Dr.Nupur Ophthalmology PG NMCH,Patna

1. DIABETIC
RETINOPATHY
PRESENTER : DR NUPUR ( 1ST YR PG)
N.M.C.H PATNA

2. DIABETES MELLITUS
 Diabetes mellitus is a group of metabolic disease
characterized by hyperglycemia resulting from defects in
insulin secretion, insulin action, or both
 The chronic hyperglycemia of diabetes is associated
with long-term damage, dysfunction, and failure of
various organs, especially the eyes, kidneys, nerves,
heart, and blood vessels.
# American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes
Care. 2004;27(suppl 1):S5-S10

3.  Type 1 diabetes (β-cell destruction,
usually leading to absolute insulin
deficiency)
Type 2 diabetes ( insulin resistance with
relative insulin deficiency )
Types of
DM
# American Diabetes Association. Diagnosis and classification of diabetes mellitus,2007

4. OPHTHALMIC COMPLICATIONS OF
DIABETES
 COMMON
RETINOPATHY
IRIDOPATHY
UNSTABLE REFRACTION.
 UNCOMMON
RECURRENT STYES
XANTHELASMA
ACCELERATED AGE-RELATED
CATARACT
NEOVASCULAR GLAUCOMA
(NVG)
OCULOMOTOR NERVE PALSIES.
REDUCED CORNEAL
SENSITIVITY
 RARE
PAPILLOPATHY,
PUPILLARY LIGHT-NEAR
DISSOCIATION
WOLFRAM SYNDROME
ACUTE- ONSET CATARACT
RHINO-ORBITAL
MUCORMYCOSIS.
# kanski’s clinical ophthalmology, 9e

5. DEFINITION OF DIABETIC
RETINOPATHY
 Diabetic retinopathy is a chronic progressive,
potentially sight-threatening disease of the
retinal microvasculature associated with the
prolonged hyperglycaemia and other
conditions linked to diabetes mellitus such as
hypertension.
https://www.rcophth.ac.uk/wp-content/uploads/2021/08/2012-SCI-267-Diabetic-Retinopathy-Guidelines-December-
2012

6. What is The Retina?
• The retina is a multilayered, light sensitive neural
tissue lining the inner eye ball. Light is focused onto
the retina and then transmitted to the brain through the
optic nerve.
• The macula is a highly sensitive area in the center of
the retina, responsible for central vision.

8. #aao.org/education/topic-detail/diabetic-retinopathy-europe,oct 2016

9. Sampe size: 63,000 ; age ≥50yrs
*sight-threatening diabetic retinopathy (STDR)

11. PATHOPHYSIOLOGY
Diabetic Retinopathy is a
microvasculopathy that causes:
• Retinal capillary occlusion
• Retinal capillary leakage
https://www.aao.org/education/topic-detail/diabetic-retinopathy-europe

12. Pathophysiology
https://www.aao.org/education/topic-detail/diabetic-retinopathy-europe

13. RISK FACTORS
 Non modifiable
Duration and age at onset
Puberty
 Modifiable Risk Factors
Diabetic control/ HbA1c
Hypertension
Pregnancy
 OTHERS : Hyperlipidemia, Smoking, Obesity

14. Risk factors 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
http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=d0c853d3-219f-487b-a524-326ab3cecd9a

15. Type 1 DM
DURATION
(YRS)
DR PDR
AFTER 5 YRS 25%
AFTER 10 YRS 60%
AFTER 15 YRS 80%
AFTER 20-30 YRS 95% 30- 50%
# https://www.aao.org/education/topic-detail/diabetic-retinopathy-europe
# Myron Yanoff and Jay S. Duker: Ophthalmology,5e

16. Type 2 DM
DURATION (YRS) DR PDR
Yanko et al.
11-13 23% 3%
≥16 60%
Klein et al.
10 67% 10%
# Myron Yanoff and Jay S. Duker: Ophthalmology,5e
$ https://www.aao.org/education/topic-detail/diabetic-retinopathy-europeMyron
$ PDR will develop in 2% of patients if duration of DM is < 5 years and 25% if >
25 years

17. Puberty
 Pre pubertal children (< 12 yrs) rarely develop
complications of diabetes.
 Puberty is a risk factor for developing retinopathy
because of the physiological increased resistance to
insulin.
 Klein et al found that diabetes duration post menarche
was associated with 30% increase risk or retinopathy
compared with diabetes duration before menarche.

