WELCOME TO ALL

Presented by:

Dr.Muhammad Saiful IslamResident,Phase AMD Neurology(NINSH)

Diabetic Retinopathy

26/9/2016

Diabetic retinopathy

The most severe ocular complications of diabetes.

Caused by damage to blood vessels of the retina, leads to retinal damage.

Microvascular complication of longstanding diabetes mellitus.

Most prevalence cause of blindness between the ages of 30 and 65 years.

Common in DM type 1 > type 2

Duration of diabetes

Long duration ass with increased risk of DR

Pt diagnosed before age 30 yr

50% DR after 10 yrs

90% DR after 30 yrs

Poor metabolic control

HbA1c ass. with risk

Pregnancy

Ass with rapid progression of DR

Risk factors

Hypertension Very common in patients with DM type 2

Should strictly control (<140/80 mmHg)

Nephropathy Ass with worsening of DR

Renal transplantation may be ass with improvement of DR and better response to photocoagulation

Other Obesity, increased BMI, high waist-to-hip ratio

Hyperlipidemia

Anaemia

Smoking

Risk factors

I. Microvascular occlusionII. Microvascular leakage

Pathogenesis

Microvascular Leakage

Degeneration and loss of pericytes

Plasma leakage

Intraretinal hemorrhageHard exudate

Capillary wall weakening

microaneurysm

Retinal edema

Microvascular Occlusion

Neovascularizationand fibrovascular proliferation

VEGF

Increased plasma viscosityDeformation of RBC

Increased platelets stickiness

Decreased capillary blood flowand perfusion

Endothelial cell damage and proliferation

Capillary basement membrane thickening

Retinal hypoxia

A-V shuntIRMA*

*intraretinal microvascular abnormalities

Proliferative retinopathy

Rubeosisiridis

Tractional retinal detachmentVitreous hemorrhage

Classification

Non-proliferative diabetic retinopathy (NPDR)

Proliferative diabetic retinopathy (PDR)

Maculopathy

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,looping,dilation,tortousity

Intra-retinal microvascular abnormalities (IRMA)

Sign NPDR

Mild NPDR

Microaneurysm sometime dots and blots haemmorhage and hard exudate

Moderate NPDR

More microaneurysm

Scattered hard exudates

Cotton-wool exudates

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 outpouching of capillary wall small red dots often in punctate pattern due to focal dilatation of capillary wall where pericytes are absent.

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 shape

Dot hemorrhages - bright red dots (same size as large microaneurysms)

Blot hemorrhages - larger lesions

Flame-shape or splinter hemorrhages More superficial - in nerve fibre layer

Indistinguishable from hemorrhage in hypertensive retinopathy

Retinal Hemorrhage

Dot & Blot vs Splinter haemorrhage

Hemorrhage

Yellowish patches of lipid and protein within the retina.

Accumulations of lipid leaks from surrounding capillaries and microaneurysms or exudates.

May form a circinate pattern.

Hard exudate

Hard exudate

White spots or patches composed of axoplasm and organelles of nerve fibre.

Also called "soft exudates"

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

More common in pt with hepertensive retinopathy

Cotton Wool Spot

Hard Exudate VS Cotton Wool Spot

Dilatation ,beading,looping of retinal vein.

Appearance resembling sausage-shaped dilatation of the retinal veins.

Sign of severe NPDR.

Venous beading

Intraretinal neovascularization arising from either major arteries or veins .

Indicate severe NPDR rapidly progress to PDR.

Intra-retinal MicrovascularAbnormalities (IRMA)

IRMA

Macular ischemia or exudates

Macular haemorrhage

Macular edema

Increased retinal vascular permeability

Seen in both NPDR and PDR

Focal or diffuse or mixed

Cause of visual loss in DR

Ass with planning for treatment

Diabetic Maculopathy

Means lesions in and around the macula

Microaneurysm

Microaneurysm and blot dot hemorrhage

Blot Dot hemorrhage

IRMAs

Hard Exudate

Cotton Wool spots

Venous Beading

5% of DM pnt develop PDR

Finding:

Neovascularization : NVD, NVE

Vitreous haemorrhage

Tractional haemorrhage

Proliferative diabetic retinopathy

Neovascularization of disc

Fluorescein dye leakage is seen in neuvascularized area

Neovascularization of elsewhere

NVD

Vitreous changes

Tractional retinal detachmentVitreous hemorrhage

NVE

Venous beading

IRMA

New vessels elsewhere

New vessels elsewhere

New vessels of the disc

New vessels of the disc (advanced)

