we discuss the ocular manifestations of diabetic retinopathy

1. DIABETIC RETINOPATHY
PRESENTER:DR.MUGABI BARNABAS
MODERATOR:DR.AMPAIRE ANNE MUSIKA
23RD/10/2023

2. OUTLINE
• ETIOLOGY
• ANATOMY
• EPIDEMIOLOGY
• PATHOPHYSIOLOGY
• RISK FACTORS
• CLASSIFICATION
• DIABETIC MACULAR EDEMA
• DIABETIC MACULOPATHY
• CLINICAL PICTURE
• IMAGING
• TREATMENT

3. DIABETES MELLITUS
• Diabetes mellitus is a group of metabolic disease characterized by
hyperglycemia resulting from defects in insulin secretion, insulin
action, or both
• The chronic hyperglycemia of diabetes is associated with long-term
damage, dysfunction, and failure of various organs, especially the
eyes, kidneys, nerves, heart, and blood vessels.

4. Types of DM
• Type 1 diabetes (β-cell destruction, usually leading to absolute insulin
deficiency)
• Type 2 diabetes ( insulin resistance with relative insulin deficiency )

5. OPHTHALMIC COMPLICATIONS OF DIABETES
COMMON
• RETINOPATHY
• IRIDOPATHY
• UNSTABLE REFRACTION.
UNCOMMON
• RECURRENT STYES
• XANTHELASMA
• ACCELERATED AGE-RELATED CATARACT
• NEOVASCULAR GLAUCOMA (NVG)
• OCULOMOTOR NERVE PALSIES. REDUCED CORNEAL
• SENSITIVITY

6. • RARE
• PAPILLOPATHY,
• PUPILLARY LIGHT-NEAR DISSOCIATION
• WOLFRAM SYNDROME
• ACUTE- ONSET CATARACT
• RHINO-ORBITAL MUCORMYCOSIS.

7. DEFINITION OF DIABETIC RETINOPATHY
• Diabetic retinopathy is a chronic progressive, potentially sight-
threatening disease of the retinal microvasculature associated with
the prolonged hyperglycaemia and other conditions linked to diabetes
mellitus such as hypertension.

8. What is The Retina?
• The retina is a multilayered, light sensitive neural tissue lining the
inner eye ball. Light is focused onto the retina and then transmitted
to the brain through the optic nerve.
• The macula is a highly sensitive area in the center of the retina,
responsible for central vision.

11. PATHOPHYSIOLOGY
• Diabetic Retinopathy is a microvasculopathy that causes:
• Retinal capillary occlusion
• Retinal capillary leakage

12. PATHOPHYSIOLOGY

13. PATHOPHYSIOLOGY

14. RISK FACTORS
• Non modifiable
• Duration and age at onset
• Puberty
• Modifiable Risk Factors
• Diabetic control/ HbA1c
• Hypertension
• Pregnancy
• OTHERS : Hyperlipidemia, Smoking, Obesity

15. Risk factors Diabetic Retinopathy
Duration of diabetes is a major risk factor associated with the
development of diabetic retinopathy
The severity of hyperglycemia is the key alterable risk factor
associated with the development of diabetic retinopathy

16. Type 1 DM
DURATION (YRS) DR PDR
AFTER 5 YRS 25%
AFTER 10 YRS 60%
AFTER 15 YRS 80%
AFTER 20-30 YRS 95% 30- 50%

17. Type 2 DM
DURATION (YRS) DR PDR
Yanko et al.
11-13 23% 3%
≥16 60%
Klein et al.
10 67% 10%
PDR will develop in 2% of patients if duration of DM is < 5 years
and 25% if > 25 years

18. Puberty
• Pre pubertal children (< 12 yrs) rarely develop complications of
diabetes.
• Puberty is a risk factor for developing retinopathy because of the
physiological increased resistance to insulin.
• Klein et al found that diabetes duration post menarche was
associated with 30% increase risk or retinopathy compared with
diabetes duration before menarche.

19. HbA1c
DCCT showed in T1DM:
Tight control had 76% reduction in rate of developments of DR (
primary prevention cohort) and 54% reduction in progression of
established DR ( secondary intervention cohort) as compared to
conventional treatment group

20. HbA1c
• The DCCT : every 1% decrease in HbA1C level decrease the incidence
of diabetic retinopathy by 28% .
• Target HbA1c value of 6 - 7%

21. Hypertension
• HTN is common in patients with T2DM.
• Target BP <140/80 mm hg
• Tight control appears to be particularly beneficial in T2DM with
maculopathy.

22. Pregnancy
• Gestational diabetes does not require an eye examination during
pregnancy and does not increase the risk of diabetic retinopathy.
• Diabetic retinopathy can worsen during pregnancy
• Macular edema in pregnant patients can improve with delivery
• Diabetic retinopathy in a pregnant patient is not a contraindication for
natural vaginal delivery.

