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Diabetic Retinopathy


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Diabetic Retinopathy

  1. 1. Diabetic Retinopathy Dr. Devin Prabhakar MS, DNB, MNAMS, FRCS Divya Prabha Eye Hospital, Trivandrum 695011 +91471-2442050,
  2. 2. ObjectivesBy the end of the session participants will be able to:• Define & classify diabetic retinopathy• List signs and symptoms of diabetic retinopathy• State why signs & symptoms occur• When referral to an ophthalmologist is required.• Treatment options available
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  4. 4. Diabetic Eye Diseases• Diabetic Retinopathy• Cataract• Glaucoma• Refractive errors• Stye
  5. 5. When Does Retinopathy ArisePrevalence of DR• At diagnosis 20%• 10 years after diagnosis 40-50%• 20 years after diagnosis – Type I 100% – Type II 60%
  6. 6. With strict control of DM:• Risk of developing retinopathy was reduced by 75%• Reduction in the rate of progression of retinopathy in existing retinopathy 50%• Diabetes Control and Complications Trial Research Group N Engl J Med 1993; 329:977-986.
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  10. 10. Microaneurysm• Small protuberances on the retinal blood vessels. The first sign of eye damage. Microaneurysms are reversible if the blood glucose control is improved
  11. 11. Hard Exudates • Yellow spots seen in the retinaThey are lipid break-down products that are left behind after localized edema resolves. You can kind of think of them like the dirt-ring that gets left behind after the bathwater drains out.
  12. 12. IRMA• Intraretinal microvascular abnormalities (lRMA) : Dilated, tortous retinal capillaries that act as a shunt between arterioles and venules. frequently seen adjacent to areas of capillary closure. IRMA may resemble focal areas of flat NVE . But in IRMA : intraretinal location. absence of profuse leakage on fluorescein angiography. failure to cross over major retinal blood vessels.
  13. 13. • A) cotton-wool spot • B) venous beading • C) intraretinal microvascular abnormalities; • D) intraretinal
  14. 14. NVD• New Vessels: Unlike IRMA, they arise on the retinal surface and may extend or be pulled into the vitreous cavity.• NVD : NV appears on or within one DD of disc margin .• NVE : any other location .
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  16. 16. • Fibrous Glial proliferation : Accompained growth of new vessels. It is proliferation between the posterior vitreous gel and the ILM. Derived from retinal glial cells fibrocytes.
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  18. 18. Oph. Invest. of dr• Fundus Photography• Fluorescein Angiography – Guide treatment of CSME to identify Ischemic maculopathy – IRMA vs NV evaluation• Optical Coherence Tomography• USG – B scan
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  21. 21. OCT• Optical Coherence Tomography OCT creates cross section of retina. It demonstrates 3 basic structural changes of the retina from diabetic macular edema (DME), that is, retinal swelling, cystoid edema, and serous retinal detachment
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  23. 23. Risk Factors for dr• Duration of diabetes : is the most important factor.• In patients diagnosed as having diabetes before the age of 30 years, the incidence of DR : • after 10 years is 50% • after 30 years is 90%
  24. 24. RISK FACTORS for dr • Age at diagnosis of diabetes • Duration • Poor control of diabetes • Pregnancy • Hypertension • Nephropathy • Hyperlipidemia • Obesity • Anemia • Smoking • Cataract surgery
  25. 25. Stages of Retinopathy• No DR • No Macular Edema• Mild NPDR • Macular Edema• Mod NPDR Present• Severe NPDR• PDR
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  27. 27. Macular edema types• Focal ME :which has identifiable leakage source.• Cystoid ME : in which fluid accumulate in OPL and INL to form cystoid spaces.• Diffuse ME : which has multiple unidentifiable source of leakage.
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  29. 29. CSME (ETDRS):definition • retinal thickening 500 from fovea • HE within 500 microns from fovea with thickening • 1500 of thickening with any part within 1 DD of fovea
  30. 30. DME: Pathophysiology• DME is the result of microvascular changes in diabetes leading to incompetence of vessels• Hypoxic state stimulate VEGF causing more CME
  31. 31. DME: Morbidity• DME is the leading cause of new blindness in the US .• Untreated , 25-30 % of CSME double their visual angle within 3 years• Treated the risk drops by 50%
  32. 32. Differential Diagnoses of dr• ARMD• Exudative BRVO• CRVO• Hypertension• Macular Edema• Irvine-Gass Uveitis
  33. 33. Treatment ModalitiesLASER Photocoagulation CSME – Focal & Grid PDR– Pan Retinal PhotocoagulationINTRA VITREAL anti VEGF – Bevacizumab, Ranibizumab steroids – Triamcinolone acetonidePARS PLANA VITRECTOMY
  34. 34. Focal/grid laser• Significant visual improvement is uncommon. Photocoagulation reduced the risk of moderate visual loss from diabetic macular edema by 50%, from 24% to 12%, 3 years after initiation of treatment.• Laser treatment is most effective when initiated before visual acuity is lost. Laser treatment of diabetic macular edema should precede panretinal photocoagulation (PRP) by at least 6 weeks because PRP before has been known to worsen diabetic macular edema. PRP should not be delayed in patients with very severe nonproliferative diabetic retinopathy or high-risk proliferative diabetic retinopathy
  35. 35. Deferral of focal laser• Hypertension or fluid retention associated with heart failure, renal failure, pregnancy, or any other causes that may aggravate macular edema.• when the center of the macula is not involved, visual acuity is excellent, and the patient understands the risks• Treatment of lesions close to the foveal avascular zone may result in damage to central vision and with time laser scars may expand and cause further vision deterioration.
