On October 15–17, the scientific and practical conference “Refractive Plein Air — 2020,” featuring international participation, was held online in Kyiv. The event was organized by the P.L. Shupik National Medical Academy of Postgraduate Education, the All-Ukrainian Association of Pediatric Ophthalmologists and Optometrists, and the All-Ukrainian Alliance of Cataract and Refractive Surgeons. The event featured discussions on a wide range of current issues in modern ophthalmology, including the pathogenesis and stages of diabetic retinopathy, as well as methods for the prevention and treatment of this condition.
Dr. Rimma Leonidovna Skripnik, MD, PhD, Professor at the Department of Ophthalmology of the Bogomolets National Medical University, delivered a presentation titled “Improving the Effectiveness of Diabetic Retinopathy Treatment.”
Diabetes mellitus (DM) is one of the most common diseases in the world. In economically developed countries, there is a trend toward an increase in its prevalence. In Ukraine, over the past 30 years, its prevalence has increased 5.5-fold, currently affecting 1 million people. One of the severe complications of DM is the development of an irreversible pathological process in the visual-nervous system—diabetic retinopathy—which leads to a reduction in, and often the loss of, visual function.
According to statistical data, DM is the leading cause of blindness, especially among patients aged 20–74. More than 80% of patients suffer from neuropathy (damage to the peripheral nerves). Diabetes is the cause of 50% of lower limb amputations. Patients with diabetes have a 2–4 times higher risk of death from cardiovascular disease than those without diabetes. Kidney disease develops in 40% of patients with diabetes.
There are two theories regarding the pathogenesis of diabetic retinopathy: vascular and neurodegenerative. It has now been proven that diabetic retinopathy is a neurodegenerative disease of the retina (Barber A.J., 2003). This is confirmed by signs of a neurodegenerative process in such patients—gradual loss of neurons, neurodegenerative changes in the outer and inner layers, thinning of the photoreceptor layer, a decrease in the number of retinal ganglion cells, and activation of microglia.
Long-standing hyperglycemia triggers a cascade of changes in the human body, including metabolic disorders; disturbances in neuronal homeostasis of capillary blood flow; hypoxia and ischemia of the optic nerve; disruption of axoplasmic flow in the optic nerve fiber; partial, and subsequently complete atrophy of the optic nerve.
The professor then discussed her own interdisciplinary study, which included a very large cohort of patients (approximately 1,000) with type 1 and type 2 diabetes. These patients were followed up over a period of more than 10 years. At the start of the study, the patients’ duration of diabetes ranged from several months to several decades. Visual function tests, traditional ophthalmological, electrophysiological, and immunological examinations were conducted, based on which a classification of optic neuropathies was developed:

• A. Acute optic neuropathies.
• B. Chronic optic neuropathies:
• Stage I — initial;
• Stage II — severe;
• Stage III — dystrophic.

