Retina 1 anatomy and diabetic retinopathy d r.k.n.jha-26.05.16

1. Retina 1
Diabetic Retinopathy
Prof K N Jha, MS
Email: kirtinath.jha@gmail.com

2. Learning Aim
• Retina: Retinal topography, and Histology
• Clinical features of diabetic retinopathy
• Diabetic retinopathy and visual impairment
• Treatment of diabetic retinopathy
• Prevention of visual impairment and blindness
due to diabetic retinopathy.

3. Development of Retina
RPE
Neurosensory
retina
Subretinal space

4. Normal Fundus: Retinal Topography

5. Retina: Schematic Diagram

7. Diabetic Retinopathy
Globally , diabetic retinopathy accounts for
about 1 % of blindness. In India, diabetic
retinopathy accounts for about 0.1 % of
blindness.

8. Diabetic Retinopathy
• The best predictor of diabetic retinopathy is the
duration of the disease.
• Type I diabetes The first 5 years of type 1 diabetes has a
very low risk of retinopathy. All patients develop
retinopathy in 15 years.
• Type II diabetes: Risk of retinopathy increases with
duration of diabetes , hypertension and smoking, and
renal pathology.

9. Diabetic Retinopathy
Risk factors:
• Diabetic age and age of the patient
• Glycemic control
• Hypertension
• Poor renal status
• Smoking
• Pregnancy, obesity, hyperlipidemia, anemia

10. Pathogenesis
 DR is predominantly a microangiopathy resulting
from hyperglycemia.
 Vascular Endothelial Growth Factor (VEGF)
appears to be of particular importance in
development of proliferative changes .

11. Pathogenesis
 Capillaropathy: loss of pericytes, thickening of
basement membrane , and proliferation of
endothelium.
 Haematological changes
 Microvascular occlusion leading to hypoxia

12. Pathogenesis

13. Consequences of chronic leakage

14. Consequences of retinal ischaemia

15. Types
● Non-Proliferative Diabetic
Retinopathy(NPDR)/background diabetic
retinopathy ( BDR)
● Proliferative Diabetic Retinopathy(PDR)

16. Clinical Features
• Asymptomatic in the beginning
• Symptoms depend upon the retinal changes.
• Painless diminution of vision
• Dilated fundus examination shows typical
features.

17. Fundus Findings
Features of NPDR
● Microaneurysms
● Dot and blot hemorrhage
● Retinal edema and exudates
● Dilatation and beading of
retinal veins
● Intra retinal Microvascular
Abnormalities (IRMA)
Features of PDR
Neovascularization disc (NVD)
Neovascularization elsewhere(NVE)
In addition to other changes of NPDR

18. Early NPDR

19. Macular Edema

20. Proliferative Diabetic Retinopathy
Extra retinal fibrovascular proliferation
extends beyond the internal limiting
membrane (ILM).
• It’s the commonest cause of spontaneous
vitreous hemorrhage in adults.
• About 2/3rd of Type I diabetics are likely to
develop PDR over 3 decades.

21. Proliferative Diabetic Retinopathy

22. Proliferative Diabetic Retinopathy

23. Summary of Fundus Findings
• Microaneurysms ,hemorrhage , hard
exudates
• Capillary non-perfusion , Intra Retinal
Microvascular Abnormalities (IRMA)
• Neovascularisation: NVD,NVE
• Vitreous hemorrhage , retinal detachment

24. Cause of Visual Impairment
NPDR
● Macular edema (capillary
leakage)
● Macular ischemia (capillary
occlusion)
● Sequelae from ischemia
related neovascularization
PDR
• Vitreous hemorrhage, retinal
detachment.
• Diabetic macular edema
• Ischemic macular changes

25. Diagnosis of Diabetic Retinopathy
Clinical Exam
• Direct ophthalmoscopy under mydriasis
• Slit lamp biomicroscopy using +90 D lens
• Fluorescein angiography

26. Screening Schedule
• : Normal fundus , rare microaneurysms:
Annual review
• Mild NPDR: Every 9 months
• Moderate NPDR: Every 6 months
• Severe NPDR, CSME: Every 2-4 months
• PDR: Every 2-4 months

27. Treatment of
Diabetic Macular Edema (DME)
Laser Photocoagulation
• Grid laser :For diffuse retinal thickening outside FAZ.
• Focal laser : microaneurysms in centre of hard exudates.
Medical Treatment:
-intravitreal injection: Triamcinolome acetonide / anti-
VEGF
- posterior sub-tenon injection of corticosteroid
Surgery: Parsplana vitrectomy

28. Treatment of PDR
• Panretinal Laser photocoagulation (PRP) : For
NVD And NVE
• Vitreoretinal surgery and PRP :
- Severe persistent vitreous hemorrhage
- Dense, persistent premacular hemorrhage
- Progressive proliferation despite laser therapy
- Retinal detachment involving macula

29. • Spot size (200-500 m)
• Follow-up 4 to 8 weeks
• Area covered by complete PRP
• Initial treatment is 1200
+ burns
Laser Panretinal Photocoagulation(PRP)

30. Prevention Visual Loss
• Patient education and good diabetic control
• Control of hypertension, hyperlipidemia, renal
disease, anaemia, and avoidance of smoking
• Periodic dilated fundus examination
• Early treatment of macular edema and PDR
• Treatment of complications

31. Points to remember
• Pathogenesis, types, clinical features and
diagnosis of diabetic retinopathy
• Cause of visual impairment in diabetic
retinopathy
• Prevention of visual loss due to diabetic
retinopathy
• Schedule of examination in diabetics

32. Frequently-Asked Questions
• Pathogenesis of diabetic retinopathy
• Fundus findings in diabetic retinopathy
• Diagnosis of diabetic retinopathy
• Patient education for prevention of blindness
from diabetes.