Diabetic retinopathy
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Diabetic retinopathy

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Diabetic retinopathy Presentation Transcript

  • 1. DIABETIC RETINOPATHY Dr Samuel Ponraj
  • 2. RISK FACTORS • Duration of Diabetes • Poor control of Diabetes • Pregnancy • Systemic diseases – Hypertension,Nephropathy,Hyperlipidemia, Anemia, Obesity • Family History
  • 3. Pathogenesis • Capillaropathy • Aldose Reductase • Vasoproliferative factors
  • 4. • Capillaropathy: Loss of Pericytes Thickening of Capillary basement membrane Endothelial cell damage Haematological changes – abnormalities of [erythrocytes and leucocytes] , increased platelet stickiness, and increased plasma viscosity Capillary leakage,occlusion,microaneurysm
  • 5. • Aldose reductase: GLUCOSE SORBITOL -Can not diffuse out easily -Intracellular Concentration rises Osmotic diffusion of water - Electrolyte imbalance
  • 6. • Vasoproliferative factors: Capillary Non - Perfusion Retinal Hypoxia VEGF induced Neovascularisation
  • 7. Classification Proposed disease severity level Findings on Ophthalmoscopy No apparent retinopathy No abnormalities Very Mild NPDR Few Microaneurysms only Mild NPDR Few microaneurysms ,Retinal haemorrhage, hard exudates in 1 or 2 quadrants Moderate NPDR Above findings seen in 2 or 3 quadrants Severe NPDR Above findings in all quadrants & atleast of the following plus signs • Cotton wool spots • > 20 intraretinal hemorrhages in each of 4 quadrants •Venous beeding in 2 or more quadrants •IRMA in 1 or more quadrants PDR One or more of following: Extraretinal neovascularisation Vitreous /preretinal hemorrhages
  • 8. Clinically significant macular oedema • Retinal thickening within 500 µm of the centre of the macula • Exudates within 500 µm of the centre of the macula, if associated with retinal thickening (which may be outside the 500 µm . • Retinal thickening one disc area (1500 µm) or larger, any part of which is within one disc diameter of the centre of the macula.
  • 9. Diabetic macular edema Due to increased retinal capillary permeability/leakage & localised edema - Most common cause of visual impairment in DM 1.Focal DME: - Well circumscribed retinal thickening - Hard exudates [circinate pattern] F/A : HF - leakage , good macular perfusion
  • 10. • Diffuse DME: - Diffuse thickening ,edema Cystoid spaces F/A : HF Diffuse leakage – Flower petal look • Ischaemic DME: - Due to microvascular blockage F/A: HF Capillary non perfusion @ FAZ.
  • 11. HIGH RISK CHARACTERISTICS • NVD - 1/4 TO 1/3 DISC area with or without VH or PRH • NVD – ¼ DISC area with VH or PRH • NVE - > ½ DISC area with VH or PRH
  • 12. Signs: • Microaneurysms - localized out-pouchings - focal dilatation of the capillary wall - fusion of two arms of capillary loop inner capillary plexus (inner nuclear layer) F/A : Tiny HF dots due to leakage • Retinal Haemorrhages : - Superficial NFL Haemorrhages – flame shaped [Precapillary arteriole] -Intraretinal [nuclear]Haemorrhages - Dot & blot Haemorrhages [Venous end of capillaries]
  • 13. • Hard Exudates: -composed of lipoprotein and lipid-filled macrophages located mainly within the outer plexiform layer [chronic localized retinal oedema] -Waxy yellow lesions – ring/clumps. F/A: HF - blockage of background choroidal and retinal capillary fluorescence.
  • 14. • Cotton wool Spots /Soft exudates/ NFL infarcts - Local ischaemia ,axoplasmic flow block swollen ends -cytoid bodies ,neuronal debris. - Small, whitish, fluffy superficial lesions - focal HF due to blockage of background choroidal fluorescence
  • 15. • Venous anomalies : -seen in ischaemia ,Sluggish retinal circulation - generalized dilatation and tortuosity, - ‘looping’ ‘beading’ ‘sausage-like’ segmentation • IRMA: - Arteriolar-venular shunts - bypassing the capillary bed [Collaterals] - Fine, irregular, red intraretinal lines F/A : HF ,no leakage.
  • 16. Investigations • Complete blood picture • Routine & microscopic urine analysis • Blood sugar fasting & post prandial • Glycosylated hemoglobin [HbA1C] • Lipid ,thyroid & renal profile • Fundus Fluorescein Angiography • OCT
  • 17. OCT • Dense material within neurosensory retina [Hard exudates]
  • 18. NORMAL DME
  • 19. Medical Therapy : Antiplatelet therapy : Ticlopidine ,Aspirin reduces stroke ,CVS morbidity by inhibiting Platelet aggregation. Anti hypertensive agents : ACE inhibitors/B- blockers – tight blood pressure control ,
  • 20. • Antiangiogenesis: Intravitreal Anti – VEGF to suppress retinal neovascularization. • Blood sugar control.
  • 21. Pan retinal Photocoagulation • Aim: To destroy ischaemic areas ,decrease production of vasoproliferative factors , stimulates release of antiangiogenic factors from RPE. • Regression of Neovascularization. • Use of Argon laser. • 1200 -2000 burns , 500 um spot size, 0.1 sec • Scatter pattern over periphery retina.
  • 22. Peripheral retinal Cryotherapy • Done for anterior retina – inadequate visualization of fundus due to opaque media.
  • 23. • Focal laser therapy: - 500–3000 µm from the centre of the macula. - Spot size -50-100 um, 0.1 sec • Grid therapy: - more than 500 µm from the centre of the macula and 500 µm from the temporal margin of the optic disc. -Spot size -100 um ,0.1 sec
  • 24. Pars plana vitrectomy • Indications: - Non clearing Vitreous haemorrhage - Macular threatening traction retinal detachment - Macular edema with thickened taut posterior hyaloid - Severe preretinal macular haemorrhage
  • 25. THANK U