Diabetic retinopathy 30-3-2011

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  • 1. Topic assignment : medical ophthalmology Diabetic retinopathyD 1.1 30/3/2011
  • 2. ContentsDiabetesDefinitionRisk factorsPathogenesisClassification : proliferative / non-proliferativeSign & symptomsDDx & other ocular complication of DMTreatment & follow upScreening for DRApply with case study
  • 3. Diabetes mellitusGroup of common metabolic disordersCaused by a complex interaction of genetics and environmental factorsLack of insulin  hyperglycemiaDiagnostic criteria : Fasting plasma glucose > 126 mg/dlType 1 DM – Insulin-dependent diabetes (IDDM) Results from pancreatic beta-cell destruction, usually leading to absolute or near total insulin deficiencyType 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 mellitusLong-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 Foot problems
  • 5. Diabetic retinopathyThe most severe of ocular complications of diabetesCaused by damage to blood vessels of the retina, leads toretinal damageMicrovascular complication of longstanding diabetes mellitus [1]Most prevalence cause of legal blindness between the ages of20 and 65 yearsCommon in DM type 1 > type 2
  • 6. Risk factorsDuration of diabetes Most important Pt diagnosed before age 30 yr 50% DR after 10 yrs 90% DR after 30 yrsPoor metabolic control Less important, but relevant to development and progression of DR  HbA1c ass. with  riskPregnancy 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. Risk factorsHypertension 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 photocoagulationOther Obesity, increased BMI, high waist-to-hip ratio Hyperlipidemia Anemia
  • 8. PathogenesisMicrovascular occlusionMicrovascular leakage
  • 9. Microvascular leakageDegeneration and loss of pericytes Capillary wall weakening Plasma leakage microaneurysm Retinal edema Hard exudate Intraretinal hemorrhage (Circinate pattern)
  • 10. Non-proliferative diabetic retinopathyRight eye: Micro aneurysm, few flame-shaped and dot-blot hemorrhages and hardexudate [with hard exudate in macula area] , neovascularizationmoderate non proliferative diabetic retinopathyLeft eye: Micro aneurysm, numerous flame-shaped and dot-blot hemorrhage [more than20 dots in 4 quadrant], hard exudate [with hard exudate in macula area]neovascularization severe non proliferative diabetic retinopathy
  • 11. Microvascular occlusion Endothelial cell damage and proliferation Capillary basement membrane thickening Decreased capillary blood flow Increased plasma viscosity and perfusion Deformation of RBC Increased platelets stickiness Retinal hypoxia VEGF A-V shunt Neovascularization IRMA* and fibrovascular proliferation Rubeosis Proliferative iridis retinopathy*intraretinal microvascular abnormalities
  • 12. Vitreous hemorrhage Tractional retinal detachment
  • 13. ClassificationNon-proliferative diabetic retinopathy (NPDR)Proliferative diabetic retinopathy (PDR)
  • 14. Non-proliferative diabetic retinopathy Mild NPDR Moderate NPDR Severe NPDR
  • 15. Sign NPDRMicroaneurysmRetinal hemorrhage “Dot or Blot” Spot “Flame or Splinter shape” hemorrhageHard exudateCotton wool SpotVenous beadingIntra-retinal microvascular abnormalities (IRMA)
  • 16. Mild NPDRMicroaneurysm
  • 17. Moderate NPDRMore microaneurysmsScattered hard exudatesCotton-wool spots
  • 18. Severe NPDR4-2-1 rule4 quadrants of severe retinal hemorrhages2 quadrants of venous beading1 quadrant of IRMAVery severe NPDR  more than 1 of above
  • 19. MicroaneurysmLocalized saccular outpouchings of capillary wall  red dots Focal dilatation of capillary wall where pericytes are absent Fusion of 2 arms of capillary loopUsually seen in relation to areas of capillary non-perfusion at the posterior pole esp temporal to foveaThe earliest signs of DR
