1. Diabetic Retinopathy (DR) Ayesha S Abdullah 03.01.2014

2. Learning outcomes By the end of the lecture the students would be able to; 1.Describe the epidemiology of DR 2.Correlate the pathogenesis of DR with the clinical presentation 3.Identify signs of DR in a given fundus photograph 4.Identify the signs of proliferative DR and high risk Non-proliferative DR on a given fundus photograph 5.Outline the management for DR

3. Diabetes Mellitus (DM)  Metabolic syndrome characterized by hyperglycaemia & insulin deficiency  Type 1, type 2 & Gestational Diabetes Mellitus  Type 2 is more common than type 1  A micro & macrovasculopathy

4. Epidemiology of DM and DR 1.We are having a “global epidemic of DM”. 2.The prevalence of DM is estimated to rise from 2.8% (2000) to 4.4% (2030) 3.Most of this increase will occur as a result of a 150% rise in developing countries. 4.The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. 5.The prevalence is estimated to be 10% in Pakistan 6.With over 5.2 million people with DM, it is the 6 th country with the largest population of people with DM. 7.With growing obesity, sedentary life style and increased aging population, the prevalence is estimated to rise further. Wild S, Roglic G, Green A, Sicree R, King H. Global Prevalence of Diabetes- Estimates for the year 2000 and projections for 2030. Diabetes Care 27:1047–1053, 2004

5. Diabetic retinopathy  Is a microvascular complication of DM  The prevalence is highest among type 1 DM (40%)  Patients with DR are 25% more likely to go blind than non-diabetics  In UK 1000 individuals are registered blind each year due to diabetic eye disease  It is the leading cause of blindness in 20-64 year age group in USA

6. Pathogenesis of Diabetic Retinopathy DR is a microangiopathy resulting in Microvascular occlusion Microvascular leakage

7. Microvascular Occlusion Factors responsible for occlusion 1. Thickening of capillary basement membrane 2. Capillary endothelial cell damage and proliferation 3. Changes in R.B.Cs 4. Increased stickiness and aggregation of platelets

11. Neovascularization Microvascular occlusion Retinal capillary non-perfusion Retinal ischaemia & Hypoxia, ischaemia of the nerve fibres- soft exudates Arteriovenous shunts - IRMA(intra-retinal microvascualr abnormalities), venous changes, stagnation of blood and more hypoxia Pathogenesis of Diabetic Retinopathy

12. Microvascular Leakage Breakdown of inner blood-retinal barrier  Retinal haemorrhages  Retinal oedema Diffuse edema Hard exudates  Microaneurysims What is inner and outer blood-retinal barrier?

15. Classification of diabetic retinopathy  Non-proliferative (NPDR)  Proliferative (PDR)  Diabetic Maculopathy

16. Signs of DR 1. Microaneurysms (MA) 2. Hard exudates (HE) 3. Haemorrrhages (H) 4. Retinal oedema- macular oedema(CSME) 5. Cotton wool spots (CWS) 6. Intra-retinal microvasuclar abnormalities(IRMA) 7. Venous changes 8. Fibrovascualr proliferation – Neovascularization

17. Microaneurysms & hard exudates

22. Haemorrhages and cotton wool spots

28. Neovasucalrization and fibrovasucalr proliferation

34. Diabetic macular oedema

36. Clinical Presentation o Blurred vision o Reduced vision o Seeing floaters o Reduced night vision o Sudden vision loss

39. Stages of DR NPDRPDR

40. DR StageSIGNS NPDRMildMicroaneurysms Haemorrhages, ModerateHaemorrhages, Microaneurysms, Soft Exudates, IRMA Severe+ Venous Changes PDRNVE & NVD, Vitreous Haemorrhage, Tractional RD Stages of DR

48. Management of DR Indications  PDR  Clinically significant macular oedema Principles & modes  Metabolic control  Control of risk factors  Laser therapy- photocoagulation  Anti-VEGF agents  Vitreoretinal surgery

52. Recommended follow-up schedule Normal or occasional MAAnnually Mild NPDREvery 09 months Moderate NPDREvery 06 months Severe NPDREvery 04 months PDREvery 2-3 months CSMEEvery 2-4 months

53. Summary Home work List the risk factors for DR How does diabetic retinopathy cause vision loss? msqheartline@hotmail.com Last date for submission 9 th Jan 2014