18. HbA1c
DCCT showed in T1DM:
Tight control had 76% reduction in rate of developments of DR (
primary prevention cohort) and 54% reduction in progression of
established DR ( secondary intervention cohort)
as compared to
conventional treatment group
*The Diabetes Control and Complications Trial (DCCT);
* tight control ( 4 measurements/day)
* conventional treatment group ( one measurement per day)

19. HbA1c
 The DCCT : every 1% decrease in HbA1C level
decrease the incidence of diabetic retinopathy by 28% .
 Target HbA1c value of 6 - 7% ( kanski’s clinical ophthalmology, 9e)

20. Hypertension
 HTN is common in patients with T2DM.
 Target BP <140/80 mm hg (# kanski’s clinical ophthalmology, 9e)
 Tight control appears to be particularly beneficial in
T2DM with maculopathy.
# kanski’s clinical ophthalmology, 9e

21.  Gestational diabetes does not require an eye examination during pregnancy
and does not increase the risk of diabetic retinopathy.
 Diabetic retinopathy can worsen during pregnancy
 Macular edema in pregnant patients can improve with delivery
 Diabetic retinopathy in a pregnant patient is not a contraindication for natural
vaginal delivery.
Pregnancy
# https://www.aao.org/education/topic-detail/diabetic-retinopathy-europeMyron

22. PREGNANT DIABETIC
WOMEN
RISK OF DEVELOPMENT REMARKS
WITHOUT DR  NPDR 10%
NPDR  PDR 4%
UNTREATED PDR REQUIRE - PAN RETINAL
PHOTOCOAGULATION
(PRP)
TREATED PDR USUALLY DOES NOT
WORSEN
Pregnancy
# Myron Yanoff and Jay S. Duker: Ophthalmology, 5e

23. Approximate equivalence of currently used alternative
classification systems for diabetic retinopathy
ETDRS NSE SDRGS AAO
INTERNATIONAL
None R0 none R0 none No apparent
retinopathy
Microaneurysm
only
R1 background R1 mild
background
Mild NPDR
Mild NPDR Mod NPDR
Moderate NPDR R2
preproliferative
R2 moderate
BDR
Moderately severe
NPDR
Severe NPDR R3 severe BDR Severe NPDR
Very severe NPDR
Mild PDR R3 proliferative R4 PDR PDR
Moderate PDR
High risk PDR
ETDRS = Early Treatment Diabetic Retinopathy Study; AAO = American Academy of Ophthalmology; NSC = National Screening Committee; SDRGS =
Scottish Diabetic Retinopathy Grading Scheme; NPDR = non-proliferative diabetic retinopathy; BDR = background diabetic retinopathy; PDR = proliferative
diabetic retinopathy;
# https://www.rcophth.ac.uk/wp-content/uploads/2021/08/2012-SCI-267-Diabetic-Retinopathy-Guidelines-December-2012

24. NO DR
 DESCRIPTION
No evidence of retinal
vascular disease
 FOLLOW-UP
Yearly with dilated
funduscopic exams

25. MILD NPDR
 DESCRIPTION
ETDRS: ≥ 1 microaneurysm with
no other findings
Kanski: Any or all :
microaneurysms, retinal
hemorrhages, exudates, cotton
wool spots, up to the level of
moderate NPDR with no IRMAs
or venous beading
 FOLLOW-UP
6-12 months with dilated
funduscopic exam
There are a few cotton-wool spots and intraretinal
hemorrhages in this photograph, which doesn't really
fit the ETDRS/International classification for true mild
NPDR. Might still mild NPDR, because while there
are multiple hemorrhages and cotton-wool spots,
there are still < 20 per quadrant.
Published in: Community Eye Health Journal Vol. 24, No.
75, September 2011
(www.cehjournal.org)

26. # kanski’s clinical ophthalmology, 9e

27. MODERATE NPDR
 DESCRIPTION
Any of the following:
≥ 20 intraretinal hemorrhages in 1-3 quadrants
Venous beading in no more than 1 quadrant
Presence of mild intraretinal microvascular abnormalities
(IRMAs) in no more than 1 quadrant
Cotton-wool spots commonly present.
 FOLLOW-UP
6 months with dilated funduscopic exam
 PROGNOSIS
PDR in up to 26% and high risk PDR in up to 8% within a
year.
# kanski’s clinical ophthalmology, 9e

