DIABETIC RETINOPATHY MANAGEMENT

BY Dr. Nitish

DIAGNOSIS

• Visual acuity test

• Pupil dilation

• Fundus examination

• Slit Lamp Biomicroscopy

• Ophthalmoscopy

• Flouresceine angiography

• Optical coherence tomography (OCT)

FUNDUS EXAMINATION WHEN ??

• FIRST EXAMINATIONIDDM-5yr after onset/puberty

NIDDM-immediately after diagnosisDIABETIC PREGNANT-early first

trimester• FOLLOW UP

NPDR without maculopathy-min 6mthsNPDR with maculopathy-min 3-4mthsPDR-2-3mthsDIABETIC PREGNANT-each trimester

FLUORESCEIN ANGIOGRAPHY

• Sodium fluorescein dye injected to Ant-cubitalvein

• 80% bound to plasma protein ,20% unbound

• Pictures taken for 12 secs at interval of 1.5 to 2 secs

• Blue light used to excite

• Green light emitted

Hyperfluorescent dots which leak in later stage bordering areas of capillary non perfusion

MICRO-ANEURYSMS

HYPOFLUORESCENC DUE TO NON FILLING

CAPILLARY CLOSURE

HYPOFLUORESCENCE DUE TO BLOCKAGE OF BACKGROUND CHOROIDAL FLUORESCENCE

HARD EXUDATE

SUPERFICIAL AND DEEP HAEMORRHAGE

Blocked choroidal fluorescence

Do not leak fluorescence except at their growing tips

IRMA

Venous dilatation , venous beading

VENOUS ABNORMALITIES

FREELY LEAKS THE DYE(hyperfluorescence )

NEO VASCULARISATION

CYSTOID MACULAR EDEMA

Capillary dilatation in perifoveal regionPetaloid pattern (fusiform cystoid spaces arranged in radial pattern)

PRE PROLIFERATIVE DIABETIC RETINOPATHY

PROLIFERATIVE DIABETIC RETINOPATHY

DIABETIC MACULOPATHY

Role of FFA

• To asess the level of DR

• To guide laser photocoagulation of microaneurysms

• To asess capillary drop out at macula-poor prognosis

• To identify lesions such as NVE or NVD

SIDE EFFECTS AND COMPLICATIONS

• Local tissue necrosis

• Nausea and vomiting

• Vasovagal reaction(circulatory shock,myocardial infarction)

• Allergic reaction,anaphylaxis

• Thrombophlebitis

• Pyrexia

Neurosensory thickening with foveal elevationCystic changes in neurosensory retina

OPTICAL COHERENCE TOMOGRAPHY

MANAGEMENT

• APPROACH• Primary level-prevention

-target high risk group(duration ,blood sugar level,asso with hypertention ,renal disease,pregnancy)

-educating• Secondary level-early diagnosis and treatment

-regular follow up-laser treatment-controlling risk factor

• Tertiary level-vitreous surgery

-visual rehabilitation

-social and vocational rehabilitation

LEVELS OF RETINOPATHY

• Non-proliferative diabetic retinopathy (NPDR)• Mild non-proliferative diabetic retinopathy• Microaneurysms• Dot and blot haemorrhages • Hard ( intra-retinal ) exudates

• Moderate-to-severe non-proliferative diabetic retinopathy• The above lesions, usually with exacerbation, plus: • Cotton-wool spots • Venous beading and loops • Intraretinal microvascular abnormalities ( IRMA )

• Proliferative diabetic retinopathy

• Neovascularization of the retina, optic disc or iris

• Fibrous tissue adherent to vitreous face of retina

• Retinal detachment

• Vitreous haemorrhage

• Pre retinal haemorrhage

• Maculopathy

• Clinically significant macular oedema (CSME )

• Ischaemic Maculopathy

LASER TREATMENT

FOCAL PHOTOCOAGULATION

• INDICATIONS

Eyes with CSME with center involved

Eyes with CSME without center also

Eyes with macular edema-watched

• TECHNIQUE

FA prior-identify treatable lesions

Microaneurysms,IRMA,leaking

• FOCAL

Micro aneurysms ,Hard Exudate

Spot size-100 to 200 m

duration-0.1 sec

End point-whitening or darkening of lesion

• GRID

Thickened retina showing leakage

Spot size-100 m

Duration-0.1 sec

PANRETINAL PHOTOCOAGULATION

• INDICATIONSVery severe NPDR or PDR without

HRC PDR having HRC Iris or angle neo vascularisationEyes with severe ischemia-risk of neo v

• Proliferative diabetic retinopathy (PDR)

create 1,000 – 2,000 burns

Reduce retina's oxygen demand-ischemia

• Advanced diabetic retinopathy

Destroy the abnormal blood vessels that form in the retina.

Will Vision Improve After Laser Treatment?

• Laser therapy can ONLY STOP the PROGRESSION of the retinopathy. It CANNOT REVERSE the damage already done.

COMPLICATIONS OF LASER TREATMENT

Optic disk damage

• Foveal burn• Macular edema• Choroidal –Hemorrhage

Neo vascularisationDetachment

• Retinal detachment• Pain • Loss of visual field• Increase in traction detachment• IOP

Intravitreal Triamcinoloneacetonide

• Injected in the vitreous cavity

Decreases the macular edema (thickening of the retina at the macula)

• The effect –transient

lasting up to three months

Repeated injections for maintaining the beneficial effect.

• Complications - cataract, steroid-induced glaucoma and Endophthalmitis

Whats New in Non-Laser Treatment?

• Anti- vascular endothelial growth factor(VEGF)

Block the signal causing growth of

abnormal retinal blood vessels

• common anti-VEGFs

pegaptanib , ranibizumab , bevacizumab

Intravitreal injection ofranibizumab

VITRECTOMY

• INDICATIONS

Vitreous hemorrhage

Tractional retinal detachment

Severe progressive fibro vascular

proliferation

Ant seg neo vascularisation with post seg

opacity

Macular edema with premaculartraction

PDR After Vitrectomy surgeryPDR before vitrectomy

CONCLUSION

• “PROMPT factors

Patient education

Research application

Ophthalmological evaluation

Mass media utilization

Physician and primary health care personel

orientation

TIMELY laser treatment

THANK

YOU

How does diabetic retinopathy cause vision loss?

Blood vessels damaged from diabetic retinopathy can cause vision loss in

two ways:

• Fragile, abnormal blood vessels

• and leak blood

• blurring vision

• Fluid can leak into the center of the macula

• fluid makes the macula swell, blurring vision

Who is at risk for diabetic retinopathy?

MEDICAL- General aspects of the ocular care of diabetics

• All people with diabetes mellitus are at risk –those with Type I diabetes

• Duration and severity of diabetis

• glycaemic control

• Ass with

blood pressure

hyperlipidemia

cardiac problem

Diabetic nephropathy

• Smokers

MEDICAL TREATMENT

• Antiplatelet therapy

• Vit E

• Lipid reduction-Diet-rich in polysaturatedfats(30%)

20% protiens

50% carbohydrates

Hypolipidemic agent

clofibrate

lovastatin

pravastatin

ELECTRORETINOGRAM

• Abnormalities at very early stage -no visible changes in fundus

• Increase in OP time

• Reduction of scotopic b-wave amplitude

• Useful in media opacities-macular function

• Genestein, a soy isoflavone

blocks VEGF receptors

ameliorate retinal vascular permeability in diabetic animals

available as Ocuvite DF.

• vitamin B1

PROLIFERATIVE DIABETIC RETINOPATHY