Diabetic retinopathyTopic assignment : medical ophthalmology

Dr.Vijay

Diabetes Definition Risk factors Pathogenesis Classification : proliferative / non-

proliferative Sign & symptoms DDx & other ocular complication of

DM Treatment & follow up Screening for DR Apply with case study

Contents

Group of common metabolic disorders

Caused by a complex interaction of genetics and environmental factors

Lack of insulin hyperglycemia

Diagnostic criteria : Fasting plasma glucose > 126 mg/dl

Type 1 DM – Insulin-dependent diabetes (IDDM)

Results from pancreatic beta-cell destruction, usually leading to absolute or

near total insulin deficiency

Type 2 DM - Non-insulin-dependent diabetes (NIDDM)

Variable degrees of insulin resistance and impaired insulin secretion,

resulting in hyperglycemia and other metabolic derangements due to

insufficient insulin action.

Diabetes mellitus

Long-standing hyperglycemia leads to multiple organ damage

Macrovascular complications

Stroke

Heart disease and hypertension

Peripheral vascular disease

Foot problems

Microvascular complications

Diabetic eye disease : retinopathy and cataracts

Renal disease

Neuropathy

Foot problems

Diabetes mellitus

Diabetic retinopathy

The most severe of ocular complications of diabetes Caused by damage to blood vessels of the retina,

leads to retinal damage Microvascular complication of longstanding diabetes

mellitus [1]

Most prevalence cause of legal blindness between the ages of 20 and 65 years

Common in DM type 1 > type 2

Duration of diabetes Most important Pt diagnosed before age 30 yr

50% DR after 10 yrs 90% DR after 30 yrs

Poor metabolic control Less important, but relevant to development and

progression of DR HbA1c ass. with risk

Pregnancy Ass with rapid progression of DR Predicating factors : poor pre-pregnancy control of DM, too

rapid control during the early stages of pregnancy, pre-eclampsia and fluid imbalance

Risk factors

Microvascular occlusion Microvascular leakage

Pathogenesis

Microvascular leakage

Degeneration and loss of pericytes

Plasma leakage

Intraretinal hemorrhageHard exudate(Circinate pattern)

Capillary wall weakening

microaneurysm

Retinal edema

Non-proliferative diabetic retinopathy

Right eye: Micro aneurysm, few flame-shaped and dot-blot hemorrhages and hard exudate [with hard exudate in macula area] , ไม่�พบneovascularization เข้�าได้�กั�บ moderate non proliferative diabetic retinopathy Left eye: Micro aneurysm, numerous flame-shaped and dot-blot hemorrhage [more than 20 dots in 4 quadrant], hard exudate [with hard exudate in macula area] ไม่�พบ neovascularization เข้�าได้�กั�บ severe non proliferative diabetic retinopathy

Microvascular occlusion

Neovascularizationand fibrovascular proliferation

VEGF

Increased plasma viscosityDeformation of RBCIncreased platelets stickiness

Decreased capillary blood flow

and perfusion

Endothelial cell damage and proliferation

Capillary basement membrane thickening

Retinal hypoxia

A-V shuntIRMA*

*intraretinal microvascular abnormalities

Proliferative

retinopathy

Rubeosis iridis

Tractional retinal detachmentVitreous hemorrhage

Classification

Non-proliferative diabetic retinopathy (NPDR)

Proliferative diabetic retinopathy (PDR)

Non-proliferative diabetic retinopathy

Mild NPDR Moderate NPDR Severe NPDR

Microaneurysm Retinal hemorrhage

“Dot or Blot” Spot “Flame or Splinter shape” hemorrhage

Hard exudate Cotton wool Spot Venous beading Intra-retinal microvascular abnormalities

(IRMA)

Sign NPDR

Mild NPDR

Microaneurysm

Moderate NPDR

More microaneurysms Scattered hard exudates Cotton-wool spots

4-2-1 rule 4 quadrants of severe retinal hemorrhages 2 quadrants of venous beading 1 quadrant of IRMA

Very severe NPDR more than 1 of above

Severe NPDR

Localized saccular outpouchings of capillary wall red dots Focal dilatation of capillary wall where pericytes are

absent Fusion of 2 arms of capillary loop

Usually seen in relation to areas of capillary non-perfusion at the posterior pole esp temporal to fovea

The earliest signs of DR

Microaneurysm

Microaneurysm

Capillary or microaneurysm is weakened rupture intraretinal hemorrhages

Dot & blot hemorrhages Deep hemorrhage - inner nuclear layer or outer plexiform

layer Usually round or oval Dot hemorrhages - bright red dots (same size as large

microaneurysms) Blot hemorrhages - larger lesions

Flame-shape or splinter hemorrhages More superficial - in nerve fiber layer Absorbed slowly after several weeks Indistinguishable from hemorrhage in hypertensive

retinopathy May have co-existence of systemic hypertension BP must

be checked

Retinal Hemorrhage

Hemorrhage

Intra-retinal lipid exudates Yellow deposits of lipid and protein within the retina Accumulations of lipids leak from surrounding

capillaries and microaneuryisms May form a circinate pattern Hyperlipidemia may correlate with the

development of hard exudates

Hard exudate

White fluffy lesions in nerve fiber layer Result from occlusion of retinal pre-capillary

arterioles supplying the nerve fibre layer with concomitant swelling of local nerve fibre axons

Also called "soft exudates" or "nerve fiber layer infarctions"

Fluorescein angiography shows no capillary perfusion in the area of the soft exudate

Very common in DR, esp if pt with HT

Cotton Wool Spot

Dilatation and beading of retinal vein Appearance resembling sausage-shaped

dilatation of the retinal veins Sign of severe NPDR

Venous beading

Abnormal dilated retinal capillaries or may represent intraretinal neovacularization which has not breached the internal limiting membrane of the retina

Indicate severe NPDR rapidly progress to PDR

Intra-retinal microvascular abnormalities (IRMA)

Venous beading

5% of DM pt. Finding

Neovascularization : NVD, NVE Vitreous changes

Advanced diabetic eye disease Final stage of Uncontrolled PRD Glaucoma (neovascularization) Blindness from persistent vitreous hemorrhage,

tractional RD, opaque membrane formation,

Proliferative diabetic retinopathy

Neovascularization of disc

Fluorescein dye leakage is seen in neovascularized area

Neovascularization of elsewhere

Rubeosis iridis(neovascularisation of the iris)

Neovascular glaucoma

Vitreous changes

Tractional retinal detachment

Vitreous hemorrhage

NVE

Venous beading

IRMA

New vessels of the disc (advanced)

Blurred or distorted vision or difficulty reading

Floaters Partial or total loss of vision

a shadow or veil across patient’s visual field Eye pain

Signs & symptoms of DR

Hypertensive retinopathy

Prevention Treat underlying conditions

Control blood sugar – HbA1c < 7 Control blood pressure – SBP < 130 mmHg Control lipid profile – TG, LDL Correct anemia Control diabetic nephropathy

Pregnancy makes DR worsen

Medical therapy

Panretinal photocoagulation (PRP) High-risk PDR (3/4)

Vitreous or preretinal hemorrhage New vessels New vessels on optic disc or within 1,500 microns

from optic disc rim Large new vessels

Iris or angle neovascularization CSME

Laser

Focal or Grid CSME in both NPDR and

PDR Panretinal (PRP)

PDR

Photocoagulation

Thank you