In diabetes mellitus, acute optic neuropathies are extremely rare, accounting for only 2%; all others are chronic optic neuropathies, which progress through three stages, each with its own characteristic features.
Stage I neuroretinopathy. In the first (initial) stage of the process, an early and persistent symptom is a change in the borders of the optic disc, clearly visible under non-red light, most often in the area where large vessels intersect. Hyperemia of the disc of varying severity is observed, along with changes in the retinal vessels: dilation of the veins and their tortuosity.
Stage II neuroretinopathy. The second (severe) stage of diabetic optic neuropathy is characterized by marked hyperemia of the optic disc, an elevated vascular index (often up to 1.5), disc protrusion of up to 1.0 mm and its bichromatic appearance, and thickening of the nerve fibers. The retinal veins are dilated and looped; microaneurysms and dot-like hemorrhages are present along the course of the vascular arches, and less commonly, hemorrhages in the form of streaks near the disc and in the interarc zone.
Stage III neuroretinopathy. In the third (dystrophic) stage of optic neuropathy, the borders of the optic disc become distinct; disc pallor, “truncation,” and the disappearance of nerve fibers are observed. The vascular index is reduced and ranges from 0.6 to 0.7.
Electrophysiological studies were conducted to objectively assess the condition of the optic nerve. Specific parameters were obtained that indicate the condition of the optic nerve and its changes from stage to stage.
These indicators include the critical flicker frequency (Hz) and the lability of the visual analyzer (Hz), which decrease from stage to stage, as well as the threshold of electrical sensitivity to phosphenes (μA), which increases from stage to stage.
The study not only included an examination of visual functions and ophthalmological examinations but was also accompanied by a morphological study of optic nerve tissue. The morphological studies conducted made it possible to identify and characterize changes in the morphology and structure of the optic nerve, as well as to summarize and highlight the main features for each stage.
In the initial stage, there was swelling of nerve fibers, adhesion of red blood cells to the capillary intima, and microthrombosis (erythrocytic and platelet microthrombosis). In the advanced stage, edema and destruction of nerve fibers were observed, along with deepening of the physiological excavation due to edema and swelling of peripapillary nerve fibers. Red blood cells were found in the capillaries of the interneuronal septa and in the zone of capillary occlusion. In the chronic form of dystrophic optic neuropathy, disorganization and destruction of nerve fibers were detected, and erythrocytes were identified in zones of microhemorrhages and in the interneuronal space of the optic nerve.
Thus, the hypothesis that diabetes mellitus is associated with optic nerve damage is confirmed not only by clinical trials but also by a series of morphological studies.
Given that diabetes mellitus is a chronic disease that does not respond to curative treatment, a very important aspect is the prescription of medications that could influence the pathogenic mechanisms of the disease and thereby reduce the risk of optic nerve fiber loss and preserve visual function long-term in this patient population. Drugs should improve the function of the optic nerve and retina, reduce the symptoms of optic neuropathy, and have no significant side effects.
When selecting medications, preference is given to those that contain multiple active ingredients capable of influencing different links in the pathogenesis. These include vitamin preparations and medications containing mineral complexes. In addition, treatment must be timely, appropriate to the intended goal and indications for use; preventive doses should exceed the physiological daily requirement, while therapeutic doses should be higher than preventive doses and higher than those used for hypo- and avitaminosis. For effective vitamin therapy, it is advisable to use combination preparations containing several vitamin components.
One such preparation that has proven effective for the treatment of diabetic retinopathy is the combination preparation Optix Forte (Kyiv Vitamin Plant). One capsule Optix Forte contains 5 mg of lutein, 1.5 mg of zeaxanthin, 50 mg of vitamin E, 2.5 mg of β-carotene, and 370 mg of omega-3 PUFAs.

To date, there is extensive experience with the use of Optix Forte not only for diseases of the posterior segment of the eyeball, but also for various other eye conditions accompanied by decreased visual acuity, photophobia, eye fatigue, and distortion of visual images—such as age-related macular degeneration, myopia, glaucomatous optic neuropathy, excessive strain, and surgical procedures.
A new product has recently been introduced in the Optix line (Kyiv Vitamin Plant)—Optix Premium, a combination preparation containing vitamins, minerals, and plant-based carotenoids. Optix Premium replenishes vitamin and mineral deficiencies and provides enhanced antioxidant protection, which is particularly necessary for the prevention and treatment of diabetic retinopathy. Each capsule contains 10 mg of lutein, 2 mg of zeaxanthin, 3 mg of astaxanthin, 370 mg of omega-3 PUFAs, 15 mcg of vitamin D, 100 mg of vitamin C, 30 mg of vitamin E, 5 mg of coenzyme Q10, 50 mg of curcumin, 5 mg of zinc, and 1000 mcg of copper.
Lutein and zeaxanthin naturally protect the retina by absorbing blue light and are powerful antioxidants. They protect the eyes from oxidative stress and free radicals, improving visual function, and prevent the oxidation of triglycerides and cholesterol by acting as protectors against lipid peroxidation in cell membranes. Lutein increases the optical density of macular pigment, which is very important for patients with diabetes who have insufficient macular pigment density.
Astaxanthin neutralizes free radicals and other oxidants, prevents damage to most eye tissues and structures, and may be beneficial in preventing age-related eye problems such as retinopathy, glaucoma, and neuropathy. Astaxanthin has anti-inflammatory effects, reduces eye strain during prolonged computer use, and improves visual acuity and quality of vision.
Vitamin D has demonstrated protective properties against macular degeneration due to its anti-inflammatory and anti-allergic effects. A deficiency increases the risk of developing age-related macular degeneration, especially in women.
Coenzyme Q10 is a cofactor with antioxidant activity and the ability to influence redox reactions in cells. It positively affects visual acuity even in healthy people and reduces eye fatigue. It has a positive effect on vision in cases of age-related farsightedness by improving the contractile ability of the ciliary muscle.
Thus, Optix Premium provides comprehensive antioxidant protection for the retina and optic nerve. Optix Premium is prescribed at a dose of 1 capsule once daily; the duration of therapy should be 2–3 months.
In conclusion, the professor expressed hope that the use of Optix Premium in patients with diabetes will help preserve visual function for a long time.

Prepared by Tatyana Chistik