This document provides information on diabetic retinopathy including its definition, risk factors, stages, symptoms, pathogenesis, epidemiology, screening recommendations, treatment options, and importance of prevention. It defines diabetic retinopathy as progressive retinal blood vessel dysfunction caused by hyperglycemia. Key points covered include the stages ranging from mild non-proliferative DR to proliferative DR, as well as treatments such as laser photocoagulation, anti-VEGF injections, and vitrectomy. Strict blood sugar and blood pressure control along with annual eye exams are emphasized for prevention of vision loss from this common diabetes complication.

1. DIABETIC RETINOPATHY

2. Learning Objectives
• At the end of the class, students shall be able to
• Recognize the importance of diabetic retinopathy as a public
health problem
• Identify the risk factors for diabetic retinopathy
• Describe and distinguish between the stages of diabetic
retinopathy
• Understand the role of risk factor control and annual dilated
eye examinations in the prevention of vision loss
2

3. Diabetes Mellitus
Diabetes Mellitus is a group of diseases characterized by high
blood glucose levels. Diabetes results from defects in the
body's ability to produce and/or use insulin.
• Type 1 diabetes is usually diagnosed in children and young
adults. In type 1 diabetes, the body does not produce insulin.
About 10% of people with diabetes have this form of the
disease.
• In Type 2 diabetes, either the body does not produce enough
insulin or the cells ignore the insulin. This is the most
common form of diabetes.
3

4. Diabetic Retinopathy (DR)
Definition
•Progressive dysfunction of the retinal blood
vessels caused by chronic hyperglycemia.
•DR can be a complication of type 1 or type 2
diabetes
•Initially, DR is asymptomatic
•If not treated, it can cause low vision and
blindness.
4

5. Diabetic Retinopathy Epidemiology
•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 people of working age in industrialized
countries.
5

6. Diabetic Retinopathy Epidemiology
•The best predictor of diabetic retinopathy is the duration
of the disease
•After 20 years of diabetes, nearly 99% of patients with
type 1 diabetes and 60% with type 2 have some degree
on 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.
-

7. Risk factors for 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
7

8. Duration of diabetes
•The best predictor of diabetic retinopathy is duration
of the disease
•After 20 years of diabetes, more than 90% of patients
with type 1 diabetes and 60% with type 2 have some
degree on 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.
8

9. Other Risk factors
9
• Poor Blood Sugar control
• Hypertension
• Hyperlipidemia
• Pregnancy
• Nephropathy
• Others: Smoking, Obesity,
Anemia

10. Diabetic retinopathy symptoms
Asymptomatic in early stages of the disease
As the disease progresses symptoms may
include
•Blurred vision
•Floaters
•Fluctuating vision
•Distorted vision
•scotoma
•Poor night vision
•Impaired color vision
•Partial or total loss of vision
10

11. Pathogenesis of Diabetic Micro angiopathy
Diabetic Retinopathy is a microvasculopathy that causes:
• Retinal capillary occlusion
• Retinal capillary leakage
Microvascular occlusion is caused by:
• Thickening of capillary basement membranes
• Abnormal proliferation of capillary endothelium
• Increased platelet adhesion
• Increased blood viscosity
• Defective fibrinolysis
Microvascular leakage is caused by:
• Impairment of endothelial tight junctions
• Loss of pericytes
• Weakening of capillary walls
• Elevated levels of vascular endothelial growth factor (VEGF)
11

12. Cotton –
wool spots
Neovascularization
Ischemia
Neovascular
glaucoma
Microvascular
Occlusion
Fibrovascular
bands
Vitreous
hemorrhage
Increased VEGF
Tractional retinal
detachment
Infarction
12

13. Edema
Retinal
hemorrhage
s
Hard exudates
Microvascular Leakage
13

14. Pathogenesis
Normal Diabetic retinopathy

15. Healthy Retina Diabetic Retinopathy
15

16. Natural History of Diabetic
Retinopathy
• Mild nonproliferative
diabetic retinopathy (NPDR)
• Moderate NPDR
• Severe NPDR
• Very Severe NPDR
• Proliferative diabetic
retinopathy (PDR)
16