23. Pregnancy
PREGNANT DIABETIC WOMEN RISK OF DEVELOPMENT REMARKS
WITHOUT DR NPDR 10%
NPDR PDR 4%
UNTREATED PDR REQUIRE - PAN RETINAL
PHOTOCOAGULATION (PRP)
TREATED PDR USUALLY DOES NOT WORSEN

24. ETDRS NSE SDRGS AAO
INTERNATIONAL
None R0 none R0 none No apparent
retinopathy
Microaneurysm
only
R1 background R1 mild
background
Mild NPDR
Mild NPDR Mod NPDR
Moderate NPDR R2
preproliferative
R2 moderate
BDR
Moderately severe
NPDR
Severe NPDR R3 severe BDR Severe NPDR
Very severe NPDR

25. NO DR
• DESCRIPTION
No evidence of retinal vascular
disease
• FOLLOW-UP
Yearly with dilated funduscopic
exams

26. MILD NPDR
• DESCRIPTION
• ETDRS: ≥ 1 microaneurysm with no
other findings
• Kanski:Any or all : microaneurysms,
retinal hemorrhages, exudates, cotton
wool spots, up to the level of moderate
NPDR with no IRMAs or venous beading
• FOLLOW-UP 6-12 months with dilated
funduscopic exam There are a few cotton-wool spots and intraretinal hemorrhages in this
photograph, which doesn't really fit the ETDRS/International classification for
true mild NPDR. Might still mild NPDR, because while there are multiple
hemorrhages and cotton-wool spots, there are still < 20 per quadrant.
Published in: Community Eye Health Journal Vol. 24, No.
75, September 2011

28. MODERATE NPDR
DESCRIPTION
• Any of the following:
• ≥ 20 intraretinal hemorrhages in 1-3 quadrants
• Venous beading in no more than 1 quadrant
• Presence of mild intraretinal microvascular
abnormalities (IRMAs) in no more than 1
quadrant
• Cotton-wool spots commonly present.
• FOLLOW-UP
• 6 months with dilated funduscopic exam
• PROGNOSIS
• PDR in up to 26% and high risk PDR in up to 8%
within a year.

29. Haemorrhages

30. Venous changes

31. Intraretinal microvascular abnormalities (IRMA)

32. Cotton-wool spots
Fig : Cotton-wool spots and IRMA,

33. SEVERE NPDR
DESCRIPTION
• One of the following (4-2-1 rule):
4 quadrants of ≥ 20 hemorrhages
≥ 2 quadrants of venous beading
≥ 1 quadrant of IRMAs
FOLLOW-UP
4 months with dilated funduscopic exam
PROGNOSIS
PDR in up to 50% and high risk PDR in up to 15%
within a year.

34. VERY SEVERE NPDR
• DESCRIPTION
• ≥ 2 of the 4-2-1 criteria
• FOLLOW-UP
• 2-3 months with dilated funduscopic
exam
• PROGNOSIS
• High-risk PDR in up to 45% within a
year. cotton-wool, spots, IRMA, and venous beading

35. PROLIFERATIVE DIABETIC RETINOPATHY
• Proliferative diabetic retinopathy (PDR) is characterized by
neovascularization arising from the optic disc and retina, which may
cause preretinal and vitreous hemorrhage.

36. Proliferative diabetic retinopathy
Mild – moderate PDR
• NVD <1/3 disc area
• NVE <1/2 disc area
• (NVD or NVE :insufficient to meet high risk criteria)
High risk PDR
• NVD > 1/3 disc area
• Any NVD with vitreous haemorrhage
• NVE > 1/2 disc area with vitreous haemorrhage

37. PDR

38. PDR

39. High risk PDR

40. PDR

41. ADVANCED DIABETIC EYE DISEASE
• Hemorrhage :
• Preretinal hemorrhage ( retrohyaloid),
• Intragel haemorrhage or
• Both
• Tractional retinal detachment
• Rubeosis iridis

42. ADVANCED DIABETIC EYE DISEASE

43. DIABETIC MACULAR EDEMA
• Diabetic macular edema is the leading cause of legal blindness in
diabetics.
• Diabetic macular edema can be present at any stage of the disease,
but is more common in patients with proliferative diabetic
retinopathy.

45. Why is Diabetic macular edema so important?
• The macula is responsible for central vision.
• Diabetic macular edema may be asymptomatic at first. As the edema
moves in to the fovea (the center of the macula) the patient will
notice blurry central vision.

