presented during primary eye care 2020 classificatio nbased on CPD malaysia

1. DiabeticRetinopathy
BY
DR ZULFAHMI
OPTHALMOLOGY DEPARTMENT
HOSPITAL SEGAMAT

2. ClinicalPractiseGuidelines(CPG):

3. OphthalmologyCPG’s

4. ClinicalPractiseGuidelines(CPG):

5. WhyDRscreeningsoimportant?
• EVERYONE with diabetes mellitus (DM) MUST undergo eye
screening
• To prevent BLINDNESS
• Healthcare professionals are the ones doing this eye
screening
• We must know what to look for during our screening
• Patient load will just keep increasing as per DM patients in M’sia
• We surely know someone with DM: parents, grandparents,
friends, siblings, even ourselves
• We must learn so that we can manage these patients

6. DIABETES MELLITUS
Highest among Indians (22.1%) followed by Malay(14.6%) and
Chinese (12.0%) (NHMS 2015)
WHO estimates that in year 2030, Malaysia would have 2.48
million people with DM (NHMS 2015)
Prevalance of Diabetes Mellitus Ethnic
Groups
National Health & Morbidity Survey 2015

9. HOW DO WE COMPARE TO OUR NEIGHBOURING COUNTRIES?

10. DIABETIC RETINOPATHY
INTRODUCTION
All DM patients are at risk of developing DR- prevalence of DR
worldwide ranges from 6.8 to 44.4% in patients with diabetes
mellitus
◦ the commonest cause of blindness and visual disability in
adults

11. DIABETIC RETINOPATHY
DEFINITION
Is a chronic progressive sight-threatening disease of retinal
microvasculature associated with prolonged hyperglycemia.

12. Risk Factors
RISK
FACTOR
Obesity /
inactive
lifestyle
Duration of DM
– the longer
duration, higher
risk
Other medical
illnesses - HPT,
CKD, CVA, CVD,
hyperlipidemia,
anemia
Pregnancy
Smoking
Poor control of
DM -
HbA1c/FBS

13. Signs and Symptoms
Early stage – ASYMPTOMATIC
‘Floaters’- black spots / web-like spots in the visual field
Metamorphopsia (distortion of straight lines)
Gradual or sudden blurring of vision

14. Pathogenesis of DR

15. Pathogenesis of DR

17. Microvascular leakage
Decompensation of endothelial blood
barrier function leads to leakage :
edema and exudates

18. ObjectiveOutline
Content No Topic
4 Diabetic Retinopathy (DR) Grading
5.4 Examination and Grading of DR by
Healthcare Professionals
6 Examination Schedule:
First screening, follow up &
referral criteria

19. HowtolookforDiabeticRetinopathy?
1. Direct
Ophthalmoscope
2. Fundus camera
3. Slit lamp examination

20. Retina
5 stages of
diabetic
retinopathy
FOVEA :
centre of
macula
Macula
Either
macula
involved
or not
DR screening: 2 main parts of the fundus

23. GradingofDR– CPGpage5:Retina
Stage of
Retinopathy
Findings of
Ophthalmoscopy
Follow up
0 No DR No fundus abnormalities 12-24 months
1 Mild
NPDR
Microaneurysms only 9-12 months
2 Moderate
NPDR
More than just
microaneurysms but less than
severe NPDR
- Dot-blot hemorrhages
- Cotton-wool spots
- Venous beading
- IRMA
6 months
Managed
at 1’ eye
care level:
KK / GP
clinics

26. ModerateNPDR Venous
beading
Cotton
wool
spots

28. GradingofDR
Stage of
Retinopathy
Findings of
Ophthalmoscopy
3 Severe
NPDR
Any of the following:
1. Each of 4 quadrants >
20
intraretinal h’ages
2. ≥ 2 quadrants:
venous beading
3. ≥ 1 quadrants: IRMA
AND no signs
proliferative disease
4:2:1 rule
52 – 75% progress to
Proliferative Diabetic
Retinopathy (PDR)
Mx: Refer to Ophthalmologist
Within 1 month

30. Grading ofDR
Stages of Retinopathy Findings on Ophthalmoscopy
4 Proliferative
Diabetic
Retinopathy (PDR)
One of the following:
1. Neovascularization: new vessels at disc (NVD) or new
vessels
elsewhere (NVE)
2. Vitreous (VH) or pre retinal h’age
REFER OPHTHALMOLOGIST
URGENTLY
Within 1 week

31. GradingofDR
Stages of Retinopathy Findings on Ophthalmoscopy
5 Advanced Diabetic
Eye Disease
(ADED)
One of the following:
1. FVP: Fibrovascular tissueproliferation
2. TRD: tractional retinal detachment dt formation of posterior
vitreous detachment
3. Dragging of retina/ distortion
4. RRD: rhegmatogenous retinal detachment
TRD
REFER
OPHTHALMOLOGIST
URGENTLY
Within 1 week or
earlier

