This document discusses diabetic retinopathy, beginning with risk factors like long diabetes duration and poor control. It describes the progression from early background changes to preproliferative then proliferative stages. Clinically significant macular edema is defined and treated initially with laser, while proliferative disease requires panretinal photocoagulation or sometimes surgery. The stages, treatments, and goals of managing this complication of diabetes are outlined.

1. DIABETIC RETINOPATHY
1. Adverse risk factors
2. Pathogenesis
5. Clinically significant macular oedema
6. Preproliferative diabetic retinopathy
3. Background diabetic retinopathy
4. Diabetic maculopathies
• Focal
• Diffuse
• Ischaemic
7. Proliferative diabetic retinopathy

2. Adverse Risk Factors
1. Long duration of diabetes
• Obesity
• Hyperlipidaemia
2. Poor metabolic control
3. Pregnancy
4. Hypertension
5. Renal disease
6. Other
• Smoking
• Anaemia

3. Pathogenesis of diabetic retinopathy

4. Consequences of retinal ischaemia

5. Consequences of chronic leakage

6. Location of lesions in background
diabetic retinopathy

7. Signs of background diabetic retinopathy
Microaneurysms usually
temporal to fovea
Intraretinal dot and
blot haemorrhages
Hard exudates frequently
arranged in clumps or
rings
Retinal oedema seen as
thickening on biomicroscopy

8. Focal diabetic maculopathy
• Circumscribed retinal thickening
• Associated complete or incomplete
circinate hard exudates
• Focal leakage on FA
• Focal photocoagulation
• Good prognosis

9. Diffuse diabetic maculopathy
• Diffuse retinal thickening • Generalized leakage on FA
• Guarded prognosis
• Grid photocoagulation• Frequent cystoid macular oedema
• Variable impairment of visual acuity

10. Ischaemic diabetic maculopathy
• Macula appears relatively normal • Capillary non-perfusion on FA
• Poor visual acuity • Treatment not appropriate

11. Clinically significant macular oedema
Hard exudates
within 500 µm
of centre of
fovea with adjacent
oedema which may
be outside 500 µm
limit
Retinal oedema one disc area or larger any
part of which is within one disc diameter
(1500 µm) of centre of fovea
Retinal oedema
within 500 µm
of centre of fovea

12. Treatment of clinically significant
macular oedema
• For microaneurysms in centre of hard
exudate rings located 500-3000 µm
from centre of fovea
Focal treatment
• Gentle whitening or darkening of
microaneurysm (100-200 µm, 0.10 sec)
• For diffuse retinal thickening located more
than 500 µm from centre of fovea and
500 µm from temporal margin of disc
Grid treatment
• Gentle burns (100-200 µm, 0.10 sec),
one burn width apart

13. Preproliferative diabetic retinopathy
Treatment - not required but watch for proliferative disease
• Cotton-wool spots
• Venous irregularities
• Dark blot haemorrhages
• Intraretinal microvascular
abnormalities (IRMA)
Signs

14. Proliferative diabetic retinopathy
• Flat or elevated
• Severity determined by comparing with area of disc
Neovascularization
Neovascularization of disc = NVD
• Affects 5-10% of diabetics
• IDD at increased risk (60% after 30 years)
Neovascularization elsewhere = NVE

15. Indications for treatment of proliferative
diabetic retinopathy
NVD > 1/3 disc in area Less extensive NVD
+ haemorrhage
NVE > 1/2 disc in area
+ haemorrhage

16. • Spot size (200-500 µm) depends
on contact lens magnification
• Gentle intensity burn (0.10-0.05 sec)
• Follow-up 4 to 8 weeks
• Area covered by complete PRP• Initial treatment is 2000-3000 burns
Laser panretinal photocoagulation

17. Assessment after photocoagulation
• Persistent neovascularization
• Haemorrhage
Poor involution
• Re-treatment required
• Regression of neovascularization
• Residual ‘ghost’ vessels or
fibrous tissue
Good involution
• Disc pallor

18. Indications for vitreoretinal surgery
Retinal detachment involving
macula
Severe persistent vitreous
haemorrhage
Dense, persistent premacular
haemorrhage
Progressive proliferation
despite laser therapy