28. Haemorrhages

29. Venous changes
# kanski’s clinical ophthalmology,
9e

30. Intraretinal microvascular abnormalities
(IRMA)
# kanski’s clinical ophthalmology, 9e

31. Cotton-wool spots
Fig : Cotton-wool spots and IRMA,
# kanski’s clinical ophthalmology, 9e

32. SEVERE NPDR
 DESCRIPTION
One of the following (4-2-1 rule):
4 quadrants of ≥ 20 hemorrhages
≥ 2 quadrants of venous beading
≥ 1 quadrant of IRMAs
 FOLLOW-UP
4 months with dilated funduscopic
exam
 PROGNOSIS
PDR in up to 50% and high risk PDR
in up to 15% within a year.
# kanski’s clinical ophthalmology, 9e

33. VERY SEVERE NPDR
 DESCRIPTION
≥ 2 of the 4-2-1 criteria
 FOLLOW-UP
2-3 months with dilated
funduscopic exam
 PROGNOSIS
High-risk PDR in up to 45%
within a year.
FIG: cotton-wool, spots, IRMA, and venous beading;
Yanoff and Jay S. Duker: Ophthalmology,5e
# kanski’s clinical ophthalmology, 9e

34. PROLIFERATIVE DIABETIC
RETINOPATHY
 Proliferative diabetic retinopathy (PDR) is
characterized by neovascularization arising
from the optic disc and retina, which may
cause preretinal and vitreous hemorrhage.

35. Proliferative diabetic retinopathy
 Mild – moderate PDR
NVD <1/3 disc area or
NVE <1/2 disc area
(NVD or NVE :insufficient to meet high risk criteria)
 High risk PDR
NVD > 1/3 disc area
Any NVD with vitreous haemorrhage
NVE > 1/2 disc area with vitreous haemorrhage
*New vessels on the disc (NVD); New vessels elsewhere (NVE)
# kanski’s clinical ophthalmology, 9e

36. PDR

37. PDR

38. High risk PDR

39. PDR

40. ADVANCED DIABETIC EYE
DISEASE
 Hemorrhage :
Preretinal hemorrhage ( retrohyaloid),
Intragel haemorrhage or
Both
 Tractional retinal detachment
 Rubeosis iridis
# kanski’s clinical ophthalmology, 9e

41. ADVANCED DIABETIC EYE
DISEASE
# kanski’s clinical ophthalmology, 9e

42. 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.

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

44. 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.
Macula
Fovea

45. International Clinical Diabetic Macular Edema
Disease Severity Scale
Proposed disease severity level Findings observable upon dilated
ophthalmoscopy
DME apparently absent
DME apparently present
DME present
No apparent retinal thickening or hard
exudates in posterior pole
Some apparent retinal thickening or hard
exudates in posterior pole
Mild DME (some retinal thickening or hard
exudates in posterior pole but distant from
the center of the macula)
Moderate DME (retinal thickening or hard
exudates approaching the center of the
macula but not involving the center)
Severe DME (retinal thickening or hard
exudates involving the center of the macula)
American Academy of Ophthalmology Retina -Vitreous Panel. Preferred
Practice Pattern® American Academy of Ophthalmology; 2014

46. DME

47. Clinically Significant Macular
Edema
 Retinal thickening located at or within 500 μm of the
center of the macula
 Hard exudates at or within 500 μm of the center if
associated with thickening of adjacent retina
 A zone of thickening larger than 1 disc area (1500 μm) if
located within 1 disc diameter of the center of the macula
# Source: Basic and Clinical Science Course, Section 12, American Academy of Ophthalmology, 2014-2015.

48. CSME

49. DIABETIC MACULOPATHY (DM)
 DM is further classified as:
Focal maculopathy
Diffuse maculopathy
Ischaemic maculopathy
Mixed
# kanski’s clinical ophthalmology, 9e

50. Focal maculopathy
 DESCRIPTION
Well circumscribed
Retinal thickening
Complete/incomplete ring of
exudates
 FA :
Late, focal hyperfluorescence
Good macular perfusion
# kanski’s clinical ophthalmology, 9e

51. Diffuse maculopathy
 DESCRIPTION
Diffuse
Retinal thickening
Cystoid changes
Scattered microaneurysms
Small hemorrhages
 FA :
Mid to Late, diffuse hyperfluorescence
# kanski’s clinical ophthalmology, 9e

