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DIABETICRETINOPATHY      Dr Paavan KalraDepartment of Ophthalmology,    S P Medical College,          Bikaner
• Diabetic retinopathy is a disorder of the retinal  vessels that eventually develops to some  degree in nearly all patien...
RISK FACTORS•   Age at diagnosis of diabetes•   Duration•   Poor control of diabetes•   Pregnancy•   Hypertension•   Nephr...
PATHOGENESIS              Hyperglycemia  Intracellular sorbitol accumulation             Free radicals       Glycated end ...
• Angiogenic stimulators  Vascular Endothelial Growth Factor – A  Platelet Derived Growth Factor  Hepatocyte Growth Factor...
CLASSIFICATIONAcc to Kanski 7th ed ( 2011)  Background Diabetic Retinopathy  Diabetic Maculopathy  Preproliferative Diabet...
NORMAL CAPILLARIES      PERICYTE LOSS            MICRO ANEURYSM        THROMBOSED                                MICRO ANE...
MICRO ANEURYSMS
INTRARETINALHEMORRHAGES
NORMAL   EDEMA : CYSTOID
EXUDATES (HARD)
NORMAL   ISCHEMIA
COTTON WOOL SPOTS (“SOFT EXUDATES”)
INTRA RETINAL MICROVASCULAR        ABNORMALITIES
Venous Loop               Venous Beading          Venous Segmentation     Retinal arteriole obliteration
PROLIFERATIVE DR      NEOVASCULARIZATION     : DISC
PROLIFERATIVE DR       NEOVASCULARIZATION  : ELSEWHERE
ADVANCED DIABETIC EYE DISEASE• Pre retinal  hemorrhage• Vitreous  hemorrhage• Traction RD• Rubeosis  Iridis• Neovascular  ...
DIABETIC MACULOPATHY     FOCAL     DIFFUSE     ISCHEMIC     DIFFUSE       FOCAL
ISCHEMIC MACULOPATHY
HIGH RISK PDR                  CONCEPTS FROM                                DRS & ETDRS   NVD > 1/4 - 1/3 disc area   NVD ...
CLINICALLY SIGNIFICANT CONCEPTS FROM   MACULAR EDEMA        DRS & ETDRS
Work Up - HistoryDuration of diabetesPast glycemic control (hemoglobin A1c)MedicationsSystemic history (e.g., obesity, ren...
Workup : ExaminationVisual acuityMeasurement of IOPGonioscopy when indicated (for   neovascularization of the iris or incr...
Work up : Ophthalmic Investigations       • Fundus Photography       • Fluorescein Angiography             to guide treatm...
INTERNATIONAL CLINICAL DIABETIC         RETINOPATHY    DISEASE SEVERITY SCALE
INTERNATIONAL CLINICALDIABETIC MACULAR EDEMADISEASE SEVERITY SCALE
Treatment Modalities• LASER Photocoagulation (ARGON)      CSME – Focal & Grid      PDR with HRC – Pan Retinal Photocoagula...
Deferral of focal photocoagulation• hypertension or fluid retention associated with  heart failure, renal failure,pregnanc...
Panretinal photocoagulation•   may be considered as patients approach    high-risk PDR.•   The benefit of early panretinal...
