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Diabetic retinopathy
- 1. DIABETIC RETINOPATHY Dr Shyam Kumar Sah Final Year PG Scholar SDM College of Ayurveda & Hospital Hassan, Karnataka E-mail: drsksah99@gmail.com
- 2. Normal Fundus Diabetic Retinopathy 2 5/7/2019
- 3. Introduction DR is a common medical condition that develops in patient with DM over a prolonged period It is progressive dysfunction of Retinal Blood Vessels (Microangiopathy) by Chronic Hyperglycaemia. Early Symptoms: Floaters, Distortion & Blurred vision Early Sign: Microaneurysm It is one of the sight threatening complications of Diabetes Leading causes of avoidable blindness 3 5/7/2019
- 5. Prevalence & Incidence of DM India is the Diabetes capital of the world. 72 million cases recorded in 2017 and may be doubled by 2025 Prevalence of DM: Type I > Type II Blindness Risk 25 times more in diabetics than other eye diseases. Gender: Female>Male ; 4:3 Between 15-30 years, 95% of both diabetics develop retinopathy. 33% of patients with DM have signs of DR 5 5/7/2019
- 6. Risk Factors Duration: 1. After 10 years: 20% T1DM & 25% T2DM develop DR 2. After 20 years: 90% T1DM & 60% T2DM develop DR 3. After 30 years: 95% both T1DM & T2DM develop DR Heredity- more PDR Pregnancy Hypertension Nephropathy Hyperlipidemia, Obesity, Anaemia, Smoking Cataract surgery Poor control of diabetes 6 5/7/2019
- 8. 8 5/7/2019
- 9. Classification of DR 1. NPDR 2. Mild NPDR 3. Moderate NPDR 4. Severe NPDR 5. Very severe NPDR 6. PDR 7. Diabetic Maculopathy 8. Advanced Diabetic Eye Disease (ADED) 9 5/7/2019
- 10. ETDRS classification 1.Non-proliferative diabetic retinopathy (NPDR) No DR Very mild NPDR: microaneurysms only Mild NPDR: microaneurysms, RH, Exudates, CWS. No IRMA or significant beading Moderate NPDR: • Severe RH in 1–3 quadrants or mild IRMA • Significant venous beading at least in one quadrant • Cotton wool spots commonly present Severe NPDR: 4–2–1 rule 4-: 1 or more severe haemorrhages in all 4 quadrant, 2: Venous beading in 2 or more quadrants 1: IRMA in 1 or more quadrants Very severe NPDR: 2 or more of the criteria for severe NPDR 2.Proliferative diabetic retinopathy (PDR) Mild-moderate PDR: NVD or NVE High Risk PDR: NVD about 1/3 disc area, Any NVD with VH NVE greater than 1/2 disc area with VH 3.Diabetic Maculopathy: DME and CSME. 4.Advance diabetic eye disease (ADED): Persistent VH, TRD and NV Glaucoma 10 5/7/2019
- 11. Non-Proliferative Diabetic Retinopathy Mild NPDR: at least one microaneurysm present MA 11 5/7/2019
- 12. Moderate NPDR Microaneurysm/ Intraretinal Haemorrhage in 2 or 3 quadrants. Early mild IRMA Hard/ soft exudates may or may not present IRMA MA +IRH DOT & BLOT Haemorrhage CWS 12 5/7/2019
- 13. Severe NPDR 4-2-1 rule. i.e. 4: 1 or more severe haemorrhages in all 4 quadrants 2: Venous beading in 2 or more quadrants 1: IRMA in 1 or more quadrants Haemorrhage in all quadrants Venous beading Hard exudates 13 5/7/2019 IRMA
- 14. Very severe NPDR Any 2 of the 4-2-1 rule criteria 4 quadrants of MA 2 quadrants of Venous beading 1 quadrant of IRMA changes 14 5/7/2019
- 15. PDR PDR WITHOUT HRC • Mild-moderate PDR: NVD or NVE PDR WITH HRC •NVD about 1/4 to 1/3 disc area with or without VH or PRH •NVD <1/4 disc area with VH or PRH •NVE > 1/2 disc area with VH or PRH Vitreous Haemorrhage NVD NVE NVE PRH 15 5/7/2019
- 16. Diabetic Maculopathy: DME and CSME Macular pathology due to DM. They are DME & CSME It may be associated with NPDR or PDR DME occurs due to increased permeability of retinal capillaries. CSME is defined according to ETDRS protocol as: 3 criteria Retinal thickening at or within 500 micron or 1/3 disc diameter of centre of macula Hard exudates at or within 500 micron of the centre of Fovea + adjacent retinal thickening Retinal thickening GREATER than 1 disc diameter in size which is within 1 disc diameter from the centre of the macula. 16 5/7/2019
- 17. Clinico-angiographic classification of Diabetic Maculopathy 1. Focal Exudative Maculopathy: MA, IRH, Macular edema & Hard exudates (arranged in RING pattern). FFA shows leakage 2. Diffuse Exudative Maculopathy: Diffuse retinal edema, thickening throughout the posterior pole and Hard exudates. FFA shows diffuse leakage at posterior pole (CME) 3. Ischemic Maculopathy: Occurs due to microvascular blockage. Clinical signs: LOV, MA, IRH, Mild or No Macular Edema and a few hard exudates. FFA-non perfusion at FAZ & in advance cases pre- capillary arterioles block seen 4. Mixed Maculopathy: Combined features of Focal, Diffuse & Ischemic Maculopathy. 17 5/7/2019
- 19. OCT Classification of Macular Edema On the basis of OCT, DME has been classified as: Non Tractional DME I. Spongy Thickness of Macula >250 micro meter II. CME III. Neurosensory Detachment (RD) with or without I & II Tractional DME I. Vitro-foveal traction (VFT) II. Taut/Thickened Posterior Hyaloid Membrane 19 5/7/2019
- 22. Advance Diabetic Eye Disease (ADED) It is the end product of uncontrolled PDR i.e Complication of PDR I. Persistent VH II. TRD III. NVG (Rubiosis Iridium) TRD VH VH 22 5/7/2019
- 23. NVI Macular Hole RD RD Macular Hole+ SRF NVI RD Macular Hole SRF 23 5/7/2019
- 24. Investigations 1. Blood sugar F/PP/R/OGTT 2. Urinary R/E & Microalbumin Test 3. Renal function tests 4. Lipid profile 5. Haemogram 6. HbA1C 7. FFA – to R/O NV, Leakage and capillary non perfusion 8. OCT 9. B-scan 10.Perimetry 24 5/7/2019
- 25. Prevention 1.Primary Prevention – •Strict glycaemic control, •Blood pressure control, •correction of dyslipidaemia, •control of associated anaemia, •control of hypoproteinemia 2.Secondary Prevention – Annual eye exams 3. Tertiary Prevention – •Retinal laser photocoagulation •Anti VEGF & Steroid injections •Vitrectomy •Antioxidants 25 5/7/2019
- 27. Conclusion Diabetic Retinopathy is preventable through strict glycaemic control, annual dilated eye exams by an ophthalmologist and modification in Life styles. 27 5/7/2019
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