1. Topic assignment : medical ophthalmology
Diabetic retinopathy
Dr.Vijay

2. Contents 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

3. Diabetes mellitus 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.

4. 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

5. 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

6. Risk factors Duration of diabetes Poor metabolic control Pregnancy
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

7. Pathogenesis
Microvascular occlusion
Microvascular leakage

8. Microvascular leakage
Degeneration and loss of pericytes
Capillary wall weakening
Plasma leakage
microaneurysm
Retinal edema
Hard exudate
(Circinate pattern)
Intraretinal hemorrhage

9. Non-proliferative diabetic retinopathy
Right eye: Micro aneurysm, few flame-shaped and dot-blot hemorrhages and hard exudate [with hard exudate in macula area] , ไม่พบ neovascularization เข้าได้กับ 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] ไม่พบ neovascularization เข้าได้กับ severe non proliferative diabetic retinopathy

10. Microvascular occlusion
Endothelial cell damage and proliferation
Capillary basement membrane thickening
Decreased capillary blood flow
and perfusion
Increased plasma viscosity
Deformation of RBC
Increased platelets stickiness
Retinal hypoxia
VEGF
A-V shunt
IRMA*
Neovascularization
and fibrovascular proliferation
Rubeosis iridis
Proliferative retinopathy
*intraretinal microvascular abnormalities

11. Vitreous hemorrhage
Tractional retinal detachment

12. Classification Non-proliferative diabetic retinopathy (NPDR)
Proliferative diabetic retinopathy (PDR)

13. Non-proliferative diabetic retinopathy
Mild NPDR
Moderate NPDR
Severe NPDR

14. Sign NPDR Microaneurysm Retinal hemorrhage Hard exudate
“Dot or Blot” Spot
“Flame or Splinter shape” hemorrhage
Hard exudate
Cotton wool Spot
Venous beading
Intra-retinal microvascular abnormalities (IRMA)

15. Mild NPDR
Microaneurysm

16. Moderate NPDR More microaneurysms Scattered hard exudates
Cotton-wool spots

17. Severe NPDR Very severe NPDR  more than 1 of above 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

18. Microaneurysm
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

19. Microaneurysm

20. Retinal Hemorrhage
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

21. Hemorrhage

22. Hard exudate 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

24. Cotton Wool Spot 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

26. Venous beading Dilatation and beading of retinal vein
Appearance resembling sausage-shaped dilatation of the retinal veins
Sign of severe NPDR

28. Intra-retinal microvascular abnormalities (IRMA)
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

31. Venous beading

32. Proliferative diabetic retinopathy
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, 32

33. 33

34. Neovascularization of disc34

35. Neovascularization of elsewhere
Fluorescein dye leakage is seen in neovascularized area

38. (neovascularisation of the iris)
Rubeosis iridis
(neovascularisation of the iris)
Neovascular glaucoma

39. 39

40. Vitreous changes 40

41. Tractional retinal detachment
Vitreous hemorrhage

42. NVE
Venous beading
IRMA

43. New vessels of the disc (advanced)

44. Signs & symptoms of DR
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 44

45. 45

46. 46

47. 47

48. Hypertensive retinopathy

49. Medical therapy 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

50. Laser 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

51. Photocoagulation Focal or Grid Panretinal (PRP)
CSME in both NPDR and PDR
Panretinal (PRP)
PDR

52. Thank you