Diabetes melitis & eye part 1 presentation at www.eyenirvaan.com

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Diabetes melitis & eye part 1 presentation at www.eyenirvaan.com

  1. 1. DIABETES MELLITUS & EYE – PART 1 Pradnya Gogate B. Optom, To view more presentations and articles, visit www.eyenirvaan.com
  2. 2. Diabetes mellitus  Endocrinological disorder  Insulin is necessary for cells to properly utilize glucose as a fuel Absence of insulin Reduction of insulin Reduced receptor ability to use insulin  Improper glucose production and use
  3. 3. Affected organs  Eyes  Kidney  Nervous system  Heart
  4. 4. Diabetes and eye  Optics  Lids  Conjunctiva  Cornea  Iris  Lens  Accommodation  Intra ocular pressure  Vitreous  Retina  Retinal occlusive diseases  Optic disc  Glaucoma  Cranial nerves
  5. 5. Optics  Myopic shift  Increase in blood sugar level  Hyperglycemia  Increase in osmotic pressure of crystalline lens  Increase in refractive index of lens
  6. 6. Optics  Hypermetropic shift  Decrease in blood sugar level  Hypoglycemia  Decrease in osmotic pressure of crystalline lens  decrease in refractive index of lens
  7. 7. Lids  Prone to infections due to high blood sugar level  Recurrent styes and internal hardeolam  Infection may spread and cause orbital cellulites
  8. 8. Conjunctiva  Tortuous and more constricted blood vessels  Conjunctival microaneurysms
  9. 9. Cornea  Superficial punctate keratitis  Delayed epithelial healing  Decreased corneal sensation
  10. 10. Iris  Rigid pupils – difficult mydriasis  Rubeosis iridis  Neovascularisation of iris  Retinal hypoxia  Release of vasoproliferative substance (angiogenic factor)
  11. 11. Lens  Pre-senile cataract  True diabetic cataract (snow-flake/snow-storm cataract)
  12. 12. Accomodation  Weakness of ciliary body  Decrease in accommodation  Precipitates presbyopia
  13. 13. Intra ocular pressure  Risk factor for primary open angle glaucoma (POAG)  IOP increases in neovascular glaucoma
  14. 14. Vitreous  Vitreous haemorrhages  Posterior vitreous detachment
  15. 15. Retina  Pathogenesis of Diabetic retinopathy  Microvascular occlusion  Microvascular leakages
  16. 16. Microvascular occlusion  Thickening of capillary basement membrane  Capillary endothelium cell damage and proliferation  Changes in red blood cells leading to defective oxygen transport  Increased stickiness and aggregation of platelets
  17. 17. Vascular changes in diabetic retinopathy  Microaneurysms  Microvascular occlusions  New vessels
  18. 18. Consequences of Microvascular occlusion  Arteriovenous shunts(IRMA’s)  Intra Retinal Microvascular abnormalities  Due to areas of capillary drop outs  Run straight course from venule to arteriole  Never cross major retinal vessels  Never leak extensively in FFA
  19. 19. Consequences of Microvascular occlusion  Neovascularisation  Hypoxic retinal tissue  Release of vasoformative substance  NVD- Neovascularisation at disc and within one disc diameter from disc  NVE – Neovascularisation elsewhere  Rubeosis iridis
  20. 20. Neovascularisation
  21. 21. Microvascular leakages  Endothelial and pericytes tight cell junction(1:1)  Loss of pericytes  Disruption of blood-retinal barrier  Leakage of plasma constituents in retina  Microaneurysms (out-pouching of blood vessels)
  22. 22. Consequences of Microvascular leakages  Diffuse retinal oedema  due to extensive capillary dilatation  Localized retinal oedema  Due to focal leakage from Microaneurysms  Hard exudates  At the junction of healthy and oedematous retina  Composed of lipoprotein and lipid-laden macrophages  Form in a circinate pattern
  23. 23. Pathogenesis of Diabetic retinopathy
  24. 24. Retinal changes in diabetic retinopathy
  25. 25. Diabetic maculopathy  Focal diabetic maculopathy  Cystoid diabetic maculopathy(diffuse)  Ischemic diabetic maculopathy  Mixed diabetic maculopathy
  26. 26. Focal diabetic maculopathy  Features of background diabetic maculopathy in macular area  Microaneurysms-  Hard exudates-  Flame shaped haemorrhages  Dot-blot haemorrhages
  27. 27. Cystoid diabetic maculopathy(diffuse)  Few Microaneurysms, haemorrhages and hard exudates  Extensive macular oedema with accumulation of extracellular fluid in Henel’s layer  Formation of microcystic spaces  FFA shows diffuse leakage at at posterior pole with a ‘flower petal’ pattern with relatively perfused macular area  Persistent oedema may lead to formation of lamellar hole at fovea
  28. 28. Cystoid diabetic maculopathy(diffuse)
  29. 29. Ischemic diabetic maculopathy  Few Microaneurysms, haemorrhages and hard exudates  Macular oedema varying from mild to Cystoid  FFA reveals areas of capillary non-perfusion in macular and paramacular regions
  30. 30. Mixed diabetic maculopathy  Shows most of the features of before mentioned types of diabetic maculopathies  Significant exudates, oedema and ischemia
  31. 31. Clinically significant macular oedema  Retinal oedema within 500micron from fovea  Hard exudates within 500micron of fovea with adjacent retinal thickening may outside 500microns  Retinal oedema of one disc diameter or larger present within one disc diameter from fovea
  32. 32. Clinically significant macular oedema  Irregular FAZ  Microaneurysms around FAZ leaking in late stages of angiogram suggestive of CSMO
  33. 33. Management of diabetic maculopathy  Laser photocoagulation  Focal treatment – for treatment of macular oedema due to focal leakage
  34. 34. Management of diabetic maculopathy  Grid treatment – for macular oedema due to diffuse leakage (CME pattern)  Laser is applied in a series of circles around fovea to reduce swollen areas
  35. 35. Continued in Part II

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