue when we do the surgery, and place either a gas bubble or a silicone oil in the eye; just depending on how advanced the disease may be for that individual.
Dr. Linda Austin: Are there any medications that you use to treat diabetic eye disease?
Dr. Esther Bowie: In some patients with diabetic macular edema, we may inject medicines; steroids, such as intravitreal triamcinolone (Kenalog). That helps to remove the fluid in some patients, however, it’s not a permanent procedure, and it may need repeating. There are also other medicines that have come out recently; not FDA approved, such as Avastin (Bevacizumab). This has been shown by case studies that it may be beneficial in some patients with fluid leakage, or macular edema, or if they have abnormal blood vessel growth. It may help in the regression of abnormal blood vessels.
Dr. Linda Austin: Dr. Bowie, thank you so much.
Dr. Esther Bowie: Thank you.
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