46. International Clinical Diabetic Macular Edema
Disease Severity Scale
Proposed disease severity level Findings observable upon dilated ophthalmoscopy
DME apparently absent No apparent retinal thickening or hard
exudates in posterior pole
DME apparently present Some apparent retinal thickening or hard
DME present exudates in posterior pole
Mild DME (some retinal thickening or hard
exudates in posterior pole but distant from the
center of the macula)
Moderate DME (retinal thickening or hard exudates
approaching the center of the macula but not
involving the center)
Severe DME (retinal thickening or hard exudates
involving the center of the macula)

47. DME

48. Clinically Significant Macular Edema
• Retinal thickening located at or within 500 μm of the center of the
macula
• Hard exudates at or within 500 μm of the center if associated with
thickening of adjacent retina
• A zone of thickening larger than 1 disc area (1500 μm) if located
within 1 disc diameter of the center of the macula

49. CSME

50. DIABETIC MACULOPATHY (DM)
DM is further classified as:
• Focal maculopathy
• Diffuse maculopathy
• Ischaemic maculopathy
• Mixed

51. Focal maculopathy
DESCRIPTION
• Well circumscribed
• Retinal thickening
• Complete/incomplete ring of
• FA :
• Late, focal hyperfluorescence
• Good macular perfusion

53. Diffuse maculopathy
DESCRIPTION:
• Diffuse
• Retinal thickening
• Cystoid changes
• Scattered microaneurysms
• Small hemorrhages
FA :
• Mid to Late, diffuse hyperfluorescence

55. Ischaemic maculopathy
• DESCRIPTION
• Macula may look relatively normal
• Reduced visual acuity
• PPDR may be present
• FA : Capillary non-perfusion at
fovea, posterior pole and
periphery

56. RECOMMENDED EYE EXAMINATION
SCHEDULE
Diabetes Type Recommended Initial Evaluation Recommended Followup*
Type 1 5 years after diagnosis Yearly
Type 2 At time of diagnosis Yearly
pregnancy (type 1 or type 2) Soon after conception and early in
the first trimester
No retinopathy-mild or moderate
NPDR: every 3-12 months
Severe NPDR or worse: every 1-3
months
Abnormal findings may dictate more frequent follow-up
examinations

57. SYMPTOMS
• Asymptomatic
• Decreased vision
• Floaters
• Metamorphopsia
• Symptoms of retinal detachment

58. OCULAR EXAMINATION
• Visual acuity
• Intraocular pressure
• Slit lamp biomicroscopy
• Gonioscopy before dilating pupils
• Funduscopic examination of the posterior pole under dilated pupil
• Examination of peripheral retina and vitreous under dilated pupil

59. IMAGING
• Digital photography
• Fluorescein angiography
• optical coherence tomography (oct)

60. TREATMENT OF DIABETIC RETINOPATHY
• Effective in 90% of cases to prevent severe visual loss
• Good glycemic control
• Adequate control of hypertension
• Encourage changes in lifestyles
• Treatment options
Laser therapy
Anti-VEGF drugs (ranibizumab, aflibercept, bevacizumab)
Surgery

61. Treatment of diabetic retinopathy
• HbA1c target (6.5-7.5%).
• NPDR with T2DM : Add fenofibrate with statin
• Macular edema : No pioglitazone
• Systolic BP ≤130mmHg : Retinopathy and/or nephropathy
• Systolic BP < 140mmHg : Without retinopathy,
• Pregnancy : No statin
• (Diabetic patients planning pregnancy should be informed on the need for assessment of diabetic
retinopathy before and during pregnancy; Tropicamide alone should be used if mydriasis is required
during pregnancy )

62. Treatment of diabetic retinopathy
DIABETIC
PREGNANT
WOMEN
1ST
ANTENATAL
VISIT
2ND
VISIT AT
(FOLLOW UP)
NO DR 28 WEEKS
DR 16-20 WEEKS
PPDR DURING
PREGNANCY
AT LEAST 6 MONTHS
FOLLOWING DELIVERY
(Macular edema in pregnant patients can improve with
delivery, no intravitreal anti-VEGF is recommended. Consider
intravitreal steroids.)

63. Treatment of diabetic macular edema
• Laser Therapy
• Focal laser : FDA approved based on ETDRS findings Micropulse laser
• Anti-VEGF Drugs
• Aflibercept
• Ranibizumab
• Bevacizumab
*Anti-VEGF injections are considered the new gold standard of therapy for eyes with centre-
involving macular oedema and reduced vision

64. Treatment of diabetic macular edema
• Steroids
Intravitreal Injections
Intravitreal implants
Ozurdex (Dexamethasone)
Iluvien (FlucinoloneAcetonide)
• Surgery
Consider in cases of vitreomacular traction
Tractional retinal detachment

65. REFERENCES
• KANSKI
• AAO
• WONG

66. THANK YOU