52. Ischaemic maculopathy
 DESCRIPTION
Macula may look relatively
normal
Reduced visual acuity
PPDR may be present
 FA :
Capillary non-perfusion at
fovea, posterior pole and
periphery
# kanski’s clinical ophthalmology, 9e

53. Diabetic Eye Disease
Key Points
 Treatments exist but work best
before vision is lost
RECOMMENDED EYE EXAMINATION
SCHEDULE
Diabetes Type Recommended Initial
Evaluation
Recommended Follow-
up*
Type 1 5 years after diagnosis Yearly
Type 2 At time of diagnosis Yearly
pregnancy
(type 1 or type 2)
Soon after conception
and early in the first
trimester
No retinopathy to mild
or moderate NPDR :
every 3-12 months
Severe NPDR or worse:
every 1-3 months.
*Abnormal findings may dictate more frequent follow-up examinations
h ttp://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=d0c853d3-219f-487b-a524-326ab3cecd9a

54. SYMPTOMS
 Asymptomatic
 Decreased vision
 Floaters
 Metamorphopsia
 Symptoms of retinal detachment
https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ

55. OCULAR EXAMINATION
 Visual acuity
 Intraocular pressure
 Slit lamp biomicroscopy
 Gonioscopy before dilating pupils
 Funduscopic examination of the posterior pole under dilated
pupil
 Examination of peripheral retina and vitreous under dilated
pupil
https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ

56. IMAGING
 Digital photography
 Fluorescein angiography
 optical coherence tomography (oct)

57. TREATMENT OF DIABETIC RETINOPATHY
 Effective in 90% of cases to prevent severe visual loss
 Good glycemic control
 Adequate control of hypertension
 Encourage changes in lifestyles
 Treatment options
 Laser therapy
 Anti-VEGF drugs (ranibizumab, aflibercept, bevacizumab)
 Surgery
https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ

58. Treatment of diabetic retinopathy
 HbA1c target (6.5-7.5%).
 NPDR with T2DM : Add fenofibrate with statin
 Macular edema : No pioglitazone
 Systolic BP ≤130mmHg : Retinopathy and/or nephropathy
 Systolic BP < 140mmHg : Without retinopathy,
 Pregnancy : No statin
(Diabetic patients planning pregnancy should be informed on the need for assessment of diabetic retinopathy before and during
pregnancy; Tropicamide alone should be used if mydriasis is required during pregnancy )
https://www.rcophth.ac.uk/wp-content/uploads/2021/08/2012-SCI-267-Diabetic-Retinopathy-Guidelines-December-2012

59. Treatment of diabetic
retinopathy
DIABETIC
PREGNANT
WOMEN
1ST ANTENATAL
VISIT
2ND VISIT AT
(FOLLOW UP)
NO DR 28 WEEKS
DR 16-20 WEEKS
PPDR DURING
PREGNANCY
AT LEAST 6 MONTHS
FOLLOWING DELIVERY
(Macular edema in pregnant patients can improve with delivery, no
intravitreal anti-VEGF is recommended. Consider intravitreal steroids.)
https://www.rcophth.ac.uk/wp-content/uploads/2021/08/2012-SCI-267-Diabetic-Retinopathy-Guidelines-December-
2012

60. Treatment of diabetic macular edema
 Laser Therapy
Focal laser : FDA approved based on ETDRS findings
Micropulse laser
 Anti-VEGF Drugs
Aflibercept
Ranibizumab
Bevacizumab
https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ
*Anti-VEGF injections are considered the new gold standard of therapy for eyes
with centre-involving macular oedema and reduced vision

61. Treatment of diabetic macular edema
 Steroids
Intravitreal Injections
Intravitreal implants
 Ozurdex (Dexamethasone)
 Iluvien (Flucinolone Acetonide)
 Surgery
Consider in cases of vitreomacular traction
 Tractional retinal detachment
https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ

62. INITIAL MANAGEMENT RECOMMENDATIONS FOR PATIENTS
WITH DIABETES
*Adjuncttive treatments that may be considered include intravitreal corticosteroids or anti-VEGF
agents.
Source: American Academy of Ophthalmology Retina -Vitreous Panel. Preferred Practice Pattern® Guidelines

63. DIABETIC RETINOPATHY