Subhyaloid haemorrhage

Subhyaloid hemorrhage

Blurred or distorted vision or difficulty in reading

Partial or total loss of vision

Eye pain

Signs & symptoms of DR

I. Medical treatment

II. Surgical Intervention:

1. Panretinal photocoagulation(PRP)

2.Vitreoretinal Haemorrhage

Treatment

Prevention by

Control blood sugar – HbA1c < 7

Control blood pressure – SBP < 130 mmHg

Control lipid profile –TG, LDL

Correct anemia

Control diabetic nephropathy

Stop smoking

Aldose reductase inhibitor can be use

Medical therapy

Panretinal photocoagulation (PRP):

High-risk PDR

Vitreous or preretinal hemorrhage

Iris or angle neovascularization

Reduce the rate of progression to blindness by about 50%

Laser

I. Focal or Grid :

NPDR and PDR

II. Panretinalphotocoagulation(PRP):PDR

Photocoagulation

Grid photocoagulation

Panretinal photocoagulation (PRP)

Pars plana vitrectomy (PPV)

Membrane peeling (MP)

Endolaser (EL)

Fluid gas exchange (FGX)

Vitreoretinal Surgery

Juvenile onset DM - 5 years after diagnosis or earlier then annually.

Adult onset DM -at diagnosis then annually.

DM with pregnancy in first trimester then every trimester.

Screening for DR

Serious vision-threatening complications of DR

Vitreous hemorrhage

Tractional retinal detachment

Opaque membrane formation

Neovascular glaucoma

Treatment : Vitrectomy

Advanced diabetic eye disease

Definition:

Hypertensive retinopathy is retinal vascular damage caused by hypertension.

Introduction:

Bilateral

Symmetrical

Small blood vessel disease

Caused by systemic hypertension

Acute or chronic

Systolic or diastolic

End organ disease manifestation

Prevalence:

The second most common retinal vascular disease

Malignant hypertension (240/140mmhg) 0.5-0.75%

Hypertensive retinopathy 4-10%

Risk factor:

Afro-Caribbeans = relative risk factor 2x

Age

Family history

Obesity

Smoking

Alcohol consumption

Stress

Lack of exercise

Pathophysiology:

Systermicchronic

hypertension

Arteriosclerosis and

atherosclerosis

Narrowing of retinal

arterioles

Retinal Ischaemia

HypoxiaIncreased capillary

permeability

Retinal Oedema, retinal haemorrhage,cotton wool spots,

hard exudates

Clinical Manifestation: Most patients are asymptomatic.

Some present with headaches and blurred vision.

On ophthalmoscopy :

Generalized arteriolar narrowing

Changes of the arterovenous crossings

Flame haemorrhage

Microaneurysms

Cotton-wool exudate

Optic disc swelling

Generalised narrowing of the retinal arterioles:

Focal narrowing of the retinal arterioles –Copper and Silver Wiring

Grade 4 Retinopathy:

ClassificationKeith-Wagener-Barker classification

Grade Description

Grade 1 Mild generalised narrowing, sclerosis, and tourtuosity of the retinal arterioles(Silver wiring) mild asymptomatic hypertension.

Grade 2G 1+Definite focal narrowing ,constriction, sclerosis at the site of AV

crossing (AV nipping); blood pressure is higher and sustained.

Grade 3 G 2+Retinopathy (cotton-wool spots, flame shape haemorrhages); blood

pressure is higher and more sustained; headaches, vertigo, and nervousness; mild impairment of cardiac, cerebral, and renal function

Grade 4 G 3+Neuroretinal oedema, including pappilloedema, blood pressure

persistently elevated; severe impairment of cardiac, cerebral, and renal function

Diagnosis: Diagnosis is made by thorough history of the

patient, ophthalmoscopy (direct or indirect) and also physical examination.

History May reveal decrease of patient vision, occipital

headache and high blood pressure.

Physical examination

May detect elevation of blood pressure

Ophthalmoscopy

Management: A major aim of treatment is to prevent, limit, or

reverse such target organ damage by lowering the patient's high blood pressure.

Lifestyle changes Promote Healthy lifestyle; exercise, healthy foods

Advice patient to reduce the Blood Pressure

Taking the medication accordingly

Referral to medical team

Differentiation of retinopathy:Hypertensive Retinopathy Diabetic Retinopathy

Dry retina

Rare oedema

Few haemorrhages

Multiple cotton wool spots

Flame-shaped haemorrhages

AV nipping present

Copper and silver wiring

Venous beading absent

IRMA usually absent

Macular star present

Wet retina

Extensive oedema

Multiple dot blot haemorrhages

Few cotton wool spots

Rare flame-shaped haemorrhages

AV nipping absent

Wiring absent

Venous beading present

IRMA may present

Macular star absent

Thank you