17. Findings Obsd
International Clinical Diabetic Retinopathy Disease Severity
Scale
Proposed Disease Severity Level
Findings Observable upon Dilated Ophthalmoscopy
No apparent retinopathy No abnormalities
Mild nonproliferative diabetic retinopathy Microaneurysms only
Moderate nonproliferative diabetic retinopathy
More than just microaneurysms but less than severe
NPDR
Severe nonproliferative diabetic retinopathy
Any of the following:
More than 20 intraretinal hemorrhages in each of
four quadrants
Definite venous beading in two or more quadrants
Prominent IRMA in one or more quadrants
and no signs of proliferative retinopathy.
Proliferative diabetic retinopathy
One or both of the following:
Neovascularization
Vitreous/preretinal hemorrhage 17

18. No retinopathy
18

19. Microaneurysms
•Focal dilatations of retinal capillaries
•Appear as red dots.
•Seen at the posterior pole, especially temporal
to the fovea.
•The first ophthalmoscopically detectable change
in diabetic retinopathy.
19

20. Retinal Haemorrhages
Dot haemorrhages
• In the inner nuclear layer or outer plexiform
layer
• Bright red dots (same size as large micro
aneurysms).
Dark Blot/ round haemorrhages
• Larger lesions
• Located within the mid retina
• Extent – marker for neovascularization
Flame Shaped haemorrhages
• Superficial and in the nerve fiber layer
20

21. Non-proliferative diabetic retinopathy (NPDR)
21

22. Non-proliferative diabetic retinopathy (NPDR)
22

23. Hard exudates ( Intra-retinal lipid exudates )
•Yellowish waxy looking patches with distinct
margins
•Outer plexiform layer
•Surrounding capillaries and
microaneurysms.
23

24. Hard exudates ( Intra-retinal lipid exudates )
24

25. Cotton Wool Spots
•Occlusion of retinal pre-capillary
arterioles supplying the nerve fibre layer
with concomitant swelling of local nerve
fibre axons.
•“Soft exudates" or "nerve fibre layer
infarctions"
•White, fluffy lesions in the nerve fibre
layer.
25

26. Cotton Wool Spots
26

27. Late non proliferative changes
Intra-retinal microvascular abnormalities (IRMA)
•Represent intraretinal arteriolar-venular shunts which
have not breached the internal limiting membrane of
the retina.
•Indicate severe non-proliferative diabetic retinopathy
that may rapidly progress to proliferative retinopathy.
Venous beading
•Focal narrowing and sausage-shaped dilatation of the
retinal veins.
•Sign of severe non proliferative diabetic retinopathy.
27

28. Late non proliferative changes
28

29. Clinical Findings
•Micro aneurysms
•Management/Treatment
•Annual follow-up
29
MILD NONPROLIFERATIVE
DIABETIC RETINOPATHY

30. MILD NONPROLIFERATIVE DIABETIC
RETINOPATHY
Microaneurysms
30

31. •Clinical Findings
•Micro aneurysms/ medium to large Intraretinal
hemorrhages in 1- 3 quadrants
•Mild Intraretinal Microvascular Abnormalities (IRMA’s)
•Venous beading in not more than 1 quadrant
• Cotton wool spots
•Management/Treatment
•6-12 month follow-up without CSME
•Color fundus photography
31
Moderate Nonproliferative Diabetic Retinopathy (NPDR)

32. Moderate Nonproliferative Diabetic
Retinopathy (NPDR)
Hard exudates
Flamed shaped
hemorrhage
Microaneurysm
32

33. Severe Nonproliferative Diabetic Retinopathy
(NPDR)
Clinical Findings
Any of the following: (4-2-1 Rule)
• More than 20 intraretinal hemorrhages in each of four quadrants
• Definite venous beading in two or more quadrants
• Prominent Intraretinal Microvascular Abnormalities (IRMA) in
one or more quadrants
• And no signs of proliferative retinopathy
33

34. Severe Nonproliferative Diabetic Retinopathy (NPDR)
Management/Treatment
• 3-4 month follow-up
• Color fundus photography
• Possible pan retinal photocoagulation
• CSME present: color fundus photography, fluorescein
angiography, focal photocoagulation, 3-4 month follow-up
34

35. Severe Nonproliferative Diabetic Retinopathy
(NPDR)
Venous beading
35

36. •Clinical Findings
•Ischemia induced neovascularization
•at the optic disk (NVD)
•elsewhere in the retina (NVE)
•New vessels on the iris (NVI)
•Vitreous hemorrhage/Pre-retinal hemorrhage
•Retinal traction, tears, and detachment
36
Proliferative Diabetic Retinopathy (PDR)