  36. 36. Intravitreal triamcinolone acetonideIVTA has been shown to significantly reduce macular edema and to improve visual acuity, particularly. Action is maximal at 1 week, lasting 3-6 months. Patients should be counseled about the risk (30-40%) of increased intraocular pressure, of which virtually all can be medically controlled. Other adverse effects include a less than 1% chance of retinal detachment, cataract, and endophthalmitis
  37. 37. Rx Intravitreal anti-VEGF agents• Ocular VEGF increases retinal vascular permeability, causes breakdown of the blood-retina barrier, and results in retina edema. VEGF is up-regulated in diabetic retinopathy. Three currently available anti-VEGF agents are pegaptanib sodium, ranibizumab, and bevacizumab
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  39. 39. CSME: Conclusion• Untreated, 25-30% of patients with CSME exhibit a doubling of the visual angle within 3 years. Treated, the risk drops by 50%.
  40. 40. Ocular Risk Factors Removal of cataract• DR may progress after cataract surgery. Patient who have CSME, SNPDR or PDR should undergo photocoagulation if the media is sufficiently clear.• If the cataract preclude retina evaluation and treatment, prompt postoperative retinal evaluation and treatment should considered
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  42. 42. Follow up of dr• Annually Normal• Every 9 months Mild NPDR• Every 6 months Moderate NPDR• Every 6 months CSME• Every 4 months Sever NPDR• Every 2- 4 months CSME• Every 2-3 months PDR
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  44. 44. Panretinal photocoagulation• The benefit of early panretinal photocoagulation at the severe nonproliferative or worse stage of retinopathy is greater in patients with type 2 diabetes than in those with type 1.• Other factors, such as poor compliance with follow-up, impending cataract extraction or pregnancy, and status of fellow eye will help in determining the timing of the panretinal photocoagulation.• It is preferable to perform the focal photocoagulation first, prior to panretinal photocoagulation to prevent laser-induced exacerbation of the macular edema
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  46. 46. DCCT 1993• 1441 subjects with IDDM followed for 6.5 years. Randomized into strict and conventional treatment. Strict control group had average hbA1c 7.2% Conventional 8.8%• Strict control resulted in reduction of retinopathy by 76%• Reduced risk of progression by 54%
  47. 47. Glycemic Control• Total lifetime exposure to glycemia was the principal determinant of the risk of retinopathy• There is no level ofglycemic control below which a reduction in risk does not occur. Improved control always reduced risk of retinopathy retinmopathy
  48. 48. Role of BP• Hypertension is an independsant risk factor for DR and its progression.• UKPDS 1998: – Tighter control of BP resulted in 34% reduction in progression of DR. – 47% reduced risk of loss 3 lines VA
  49. 49. Role of cholesterol• WESDR 19914: Higher serum cholesterol increased risk of HE in type I• ETDRS 1996: Higher serum lipids increased risk of HE and loss of VA• Elevated lipids may increase the morbidity of diabetic macular edema.
  50. 50. Pregnancy : DRDR accelerate during pregnancy and improve postpartum. Do not hesitate to treat with laser when indicated. FFA should be avoided in all but the most difficult cases of macular edema.
  51. 51. Quiz #1 True of False• People with diabetes are more likely than people without diabetes to develop certain eye diseasesTrue
  52. 52. #2 True or False• Diabetes eye diseases has early warning signs• FALSE
  53. 53. #3 True or False• People with diabetes should have yearly eye examinations• TRUE
  54. 54. #4 True or False• Diabetic retinopathy is caused by changes in the blood vessels in the eye.• TRUE. In some people, blood vessels in the retina may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina.
  55. 55. #5 True or False• People with diabetes are at low risk for developing glaucoma.• FALSE
  56. 56. #6 True or False• Laser surgery can be used to halt the progression of diabetes retinopathy• TRUE. In laser surgery, laser light is used to shrink the abnormal vessels or seal leaking blood vessels. Laser surgery has been proven to reduce the 5 year risk of vision loss from advanced retinopathy by more than 90%
  57. 57. #7 True or False• People with diabetes should have regular eye examination through dilated pupils.• TRUE
  58. 58. #8 True or False• Cataract are common among people with diabetes.• TRUE
  59. 59. #9 True or False• People who have good control of their diabetes are not at high risk for diabetic eye disease.• FALSE. Even with good control of blood glucose, there is still a risk of developing diabetic eye disease. However studies have shown that careful management of blood sugar levels slows the onset and progression of diabetic retinopathy.
  60. 60. #10 True or False• The risk of blindness from diabetic eye disease can be reduced.• TRUE. With early detection and timely treatment, the risk of blindness from diabetic eye disease can be reduced.
  61. 61. “We choose our joys andsorrows long before we experience them.” ― Kahlil Gibran