Lecture on Diabetic Retinopathy For 4th Year MBBS Undergraduate Students By Prof. Dr. Hussain Ahmad Khaqan

1. Diabetic Retinopathy
Prof. Dr. Hussain Ahmad Khaqan
 MD
 FRCS(Glasgow)
 FCPS(Ophth.)
 FCPS(Vitreo Retina)
 MHPE (KMU)
 CICO(UK)
 CMT(UOL)
 Fellowship in Medical Retina (LMU, Munich)
 Fellowship in Vitreo Retinal Surgery (LMU, Munich)
 Consultant Ophthalmologist & Retinal Surgeon
Professor of Ophthalmology
Lahore General Hospital, Lahore
Ameer Ud Din Medical College, Lahore
Post Graduate Medical Institute, Lahore
Shaukat Khanum Memorial Cancer Hospital & Research Centre ,Lahore

2. DEFINITION
• Progressive dysfunction of the retinal vasculature
caused by chronic hyperglycemia resulting in
structural damage to the neural retina.

3. SYMPTOMS
• Decreased vision

4. SIGNS Continue..
• Micro aneurysms.
• Retinal hemorrhages.
• Retinal lipid exudates, circinate retinopathy
• Cotton–wool spots.
• Venous beading
• Vascular loops
• Intraretinal microvascular abnormalities (IRMAs)

5. • Macular edema.
• Neovascularization (NVD, NVE)
• Vitreous hemorrhage.
• Retinal detachment.
• Neovascular glaucoma.
• Early onset cataract.
• Cranial nerve palsies
SIGNS

6. DIABETIC RETINOPATHY DISEASE SEVERITY SCALE
Continues
• No apparent retinopathy.
• Mild nonproliferative diabetic retinopathy (NPDR):
Microaneurysms only
• Moderate NPDR: More than mild NPDR, but less
than severe NPDR. May have cotton wool spots
(CWS) and venous beading.

7. • Diabetic macular edema
• Clinically significant macular edema (CSME)
• PDR (proliferative diabetic retinopathy):
Neovascularization of one or more of the following:
iris, angle, optic disc, or elsewhere in retina; or
vitreous/preretinal hemorrhage.
DIABETIC RETINOPATHY DISEASE SEVERITY SCALE

8. Figure: Mild NPDR Figure: moderate NPDR
Figure: Severe NPDR

9. INVESTIGATION
Systemic:
• Venous fasting plasma glucose ≥7mmol/L.
• Oral glucose tolerance test (usually performed by
physician) with a 2h value of >11.1mmol/L.
• HbA1C
• Renal function tests (RFT)
• Fasting lipid profile
Ocular:
• Fluorescein angiography
• Optical coherence tomography (OCT)

10. DIFFERENTIAL DIAGNOSIS
• CRVO (central retinal vein occlusion)
• BRVO (branch retinal vein occlusion)
• Hypertensive retinopathy
• Radiation retinopathy
• Neovascular complications of CRAO (central retinal
artery occlusion), CRVO, or BRVO.
• Sickle cell retinopathy
• Embolization from intravenous drug abuse (talc
retinopathy)
• Sarcoidosis: May have uveitis, exudates around
veins (“candle-wax drippings”), NVE, or systemic
findings.

11. TREATMENT Continue..
Systemic
Glycaemic control
• HbA1c 6.5–7.5% (48–58mmol/mol); set less strict targets in
patients with established cardiovascular disease and in older
subjects.
BP control
• Aim for systolic ≤130mmHg in those with established
retinopathy and/or nephropathy (in those without
retinopathy, usually aim for <140mmHg).
• Encourage regular monitoring of blood pressure (BP)
(including at home, if possible).
• Effective anti-hypertensives include angiotensin converting
enzyme (ACE) inhibitors (usually first line in type 2 diabetes),
angiotensin II receptor (AIIR) antagonists, β-blockers, or
thiazide diuretics.

12. Cholesterol control
• Aim for lipid lowering if >30% 10y risk of coronary heart disease
(current recommendations, although ideally treat all with risk
>15%).
• A statin is the drug of choice; consider adding fenofibrate to a statin
for non-proliferative retinopathy in type 2 diabetes (evidence for
benefit in the ACCORD eye study).
Support renal function
• Micro albuminuria is indicative of early nephropathy and is
associated with increased risk of macrovascular
complications.
• angiotensin converting enzyme (ACE) inhibitors or angiotensin II
receptor (AIIR) antagonists are preferred.
TREATMENT Continue..

13. Lifestyle
• Smoking cessation: smoking greatly increases macrovascular
disease, and strategies to assist the patient ‘give-up’ should be
explored.
• Weight control: mainly in type 2 disease, particularly if body mass
index (BMI) >25.
• Exercise >30min/d: weight, blood pressure (BP), insulin sensitivity,
improves lipid profile.
Pregnancy
• Progression of retinopathy is a significant, but relatively low, risk in
pregnancy.
• Pregnant women with pre-existing diabetes should be offered
retinal assessment following their first antenatal clinic appointment
TREATMENT Continue..

14. Ocular
Antiangiogenesis Agents
• Pegaptanib sodium, a VEGF (vascular endothelial growth factor) aptamer
(Macugen, Eyetech Pharmaceuticals, NY).
• Ranibizumab (Lucentis, Genentech).
• Bevacizumab (Avastin, Genentech).
• Aflibercept (Eylea, Regeneron)
• Co-formulation of two drugs (aflibercept and nesvacumab)
• Laser: focal or grid laser
• Intravitreal steroid: triamcinolone
• PRP (panretinal photocoagulation)
• Surgery: pars plana vitrectomy
TREATMENT Continue..

15. Indications for Vitrectomy
• Vitrectomy may be indicated for any one of the following
conditions:
1. Dense VH (vitreous hemorrhage) causing decreased vision,
especially when present for several months.
2. Traction retinal detachment (RD) involving and progressing
within the macula.
3. Macular epiretinal membranes (ERMs) or recent-onset
displacement of the macula.
4. Dense premacular hemorrhage.
5. Chronic ME (macular edema) not responsive to other treatment.
6. Severe retinal neovascularization and fibrous proliferation that is
unresponsive to laser photocoagulation.
TREATMENT