• Screening of all cases above the age of 40  years irrespective of status of diabetes
THANK YOU
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Diabetic retinopathy

  1. 1. DIABETICRETINOPATHY Dr Paavan KalraDepartment of Ophthalmology, S P Medical College, Bikaner
  2. 2. • Diabetic retinopathy is a disorder of the retinal vessels that eventually develops to some degree in nearly all patients with long- standing diabetes mellitus.• Contributes 4.8% of the 37 million cases of blindness throughout the world• Most Common cause of bilateral severe visual loss in working age group in US• A recent study in urban population in south India estimates prevalence of DM in adult population as high as 28% & the prevalence of DR in diabetics to 18%
  3. 3. RISK FACTORS• Age at diagnosis of diabetes• Duration• Poor control of diabetes• Pregnancy• Hypertension• Nephropathy• Hyperlipidemia• Obesity• Anemia• Smoking• Cataract surgery
  4. 4. PATHOGENESIS Hyperglycemia Intracellular sorbitol accumulation Free radicals Glycated end products Disruption of ion channel function Protein kinase C activation Microangiopathy Hematological &Direct effect (damage to Rheological changeson retinal cells capillary wall) Intra retinal Edema Microvascular Occlusion hemorrhages Exudates Ischemia IRMA Neovascularization hemorrhage Fibrosis Traction
  5. 5. • Angiogenic stimulators Vascular Endothelial Growth Factor – A Platelet Derived Growth Factor Hepatocyte Growth Factor• Angiogenesis inhibtors Endostatin Angiostatin Pigment Epithelium Derived Factor
  6. 6. CLASSIFICATIONAcc to Kanski 7th ed ( 2011) Background Diabetic Retinopathy Diabetic Maculopathy Preproliferative Diabetic Retinopathy Proliferative Diabetic Retinopathy Advanced Diabetic Eye DiseaseMost detailed classification was given by ETDRS study
  7. 7. NORMAL CAPILLARIES PERICYTE LOSS MICRO ANEURYSM THROMBOSED MICRO ANEURYSM
  8. 8. MICRO ANEURYSMS
  9. 9. INTRARETINALHEMORRHAGES
  10. 10. NORMAL EDEMA : CYSTOID
  11. 11. EXUDATES (HARD)
  12. 12. NORMAL ISCHEMIA
  13. 13. COTTON WOOL SPOTS (“SOFT EXUDATES”)
  14. 14. INTRA RETINAL MICROVASCULAR ABNORMALITIES
  15. 15. Venous Loop Venous Beading Venous Segmentation Retinal arteriole obliteration
  16. 16. PROLIFERATIVE DR NEOVASCULARIZATION : DISC
  17. 17. PROLIFERATIVE DR NEOVASCULARIZATION : ELSEWHERE
  18. 18. ADVANCED DIABETIC EYE DISEASE• Pre retinal hemorrhage• Vitreous hemorrhage• Traction RD• Rubeosis Iridis• Neovascular Glaucoma
  19. 19. DIABETIC MACULOPATHY FOCAL DIFFUSE ISCHEMIC DIFFUSE FOCAL
  20. 20. ISCHEMIC MACULOPATHY
  21. 21. HIGH RISK PDR CONCEPTS FROM DRS & ETDRS NVD > 1/4 - 1/3 disc area NVD < 1/4-1/3 disc area with pre retinal or vitreous hemorrhage NVE >1/2 disc area with pre retinal or vitreous hemorrhage
  22. 22. CLINICALLY SIGNIFICANT CONCEPTS FROM MACULAR EDEMA DRS & ETDRS
  23. 23. Work Up - HistoryDuration of diabetesPast glycemic control (hemoglobin A1c)MedicationsSystemic history (e.g., obesity, renal disease, systemic hypertension, serum lipid levels, pregnancy)Ocular history
  24. 24. Workup : ExaminationVisual acuityMeasurement of IOPGonioscopy when indicated (for neovascularization of the iris or increased IOP)Slit-lamp biomicroscopyDilated funduscopy including stereoscopic examination of the posterior poleExamination of the peripheral retina and vitreous, best performed with indirect ophthalmoscopy or with slit-lamp biomicroscopy, combined with a contact lens
  25. 25. Work up : Ophthalmic Investigations • Fundus Photography • Fluorescein Angiography to guide treatment of CSME to identify Ischemic maculopathy IRMA vs NV evaluation in hazy media not a screening modality not a routine investigation • Optical Coherence Tomography Retinal thickening assessment & Monitoring of edema vitreo macular traction • USG – B scan
  26. 26. INTERNATIONAL CLINICAL DIABETIC RETINOPATHY DISEASE SEVERITY SCALE
  27. 27. INTERNATIONAL CLINICALDIABETIC MACULAR EDEMADISEASE SEVERITY SCALE
  28. 28. Treatment Modalities• LASER Photocoagulation (ARGON) CSME – Focal & Grid PDR with HRC – Pan Retinal Photocoagulation• Other LASERS for CSME – Frequency doubled Nd YAG Micro pulse Diode• INTRA VITREAL anti VEGF – Bevacizumab, Ranibizumab• INTRA VITREAL steroids – Triamcinolone acetonide• PARS PLANA VITRECTOMY Strict Glycemic Control delays the onset and progression
  29. 29. Deferral of focal photocoagulation• 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.• Adjunctive treatment may be considered- intravitreal corticosteroids or antivascular endothelial growth factor agents (off-label use).
  30. 30. Panretinal photocoagulation• may be considered as patients approach high-risk PDR.• 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.
  31. 31. • Screening of all cases above the age of 40 years irrespective of status of diabetes
  32. 32. THANK YOU
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