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Gos 31 Presentation 1by Dr. Anand Sudhalkar, Baroda
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Gos 31 Presentation 1by Dr. Anand Sudhalkar, Baroda

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  • Good morning everybody. With my respects for the eminent dignitaries with whom I have the opportunity to share this dias, I thank Dr. Nitinbhai for the trust he put in me for the subject and the role of a moderator. I would like to perform both the duties simultaneously to save more time for the panel discussion and hence I would like to request our convener Dr. Mrs. Ushaben to be little considerate about my timings.
  • long standing hyperglycemia leads to many situations, out of which these three are important in order of their frequency. They have a close association and detection of one should compel the concerned specialist to look for others. Ophthalmoscopic examination is the only "visible" and documentable indicator and hence the role of ophthalmologist is very valuable.
  • The classification, we all know, and so important for post graduates, needs fast brushing up before we go to the practical aspects. The retinopathy does go through all the stages and some signs need need special attention from prognostic and treatment point of view. It is imperative to look for signs of vision threatening macular edema at any stage of the disease and not wait for loss of visual acuity. This is where an ophthalmologist with good ophthalmoscopy experience can help tremendously in preventing diabetic blindness.
  • NOT SEEN EVEN WITH 90D FFA REVEALS THEM
  • INCREASE IN SNUMBER OF SOFT AND HARD EXUDATES WITH RETINAL THICKENING IN MACULAR REGION
  • NUMBER OF SOFT EXUDATES IS A DIRECT POINTER TO THE DEGREE OF ISCHEMIA AND IT'S OCCURANCE SHOULD LEAD ONE TO LOOK FOR FURTHER EVIDENCES LIKE, VENOUS BEADS, BLOT HEMORRHAGES, IRMA, and evidence of advancing retinopathy.
  • Intraretinal microvascular abnormalities, capillary non perfusions are best diagnosed by FFA . VENOUS DILATATIONS, TORTUOSITY, BEADING, LOUPING ARE SIGNS OF INCREASING DEGREE OF STASIS AND INDICATORS OF ISCHEMIA.
  • NVE, IN EARLY STAGES CAN BE CONFUSED WITH IRMA BUT FFA CAN CLEAR THE DOUBTS FAST. VENOUS STASIS INDICATED BY SACULAR DILATATIONAS AND BEADING SHOULD WARN THE OBSERVER AND JUSTIFY EARLY INITIATION OF PRP IN CERTAIN CASES.
  • NVD AND SUBHYALOID/VITREOUS HEMORHHAGE ARE THE AGE OLD FEATURES OF 'HIGH RISK' GROUP NEEDING PROMPT PRP.
  • SOMETIMES VISION LOSS IS NOT ENTIRELY DUE TO MACULAR EDEMA AND WE NEED TO ADD DIFFERENTIAL DIAGNOSIS, NOT TREATABLE BY FOCAL LASER. THEY ARE, MACULAR EDEMA, ISCHEMIA, ARMD, ERM ETC.
  • Transcript