  • 20. Microaneurysm
  • 21. Scattered hyperfluorescentMicroaneurysms may leakplasma constituents intothe retina
  • 22. Retinal HemorrhageCapillary or microaneurysm is weakened  rupture intraretinal hemorrhagesDot & 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 lesionsFlame-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
  • 23. Dot & blot VS splinter hemorrhage
  • 24. Dot Spot VS Flame Shape
  • 25. Dot Spot VS Flame Shape
  • 26. Hemorrhage
  • 27. Hard exudateIntra-retinal lipid exudatesYellow deposits of lipid and protein within the retinaAccumulations of lipids leak from surrounding capillaries andmicroaneuryismsMay form a circinate patternHyperlipidemia may correlate with the development of hardexudates
  • 28. Cotton Wool SpotWhite fluffy lesions in nerve fiber layerResult from occlusion of retinal pre-capillary arteriolessupplying the nerve fibre layer with concomitant swelling oflocal nerve fibre axonsAlso called "soft exudates" or "nerve fiber layer infarctions"Fluorescein angiography shows no capillary perfusion in thearea of the soft exudateVery common in DR, esp if pt with HT
  • 29. Hard Exudate VS Cotton Wool Spot
  • 30. Venous beadingDilatation and beading of retinal veinAppearance resembling sausage-shaped dilatation ofthe retinal veinsSign of severe NPDR
  • 31. Intra-retinal microvascular abnormalities (IRMA)Abnormal dilated retinal capillaries or may representintraretinal neovacularization which has not breachedthe internal limiting membrane of the retinaIndicate severe NPDR  rapidly progress to PDR
  • 32. Area of capillary non-perfusionFA shows extensive areas of hypofluorescence due tocapillary non-perfusion and venous beading
  • 33. Diabetic maculopathyMacular ischemia Retinal capillary non-perfusion Progressive NPDRMacular 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
  • 34. Focal macular edemaDiffuse macular edema
  • 35. Macular ischemia
  • 36. Clinical Significant Macular Edema (CSME) 1 of 3 Retinal edema Hard exudates within Retinal edema > 1 discwithin 500 microns 500 microns of fovea diameter, any part is of centre fovea if ass with adjacent within 1 disc diameter retinal thickening of centre of fovea
  • 37. microaneurysm
  • 38. microaneurysm andblot dot hemorrhage
  • 39. blot dot hemorrhage
  • 40. IRMAs
  • 41. hard exudate
  • 42. Cotton wool spots
  • 43. Venous beading
  • 44. 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,
  • 45. Neovascularization of disc
  • 46. Neovascularization ofelsewhereFluorescein dye leakage isseen in neovascularizedarea
  • 47. Rubeosis iridis Neovascular glaucoma(neovascularisation of the iris)
  • 48. Vitreous changes
  • 49. Vitreous hemorrhage Tractional retinal detachment
  • 50. NVE Venous beading IRMA
  • 51. New vessels elsewhere
  • 52. New vessels elsewhere
  • 53. New vessels of the disc
  • 54. New vessels of the disc (advanced)
  • 55. Subhyaloid hemorrhage
  • 56. Subhyaloid hemorrhage
  • 57. 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
  • 58. Differential Diagnosis Diabetic retinopathy
  • 59. Mostly missHypertensive retinopathyRadiation retinopathyCentral retinal vein occlusion (CRVO)Branch retinal vein occlusion (BRVO)Ocular ischemic syndromeHIV-related retinopathy
  • 60. Hypertensive retinopathy
  • 61. Radiation retinopathy
  • 62. Central retinal vein occlusion (CRVO)
  • 63. Branch retinal vein occlusion (BRVO)
  • 64. For symptomsCataractGlaucomaHypertensive retinopathyRadiation retinopathyRetinal vitreous obstructionRetinitis pigmentosaSenile macular degeneration
  • 65. For cotton wool spotSimilar lesions are also caused by the alpha-toxin ofClostridium novyi
  • 66. For Cotton wool spot
  • 67. For Hard exudates
  • 68. For Hemorrhage