32. Retina
5 stages of
diabetic
retinopathy
FOVEA :
centre of
macula
Macula
Either
macula
involved
or not
DR screening: 2 main parts of the fundus

33. Macula
Macula Odema Ophthalmoscopy Findings
Absent No thickening/ hard exudates
Present : maculopathy/ DME
- Retinal thickening
- Hard exudate (HE)
Mild In posterior pole but distant from
macula
Moderate Approaching centre of macula
Severe Involving centre of macula
Refer
Ophthalmologist
Mild
Moderate
Severe

34. DiabeticMaculaOdema-DME
• Upon your referral
• Further managed
by
Ophthalmologist
• Based on our
Diabetic Macula
Edema (DME)
CPG

35. Algorithm for
Screening

36. EXAMINATION SCEDULE
Timing of first schedule
Recommendation: First for diabetic retinopathy (DR) should be done at:

37. Recommended Follow Up Schedule

38. When to Refer???
Criteria for referral:
◦Any level of diabetic maculopathy
◦Severe NPDR
◦Any PDR
◦Unexplained visual loss
◦If screening cannot be performed including ungradable
fundus photo

39. CRITERIA FOR URGENT REFERRAL
URGENCY OF REFERRAL OCULAR FEATURES
Emergency (same day referral) • Sudden severe visual loss
• Symptoms or signs of acute retinal detachment
Within 1 week • Presence of retinal new vessels
• Preretinal haemorrhages
• Vitreous haemorrhage
• Rubeosis iridis
Within 4 weeks • Unexplained drop in visual acuity
• Any form of maculopathy
• Severe NPDR
• Worsening retinopathy

40. Treatmentoptions forDR
1. MAINLY/ FIRST and FOREMOST: DM control
2. Laser: pan retinal photocoagulation (PRP), focal laser or grid
laser
3. Intraocular injections: Anti – VEGF, intraocular steroids
(expensive, not widely available)
4. In ADED/ VH cases: diabetic vitrectomy (by vitreo retinal
surgeon – only 1 in gov sector in Johor – HSA currently)
Educate, screen, control DM  prevention is better then cure

41. TREATMENT FOR DIABETIC RETINOPATHY
STAGE OF DR MODE OF TREATMENT
DME • Laser - focal/ grid
• Intraocular steroids
• Intraocular anti-vascular endothelial growth factor
(anti-VEGF)
Severe NPDR • No treatment, gm control
• Laser - scattered pan-retinal photocoagulation (PRP)
PDR • Laser - PRP
ADED • Intraocular steroids
• Intraocular anti-vascular endothelial growth factor
(anti- VEGF)
• Vitrectomy

42. Practisesession
1. Diabetic
Retinopathy
Grading
2. Management

43. Normal
fundus
anatomy

44. DR stage Mx
No DR Yearly f/up

45. Case
DR stage Mx
Mild NPDR, MA
only
No maculopathy
9 – 12
monthly

46. DR stage Mx
Severe NPDR,
maculopathy
Refer
within
1
month

47. DR stage Mx
Proliferative
diabetic
retinopathy
(PDR) with
maculopathy
(plaque of
HE)
Refer
within
1
weeks

48. DR stage Mx
Moderate
NPDR,
moderate
maculopathy
Refer
within
1
month

49. DR stage Mx
Advanced
diabetic eye
disease
Refer
within 1
week/
earlier /
urgently

50. Case
DR grading Management
Proliferative
Diabetic
Retinopathy: PDR
Refer
Ophthalmologi
st within 1
week or
earlier /
urgently

51. DR stage Mx
ADED with FVP,
fibrosis, TRD
Refer
urgently
within a
week or
less

52. DR stage Mx
Proliferative
diabetic
retinopathy with
subhyaloid
h’age
Refer
urgently
within 1
week or
less

53. DR stage Mx
Lasered/ quiescent proliferative
diabetic retinopathy
Follow up 4 – 6
monthly

54. DR stage Mx
Proliferative
diabetic
retinopathy
Refer
urgently
within 1
week or
less

55. DR stage Mx
Proliferative
diabetic
retinopathy with
vitreous h’age:
hazy view of
fundus
Refer
urgently
within 1
week or
less

56. DR stage Mx
Severe NPDR,
No maculopathy
F/up
6 months

57. THANKYOU

58. Reference
International Diabetes Federation; Diabetes Atlas - 8th Edition, 2017
CPG Guideline Screening of Diabetic Retinopathy, 2011
National Health & Morbidity Survey 2015