37. Proliferative Diabetic Retinopathy (PDR)
•Management/Treatment
–2-4 month follow-up
–Color fundus photography
–Pan retinal photocoagulation (3-4 month
follow-up)
–Vitrectomy
37

38. PROLIFERATIVE
DIABETIC
RETINOPATHY
Neovascularization
Neovascularization
Hard exudate
Cotton-wool
spot
Blot hemorrhage
38

39. PROLIFERATIVE DIABETIC RETINOPATHY
39

40. High-Risk Proliferative diabetic retinopathy
At risk for serious vision loss
Any combination of three of the following four findings
• NVD <1/4 disc area with vitreous or preretinal hemorrhage.
• NVE > 1/2 disc area with vitreous or preretinal hemorrhage.
• NVD 1/4 to 1/3 disc area with or without vitreous or preretinal
hemorrhage.
• Moderate to severe extent of new vessels.
40

41. 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.
41

42. 42
Meta analysis and review on the effect on bevacizumab in diabetic macular edema
Graefes Arch Clin Exp Ophthalmol(2011) 249:15-27

43. 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.
•The ability to read and
recognize faces will be
compromised.
43
Macula
Fovea

44. 44
• Normal • Macular Edema

45. Clinically significant Diabetic macular edema
(CSDME)
•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.
45

46. 46
Imaging of macular edema with optical
coherence tomography

47. Advanced diabetic eye Disease
•Persistent vitreous haemorrhage
•Diabetic tractional retinal detachment
•Neovascular Glaucoma
47

48. Clinical Stages of Retinopathy
Vitreous hemorrhage

49. Late Complications
49
TRACTIONAL RETINAL DETACHMENT

50. Clinical Stages of Retinopathy
New vessel growth

51. Diabetic Eye Disease
Key Points
•Treatments exist but work best
before vision is lost
51
RECOMMENDED EYE EXAMINATION
SCHEDULE
Diabetes Type Recommended Time of
First Examination
Recommended Follow-
up*
Type 1 3-5 years after
diagnosis
Yearly
Type 2 At time of diagnosis Yearly
Prior to pregnancy
(type 1 or type 2)
Prior to conception and
early in the first
trimester
No retinopathy to mild
moderate NPDR every
3-12 months
Severe NPDR or worse
every 1-3 months.
*Abnormal findings may dictate more frequent follow-up examinations

52. Screening for diabetic eye problems should
ideally include the following
•The history of any visual symptoms or changes in
vision
•Measurement of visual acuity
•Iris examination by slit lamp biomicroscopy prior to
pupil mydriasis.
•Pupil mydriasis. ( tropicamide 0.5 %
•Patients should be accompanied by a relative and
instructed not to drive home.
•Examination of the crystalline lens
•Fundus examination
52

53. PREVENTION
53
90 percent of diabetic eye disease can
be prevented simply by proper regular
examinations, treatment and by
controlling blood sugar.

54. Primary prevention
Strict glycemic control
Blood pressure control
Secondary prevention
Annual eye examination
Tertiary prevention
Retinal Laser photocoagulation
Intravitreal Injections of Anti VEGF
Vitrectomy
54

55. DIABETIC RETINOPATHY TREATMENT
55
The best measure for prevention of loss
of vision from diabetic retinopathy is
strict glycemic control

56. Laser Photocoagulation
Laser Photocoagulation is recommended for eyes
with:
•Clinical significant macular edema CSME
•High risk Proliferative diabetic retinopathy
56

57. Treatment

58. Panretinal laser photocoagulation
58

59. Anti VEGF Injections
•Aflibercept
•Ranibuzumab
•Bevacizumab
59

60. VITRECTOMY
•Remove vitreous
hemorrhage
•Repair retinal
detachment
•Allow treatment
with PRP

61. Treatment

62. CONCLUSIONS
62
Diabetic Retinopathy is
preventable through strict
glycemic control and annual
dilated eye examination by an
ophthalmologist.

63. "Alone we can do so little, together we can do so much.”
Helen Keller

64. References
• http://www.ncbi.nlm.nih.gov/pubmed/19896746
• http://www.aao.org/eyecare/news/upload/Eye-Health-Fact-
Sheet.pdf
• http://www.who.int/bulletin/volumes/82/11/en/844.pdf
• http://jama.ama-assn.org/content/304/6/649.short?rss=1
• http://www.aao.org/newsroom/release/20091030.cfm
• http://www.diabetes.org/diabetes-basics/?loc=GlobalNavDB
• http://www.ophed.com/group/2205