  • 69. TreatmentLaser Photocoagulation**Vitreoretinal surgery**Intravitreal triamcinolone acetonide
  • 70. Medical therapyPreventionTreat underlying conditions Control blood sugar – HbA1c < 7 Control blood pressure – SBP < 130 mmHg Control lipid profile – TG, LDL Correct anemia Control diabetic nephropathyPregnancy makes DR worsen
  • 71. LaserPanretinal 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
  • 72. PhotocoagulationFocal or Grid CSME in both NPDR and PDRPanretinal (PRP) PDR
  • 73. Laser panretinal photocoagulation (PRP)Inducing involution of new vesselsPreventing vitreous hemorrhage and preventing visual lossLimitations : Patient must have clear lens and vitreous If cataract  treat before laser PRP If vitreous hemorrhage  vitrectomy + laser photocoagulation
  • 74. Focal photocoagulation
  • 75. Grid photocoagulation
  • 76. Panretinal photocoagulation (PRP)
  • 77. SurgeryIndications for pars plana vitrectomy (PPV) in DR Severe persistent vitreous hemorrhage Progressive tractional RD (threatening or involving macula) Combined tractional and rhegmatogenous RD Premacular subhyaloid hemorrhage Recurrent vitreous hemorrhage after laser PRP
  • 78. Vitreoretinal SurgeryPars plana vitrectomy (PPV)Membrane peeling (MP)Endolaser (EL)Fluid gas exchange (FGX) SF6 C3F8
  • 79. Screening for DRJuvenile onset DM > 5 years then every yearAdult onset DM at diagnosis (> 30) then every yearDM with pregnancy in first trimester then every trimester
  • 80. Follow up Retinal abnormality Follow upNormal or rare microaneurysms Once a year Mild NPDR q 9 months Mod NPDR q 6 months Severe NPDR q 4 months or laser CSME q 2-4 months ** or laser PDR q 2-3 months ** or laser
  • 81. Advanced diabetic eye disease Serious vision-threatening complications of DR persistent vitreous hemorrhage tractional retinal detachment opaque membrane formation neovascular glaucoma Treatment : complicated vitrectomy Poor prognosis
  • 82. Case scenario
  • 83. CaseIdentification data :Chief complaint :
  • 84. Present illness-
  • 85. Past historyUnderlying diseases : DM poor controlled ,HT poor controlledCurrent medication metformin 500 mg 2*1 o pc Nifedipine 20 mg 1*2 o pc Amlopine 10 mg 1*1 o pc
  • 86. Physical examinationGA : a middle aged woman with normalconsciousness, good co-operationV/S : T 36.9 BP 157/83 mmHg P 94/minRR 16/minHENT : no discharge per ears, nose, nobleeding per gum, cervical LN cant’ bepalpableHeart : normal S1S2, no murmursLungs : clear & equal breath sounds bothlungs
  • 87. Ocular examination OD OSVA c C 6/9 -2 PjVA c PH 6/9 -Lids & Lashes & Normal NormalConjunctivaCornea Clear ClearIrisLens Clear ClearAnterior chamber Normal depth, clear Normal depth, clearPupil 3 mmRTLBE RAPD -EOM Full FullIOP 20 20
  • 88. Fundus examination OD OSRed reflex Normal NormalVessels Normal 2:3 Normal 2:3Background & Macula Dot & blot hemorrhage dot blot hemorrhage , NVE NVE , old hemorrhage Fibrous and retinal break involve maculaDisc No NVD , C:D 0.3 No NVD , C:D 0.3
  • 89. Problem lists
  • 90. Problem listUnilateral chronic painless visual lossFlashing and FloatersPoor controlled DM, poor controlled HTDot & blot hemorrhages with NVE BEFibrous & Retinal break involve macula LE
  • 91. Provisional diagnosisRight eye : PDRLeft eye : PDR with TRD+RRD
  • 92. Differential diagnosisHypertensive retinopathyCentral retinal vein occlusion (CRVO)Branch retinal vein occlusion (BRVO)Ocular ischemic syndrome
  • 93. Management in this case DRLE PPV Pars plana vitrectomy membrane peeling Indications for PPV in DR Severe persistent VH Endolaser Progressive tractional RD Combined TRD & RRD silicone oil injection Premacular subhyaloid hemorrhage Recurrent VH after laser PRP
  • 94. Closed observe (q 2-3 months)Laser PRPPPV + MP + EL + SOI
  • 95. 2
  • 96. Thank you