    • 1. Diabetic Retinopathy Presentation and Classification Dr Anand Sudhalkar
    • 2. PROLONGED Hyperglycemia complications :
      • END STAGE RENAL DISEASE
      • RETINOPATHY
      • NON-TRAUMATIC LOWER LIMB AMPUTATIONS
    • 3. END STAGE RENAL DISEASE AND RETINOPATHY: DENMARK STUDY
      • TI: Incidence of retinopathy in type I (insulin-dependent) diabetes: association with clinical nephropathy.
      • AU: Kofoed-Enevoldsen-A; Jensen-T; Borch-Johnsen-K; Deckert-T
      • SO: J-Diabet-Complications. 1987 Jul-Sep; 1(3): 96-9
      • 110 IDDM 5 YEARS FOLLOWUP
      • PDR IN 74% WITH PROTEINUREA, AGAINST 14% IN WITHOUT.
      • BDR IN 93% WITH AND 37% WITHOUT PROTEINUREA.
    • 4. PREVALENCE OF RETINOPATHY
      • 10% AMONGST ALL DM
      • 40% Of these have CSME
      • Out of all BDR 3% have CSME
      • Out of all PPDR 38% have CSME
      • out of all PDR 71% have CSME
      • 5% of maturity-onset, IDDM at diag.
      • Prevalence  Duration of Hyperglycemia
      • After 20 yr. 99% of IDDM and 60% of NIDDM have retinopathy
    • 5. CHI-SQURE : 57.26132 DF : 4 SIGNIFICANCE : .00000 REVIEW OF 250 DIABETIC PATIENTS
    • 6.  
    • 7.  
    • 8. (11) (19) (25) (68) (81) (46)
    • 9. RETINOPATHY (Theoretical) CLASSIFICATION:
      • BDR : Mild, Mod., Sev.
      • PPDR (Florid)
      • PDR
      • GLIOSIS AND TRD
      • END STAGE : NVI, NVG
      Clinically significant Macular oedema can exist at any stage
    • 10. BDR : MILD
      • MICROANEURYSMS
      • DOT HAEMORRHAGES
      • HARD EXUDATES
      • SOFT EXUDATES
      OCCASIONAL
    • 11. MICROANEURYSMS
    • 12. BDR : MODERATE HARD EXUDATES SOFT EXUDATES RETINAL THICKENING
    • 13. SEVERE BDR & PPDR:
      • Blot Haem 4 Quadr.
      • Venous Beading 2 Quadrants,
      • IRMA 1 quadrant. ( 45% go to PDR in one yr.)
    • 14. PDR VENOUS DILATATIONS AND BEADING, LARGE AREAS OF IRMA, NON-PERFUSION, NVE
    • 15. PDR VENOUS DILATATIONS AND BEADING, LARGE AREAS OF IRMA, NON-PERFUSION, NVE
    • 16. PDR : NVD SUBHYALOID AND VITREOUS HEMORRHAGES High Risk : NVD > 2/3 rd, NVE 2 places, V.H
    • 17. STAGE OF FIBROUS PROLIFERATION
      • GLIOSIS
      • TRD
    • 18. STAGE OF RUBIOSIS IRIDIS
      • NVI
      • NVG
    • 19. TREATMENT ORIENTED OUTLOOK
      • WHEN & HOW SHOULD WE TREAT ?
      • IDENTIFY :
      • 1 CSME & differentiate from
      • MACULAR ISCHEMIA AND
      • HAEMORRHAGE
      • 2 PRE-PROLIFERATIVE STAGE
      • HIGHRISK FACTORS
    • 20. CSME
    • 21. International Clinical Classification of Diabetic Retinopathy, Severity of Diabetic Macular Edema, Detailed Table
      • Mild Diabetic Macular Edema : Some retinal thickening or
      • hard exudates in posterior pole but
      • distant from the macula
      • Moderate Diabetic Macular Edema : Retinal thickening or
      • hard exudates approaching the
      • center of the macula but not
      • involving the center
      • Severe Diabetic Macular Edema : Retinal thickening or
      • hard exudates involving the center o
      • the macula
    • 22. CSME : FOCAL
    • 23. CSME DIFFUSE
    • 24. Differenciate from : MACULAR ISCHEMIA,
    • 25. Differenciate from : MACULAR HEMORRHAGE
    • 26. CLASSSIFY ACCORDING TO TREATMENT PROTOCOLS :
      • BDR + CSME ( Focal laser )
      • PDR + CSME ( FOCAL + PRP)
      • PDR+V.H. NONABSORBING
      • ( PPVIT)
      • PDR+MACULAR TRACTION
      • ( PPVIT)
      • TRD ( PPVIT + ENDOLASER)
    • 27. FACTORS MODIFYING CLINICAL PRESENTATION
      • RVO
      • CAROTID ARTERY DISEASE
      • HYPERTENSION
    • 28. CHI-SQURE :32.97361 DF : 10 SIGNIFICANCE : .00028 (11) (19) (25) (68) (81) (46) COMPARISION OF 250 WITH I & N DIABETIC PATIENTS
    • 29. Today’s Situation
      • Summary of the current situation
      • Use brief bullets, discuss details verbally
      • Original assumptions that are no longer valid
    • 30. Available Options
      • State the alternative strategies
      • List advantages & disadvantages of each
      • State cost of each option
    • 31. Recommendation
      • Recommend one or more of the strategies
      • Summarize the results if things go as proposed
      • What to do next
      • Identify action items

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