basics of diabetic retinopathy covered

1. UNDERSTANDING DIABETIC
EYE DISORDERS
Dr Manmath Kumar Das
Consultant VR surgeon
KIMS, Bhubaneswar

2. DIABETES & EYE
 Lids & Adnexa – soft tissue infections
 Cornea – decreased sensitivity, neurotropic ulcers, delayed healing
 Lens - cataract
 Pupil – delayed dilatation
 Glaucoma - NVG in advanced PDR
 Retina - retinopathy
 EOM – paralysis

3. DIABETES & CORNEA
 Decreased corneal sensitivity neurotropic ulcers
 Superficial punctate keratitis
 Delayed epithelial healing after trauma

4. DIABETES & LENS
 Refractive error ( due to collection of sorbitol , lens swells up)
 Cataract Progression

5. DIABETES & IRIS, ANGLE & GLAUCOMA
 NVG/NVI

6. DIABETES & ONH, RETINA
 Diabetic Papillopathy : does not cause Vision loss
 NA-AION: cause mild to severe degree of vision loss
 Diabetic Retinopathy: cause variable degree of vision loss

7. SYMPTOMS
Diabetic retinopathy is asymptomatic in early stages of
the disease. As the disease progresses symptoms may
include :
• Blurred vision
• Floaters
• Dark areas in the vision
• Partial or total loss of vision

8. Preclinica
changes
Macular
Edema
Proliferativ
e DR
Diabete
s
Background
DR
CSME
Vit hge / RD /
Neovascular
Glaucoma
Preproliferati
ve DR
Vision
loss
Causation of Vision Loss

9. RISK FACTORS FOR DIABETIC
RETINOPATHY
Duration of diabetes
 10 yrs – up to 50%
 30 yrs - up to 90%
Pregnancy
Hypertension
Nephropathy
Hyperlipidemia
Elevated glycosylated
hemoglobin levels
Smoking

10. DIABETIC RETINOPATHY –
CLASSIFICATION
NPDR (with or without CSME)
 Mild NPDR
 Moderate NPDR
 Severe NPDR
 Very severe NPDR
PDR (with or without CSME)
 Non high risk PDR
 High risk PDR
PDR with complications
 Vitreous hemorrhage
 Tractional RD
 End stage diabetic eye

11. Mild NPDR Moderate NPDR
Severe NPDR CSME
VISUAL LOSS IS A LATE SYMPTOM OF DIABETIC
RETINOPATHY

12. PATHOPHYSIOLOGY
Diabetic Retinopathy is a microvasculopathy that causes:
 Retinal capillary occlusion & leakage
• Loss of mural pericytes
• Proliferation of endothelial cells
• Thickened basement membrane
• Venous beading
• IRMA – Intraretinal Microvascular Abnormalities
• Neovascularization

13. MICROVASCULAR OCCLUSION
Microvascular occlusion is caused by:
Thickening of capillary BM
Endothelium proliferation
Increased platelet adhesion
Increased blood viscosity
Defective fibrinolysis

14. Cotton – wool
spot
Neovascularizatio
n
Ischemia
Neovascular
glaucoma
Microvascular
Occlusion
Fibrovascular
bands
Vit.
hemorrhage
Increased VEGF
Tractional RD
Infarction

15. MICROVASCULAR LEAKAGE
Microvascular leakage is caused by:
Impairment of endothelial tight junctions
Loss of pericytes
Weakening of capillary walls
 levels of vascular endothelial growth factor (VEGF)
Edema
Retinal
hemorrhage
Hard exudates
Microvascular
Leakage

16. MICROANEURYSMS
Earliest clinically detectable sign
Reflect a weakening of capillary wall (pericyte loss) or
active cellular response to retinal hypoxia
Hyperfluorescent dots on Fl. angiography

17. INTRARETINAL HEMORRHAGE
IRMA (Intraretinal Microvascular Abnormalities)

18. NEOVASCULARIZATION

19. MACULOPATHY IN DR
Macular edema
CSME
 Focal
 Diffuse
Macular ischemia

20. DIABETIC MACULAR EDEMA
Major contribution to vision
loss from diabetes
Most mild-moderate vision
loss (2- 6 lines) due to CSME
Significant morbidity, often
irreversible
Untreated visual loss of 2
lines or more in > 50%
10% in patients > 10 years
25% in patients > 25 years

21. CLINICALLY SIGNIFICANT MACULAR
EDEMA (CSME)
Thickening of the retina at or within 500 µm of the
center of the macula.
Hard exudates at or within 500 µm of the center of
the macula, if associated with thickening of the
adjacent retina.
Area of retinal thickening 1 disc area or larger,
within 1 disc diameter of the center of the macula

22. MILD NPDR
• Retinal hemorrhages
• Hard exudates

23. MOD. NPDR
 Hemorrhages
 Hard exudates
 COTTON WOOL SPOTS

24. SEVERE & VERY SEVERE NPDR
Presence of ANY of following features s/o SEVERE
Presence of TWO or more s/o Very severe
 Microaneurysms or hemorrhages in 4 quadrants
 Venous beading in 2 or more quadrants
 IRMA in 1 or more quadrants

25. PROLIFERATIVE DIABETIC
RETINOPATHY
PDR without high risk characteristics
 new vessels
PDR with high risk characteristics
 NVD > 1/3 of disc
 NVD + vitreous hemorrhage
 NVE > 1/2 disc area + vitreous hemorrhage

26. PDR WITH COMPLICATIONS
Vitreous hemorrhage
Tractional Retinal Detachment
Combined mechanism RD
Advanced PDR - Absolute glaucoma,
Phthisis bulbi /Atrophic bulbi

27. SUMMARY
 DM can affect any part of the eye including adnexa
 Diabetic retinopathy, DME / CSME, NA-AION : responsible for vision
loss depending upon its severity

28. THANK YOU