diabetic Retinopathy for General Physicians

1. DIABETIC RETINOPATHY
- A n O v e r v i e w & Multi disciplinary
approach
Dr Manmath Kumar Das
Consultant Vitreo-Retinal Surgeon,
K.I.M.S., Bhubaneswar &
Nayonika Eye Care

2.  Progressive dysfunction of the retinal
blood vessels caused by chronic
hyperglycemia.
 DR is a highly specific vascular
complication of both type I &II diabetes
 Characterized by various degree of
microaneurysm, hemorrhage, exudates,
venous changes, neovascularization &
retinal thickening
 Can involve peripheral retina, the
macula or both

3.  The total number of people with diabetes is
projected to rise from 285 million in 2010 to 439
million in 2030.
 Diabetic retinopathy is responsible for 1.8
million of the 37 million cases of blindness
throughout the world .
 Diabetic retinopathy (DR) is the leading cause of
blindness in working age group in industrialized
countries.

4.  The best predictor of diabetic retinopathy is the
duration of the disease
 After 20 years of diabetes, nearly 99% of patients
with type-I diabetes and 60% with type-II have
some degree of diabetic retinopathy
 33% of patients with diabetes have signs of diabetic
retinopathy
 People with diabetes are 25 times more likely to
become blind than the general population.

5. • Report of W.H.O confirms & states that—
 In 1995 an estimated 135 million had Diabetes, which is
expected to increase to 300 million by 2025, an increase
of 122%
 India`s contribution- would be 57.2 millions from
1995 figure of 19.4 million, an increase of 195%. It
means every 5th diabetic in the world would be from
India
 PDR affects about 5-10% of the diabetic population.
 Patients with IDDM at increased risk -- 60% after 30 yrs

6. • Type of diabetes
• 1st line treatment
• Regular glycaemic and
BP control
• Detection of Pt. at risk of
long term complication
• Diagnosis of DR
• Early referral to
Specialist.
• Close co-operation with
Ophthalmologist
• Early referral from
physician
• Early detection of DR
• Diagnostic methods
• Regular Follow up
• Disease prognosis & risk
of loss of vision
• Medication alone, Laser
treatment & Surgery
• Close co-operation with
Physician

7. Incidence of Diabetic Retinopathy increasing due to
•  Incidence of Diabetes Mellitus
•  Life expectancy due to better Medicare
• Lack of facilities for Vitreo-retinal surgery
Incidence

8. Diabetic retinopathy is asymptomatic in early stages of
the disease. As the disease progresses symptoms may
include :
• Blurred vision
• Floaters
• Fluctuating vision
• Distorted vision
• Dark areas in the vision
• Poor night vision
• Impaired color vision
• Partial or total loss of vision

9. Preclinical
changes
Macular
Edema
Proliferative
DR
Diabete
s
Background
DR
CSME
Vit hge / RD /
Neovascular
Glaucoma
Preproliferativ
e DR
Vision
loss
Causation of Vision Loss

10.  Duration of diabetes
 10 yrs – up to 50%
 30 yrs - up to 90%
 Intensive metabolic
control
 Pregnancy
 Hypertension
 Nephropathy
 Hyperlipidemia
 Elevated glycosylated
hemoglobin levels
 Smoking

11.  Background Retinopathy -
microaneurysm formation,
capillary leakage causing dot /
blot hemorrhage & hard exudates
 Pre-proliferative Retinopathy -
cotton-wool spots due to
infarction of RNF layers &
venous beading
 Proliferative Retinopathy (PDR) -
growth of new blood vessels
(neovascularization) from optic n.
head or post. surface of vitreous

12.  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

13. Mild NPDR Moderate NPDR
Severe NPDR CSME

14. Diabetic Retinopathy is a microvasculopathy that causes:
• Retinal capillary occlusion
• Retinal capillary leakage
 Loss of mural pericytes
 Proliferation of endothelial cells
 Thickened basement membrane
 Microaneurysms
 Intraretinal hemorrhages
 Hard exudates
 Soft exudates (cotton wool spots)
 Venous beading
 IRMA – Intraretinal Microvascular Abnormalities
 Neovascularization

15. Microvascular occlusion is caused by:
• Thickening of capillary BM
• Endothelium proliferation
• Increased platelet adhesion
• Increased blood viscosity
• Defective fibrinolysis

16. Cotton – wool
spot
Neovascularizati
on
Ischemia
Neovascular
glaucoma
Microvascular
Occlusion
Fibrovascular
bands
Vit.
hemorrhage
Increased VEGF
Tractional RD
Infarction

17. 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

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

19. IRMA (Intraretinal Microvascular Abnormalities)

21.  Macular edema
 CSME
 Focal
 Diffuse
 Macular ischemia

22.  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

23. Imaging of macular edema with OCT

24.  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

25.  Presence of two of the following features
 Microaneurysms or hemorrhages in 4 quadrants
 Venous beading in 2 or more quadrants
 IRMA in 1 or more quadrants

