Treatment of Retinal Bleeding In Diabetic Patients in Jordan
علاج نزيف الشبكية عند مرضى السكري
Retinal bleeding in a person with diabetes is leakage of blood from vessels weakened by long-standing high blood sugar, either within the layers of the retina itself or into the vitreous cavity, where it blocks light and causes a sudden fall in vision. The origin of the problem is that raised glucose damages the walls of the small capillaries so that they leak and close off; part of the retina becomes short of oxygen and releases signals that create fragile new vessels which bleed easily and pull on the retina through fibrous membranes. The most dangerous fact about this disease is that it is **silent until advanced stages**. Your retina may already be at a proliferative stage requiring urgent treatment while your vision is still perfectly good, and the first symptom may be a sudden large bleed. For that reason, **an annual dilated eye examination for a person with diabetes is not optional but part of treating the diabetes itself**, and the interval is shortened when retinopathy is present, during pregnancy, or when glucose control is poor. Treatment rests on four pillars. The first is laser photocoagulation, which reduces the drive to grow abnormal new vessels and lowers the risk of major bleeding and traction detachment. The second is intraocular injections to shrink new vessels and treat macular oedema, and these are **continuing treatment rather than a single dose**. The third is vitrectomy surgery to remove blood that has not cleared, excise contracting membranes and repair traction detachment. The fourth, the most important and the most neglected, is that **controlling blood sugar, blood pressure and cholesterol slows the deterioration** and improves the outcome of every eye treatment. The limits must be stated plainly. These procedures protect vision but do not cure diabetes; bleeding can recur while the disease remains active; removing blood surgically does not necessarily restore sight if the retina or macula was already damaged; and nothing replaces neural tissue that has died. Certain signs demand action the same day: **sudden flashes of light, a new shower of dense floaters, a black curtain covering part of the field of vision, or a sudden drop in sight all require an eye examination the same day, and delay costs sight that cannot be recovered**. Suitability for any treatment is determined by dilated examination and imaging, not by reading.
Procedure steps
- 1
Urgent assessment and identifying the source
Vision and eye pressure are measured and the pupil is dilated to examine the back of the eye, locate the bleeding, judge its density and look for new vessels or contracting membranes. If blood blocks the view, an ocular ultrasound is used to make sure there is no retinal detachment hidden beneath the haemorrhage, a finding that changes the plan from observation to urgent surgery.
- 2
Imaging and staging the disease
Cross-sectional retinal imaging assesses the macula and any fluid within it, and dye angiography is requested when the view allows, to map ischaemic and leaking areas. The stage of retinopathy is defined precisely, because the plan differs completely between non-proliferative disease that is monitored and proliferative disease that needs laser or injections without delay.
- 3
Laser and intraocular injections
Laser photocoagulation is applied to poorly perfused areas of retina to reduce the stimulus for new vessels, and the treatment may be divided into several sessions. Intraocular injections are added to shrink new vessels or treat macular oedema, on a repeating schedule guided by imaging. It is explained that the aim is to protect vision and halt deterioration rather than to recover acuity already lost.
- 4
Vitrectomy surgery when needed
If the haemorrhage does not clear, is dense, or is accompanied by traction detachment or membranes pulling on the macula, intraocular surgery is performed to remove the vitreous gel together with the blood, excise the membranes and apply internal laser, sometimes leaving a gas bubble or silicone oil. It is usually done under local or general anaesthesia as a day case or with a short overnight stay.
- 5
Controlling the underlying disease and follow-up
Working with your diabetes physician, glucose is brought under control gradually, along with blood pressure, cholesterol and kidney function, sleep apnoea is treated and smoking cessation is advised. Lifelong periodic reviews with imaging are scheduled, and patients are examined before and during pregnancy at closer intervals, because retinopathy can accelerate in pregnancy.
Before the procedure
Bring someone to take you home, since you will not be able to drive after dilation, and bring sunglasses. Bring your glycated haemoglobin result, recent home glucose readings, blood pressure measurement, kidney and lipid results, and a complete list of your medicines including insulin and blood thinners, but do not stop any drug on your own. State precisely how long you have had diabetes and when your last dilated retinal examination was, and when the symptoms started: whether you saw floaters, flashes, a black curtain or a sudden drop in vision, and in which eye. Tell the doctor about any previous laser, injections or eye surgery, about kidney disease, hypertension, pregnancy or plans for pregnancy, and about sleep apnoea or smoking. If surgery is planned, follow the fasting instructions and ask about your insulin dose on the day.
After the procedure
Use the prescribed drops on schedule, do not rub the eye, and avoid strenuous exertion, heavy lifting and prolonged bending for the period your doctor specifies, since these increase the chance of fresh bleeding. If a gas bubble has been left in your eye, keep to the prescribed posture, **do not travel by air or go to high altitude, and tell any anaesthetist that the bubble is present**. Expect the haemorrhage to clear gradually, which may take weeks, and to see moving shadows or floaters meanwhile. **Seek same-day review for any new sudden drop in vision, flashes of light, a large increase in floaters, a black curtain covering part of your field, or severe eye pain with redness and light sensitivity.** Most important in the long run: keep control of your glucose, blood pressure and cholesterol and attend your eye appointments, because **the absence of symptoms does not mean the retina is healthy**.
Expected duration
A full examination with dilation and imaging usually takes one to two hours. A laser session typically takes 10 to 30 minutes and may be divided across several appointments, while an injection takes minutes within a visit of about half an hour. Vitrectomy surgery generally takes one to two and a half hours. A mild haemorrhage may need weeks to months to clear, and follow-up continues for life.
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