26.  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

27.  Vitreous hemorrhage
 Tractional Retinal Detachment
 Secondary rhegmatogenous RD
 Advanced PDR - Absolute glaucoma,
Phthisis bulbi /Atrophic bulbi

28.  Indirect ophthalmoscopy
 Fluorescein Angiography
 Optical Coherence Tomography
 Ultra sonography (B-scan)

29. Patient group Recommended
first examination
Min. routine
follow-up
Below 30 years Within 3–5 years after
diagnosis of diabetes
once patient is aged 10
years or older
Yearly
30 years and older At time of diagnosis of
diabetes
Yearly
Pregnancy in pre-
existing diabetes
Prior to conception and
during 1st trimester
Physician discretion
pending results of
1st-trimester exam

30.  To image retinal, choroidal, optic
disc, or iris vasculature or
combination of these, so as to use
as diagnostic tool.
 Transit time between inj. & appearance of dye in
choroid, retinal arteries, veins can be used to implicate
flow through imaged vessels.
 To look for capillary non perfusion &
neovascularization
Retinal neovascularisation.

31.  Medical management : glycemic control,
hypertension, hyperlipidemia, anemia, renal transplant
 Laser treatment
 Injections ( Intravitreal) : Avastin / Accentrix
 Surgical treatment

32.  DR is a risk marker of other systemic vascular
complications
 So even if DR is mild, it triples the risk of CHD, Stroke
& Heart failure1,2,3
1) Cheung N. DR an independent risk factor for ischaemic stroke. Stroke 2007; 38: 398-
401
2 )Cheung N. DR and risk of CHD. Diabetes Care 2007; 30: 1742-46
3) Cheung N. DR and heart failure. J Am Coll Cardiol 2008; 51:1573-78

33.  Dyslipidemia
hypertriglyceridemia
high LDL
Low HDL
ETDRS study found: 36% had cholesterol level more
than 240mg/dl & 26% had LDL more than 160mg/dl
Ophthalmology 1998 suppl 741-56; 1991

34.  EURODIAB
 EUCLID
 ADVANCE
 UKPDS
Every 10 mm of Hg increase in SBP increases risk
of non proliferative retinopathy by 10% &
proliferative retinopathy by 15%1
1Wisconsin epidemiologic study of progression of diabetic retinopathy .Ophthalmology
2008;115: 1859-68

35.  For every 1% reduction in HbA1c there is a 37% decrease in
laser treatment & 10% reduction in cataract extraction
 For every 10 mm Hg reduction in the systolic B.P., there is
11% reduction in need of laser treatment
 Statins decrease lipid exudation in macula
 Anemia: since it also causes tissue hypoxia
 RenalTransplant: stabilizes retinopathy in majority of cases

36. A major therapeutic modality in the management of
retinochoroidal & vitreal disorders. Laser -
 Reduces demand and improves circulation
 Converts hypoxaemic area to anoxiaemic one
 Reduces forming of neovascular growth factor
 Helps formation of neovascular inhibitory factor
 Removes custom barrier of pigment epithelium
 Reduces bleeding chances
 Prevents causation of PVD

37. Suggested follow-up
Retinal Finding
Annually
Normal
Every 9 months
Mild NPDR
Every 6 months
Moderate NPDR
Every 4 months
Sever NPDR
Every 2- 4 months
CSME
Every 6 months
CNSME
Every 2-3 months
PDR

38.  Extensive bleeding from damaged blood vessels calls for
vitrectomy.
 Vitrectomy is performed if a lot of blood in the vitreous.
 Vitrectomy is often done under local anesthesia
 Vision gradually improves after the vitrectomy, and the
vitreous humor is gradually replaced.
 Even people with advanced retinopathy have a good chance
of keeping their vision if it is treated before the retina is
severely damaged

39.  Every diabetic is a potential candidate for D.R.
 80% of diabetics need only follow up and
management of systemic risk factors
 Only 20% need active intervention by Eye specialist
 Symptomless
 All diabetics – annual retina exam is a MUST
 Prevention of development and progression of DR :
Our aim
Please do remember !

40. Summary
• Lack of patient awareness still persisting
• Visual loss due to DR can be prevented /
reduced by adopting following measures :-
 Early diagnosis & prompt referral
 Tight control of Blood glucose level
 Periodical screening
 Judicious use of Laser photocoagulation
 Timely surgical intervention
 Patient, Physician, Diabetologist & Ophthalmologist must
join hands to prevent visual loss due to Diabetic
Retinopathy

41. VA = CF @ 1 METER VA = 6/60

42. VA =6/18 VA= 6/9

43. VA = 6/6
PRE- TREATMENT (
VA=HM+)

44. VA = 6/18