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DIABETIC
RETINOPATHY

      Dr Paavan Kalra
Department 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 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%
RISK FACTORS
•   Age at diagnosis of diabetes
•   Duration
•   Poor control of diabetes
•   Pregnancy
•   Hypertension
•   Nephropathy
•   Hyperlipidemia
•   Obesity
•   Anemia
•   Smoking
•   Cataract surgery
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 changes
on retinal cells
                    capillary wall)

  Intra retinal Edema       Microvascular Occlusion
 hemorrhages Exudates             Ischemia
                                    IRMA
                             Neovascularization     hemorrhage
                                   Fibrosis         Traction
• Angiogenic stimulators
  Vascular Endothelial Growth Factor – A
  Platelet Derived Growth Factor
  Hepatocyte Growth Factor

• Angiogenesis inhibtors
  Endostatin
  Angiostatin
  Pigment Epithelium Derived Factor
CLASSIFICATION
Acc to Kanski 7th ed ( 2011)
  Background Diabetic Retinopathy
  Diabetic Maculopathy
  Preproliferative Diabetic Retinopathy
  Proliferative Diabetic Retinopathy
  Advanced Diabetic Eye Disease

Most detailed classification was given by ETDRS study
NORMAL CAPILLARIES      PERICYTE LOSS




            MICRO ANEURYSM        THROMBOSED
                                MICRO ANEURYSM
MICRO ANEURYSMS
INTRARETINAL
HEMORRHAGES
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




      NEO
VASCULARIZATION
     : DISC
PROLIFERATIVE DR




       NEO
VASCULARIZATION
  : ELSEWHERE
ADVANCED DIABETIC EYE DISEASE

• Pre retinal
  hemorrhage
• Vitreous
  hemorrhage
• Traction RD
• Rubeosis
  Iridis
• Neovascular
  Glaucoma
DIABETIC MACULOPATHY



     FOCAL
     DIFFUSE
     ISCHEMIC




     DIFFUSE       FOCAL
ISCHEMIC MACULOPATHY
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
CLINICALLY SIGNIFICANT CONCEPTS FROM
   MACULAR EDEMA        DRS & ETDRS
Work Up - History
Duration of diabetes
Past glycemic control (hemoglobin A1c)
Medications
Systemic history (e.g., obesity, renal
  disease, systemic hypertension, serum
  lipid levels, pregnancy)
Ocular history
Workup : Examination

Visual acuity
Measurement of IOP
Gonioscopy when indicated (for
   neovascularization of the iris or increased
   IOP)
Slit-lamp biomicroscopy
Dilated funduscopy including stereoscopic
   examination of the posterior pole
Examination of the peripheral retina and
   vitreous, best performed with indirect
   ophthalmoscopy or with slit-lamp
   biomicroscopy, combined with a contact
   lens
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
INTERNATIONAL CLINICAL DIABETIC
         RETINOPATHY
    DISEASE SEVERITY SCALE
INTERNATIONAL CLINICAL
DIABETIC MACULAR EDEMA
DISEASE SEVERITY SCALE
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
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).
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.
• Screening of all cases above the age of 40
  years irrespective of status of diabetes
THANK YOU

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Muscle Energy Technique (MET) with variant and techniques.Muscle Energy Technique (MET) with variant and techniques.
Muscle Energy Technique (MET) with variant and techniques.
 

Diabetic retinopathy

  • 1. DIABETIC RETINOPATHY Dr Paavan Kalra Department of Ophthalmology, S P Medical College, Bikaner
  • 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. RISK FACTORS • Age at diagnosis of diabetes • Duration • Poor control of diabetes • Pregnancy • Hypertension • Nephropathy • Hyperlipidemia • Obesity • Anemia • Smoking • Cataract surgery
  • 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 changes on retinal cells capillary wall) Intra retinal Edema Microvascular Occlusion hemorrhages Exudates Ischemia IRMA Neovascularization hemorrhage Fibrosis Traction
  • 5. • Angiogenic stimulators Vascular Endothelial Growth Factor – A Platelet Derived Growth Factor Hepatocyte Growth Factor • Angiogenesis inhibtors Endostatin Angiostatin Pigment Epithelium Derived Factor
  • 6. CLASSIFICATION Acc to Kanski 7th ed ( 2011) Background Diabetic Retinopathy Diabetic Maculopathy Preproliferative Diabetic Retinopathy Proliferative Diabetic Retinopathy Advanced Diabetic Eye Disease Most detailed classification was given by ETDRS study
  • 7. NORMAL CAPILLARIES PERICYTE LOSS MICRO ANEURYSM THROMBOSED MICRO ANEURYSM
  • 10. NORMAL EDEMA : CYSTOID
  • 12. NORMAL ISCHEMIA
  • 13. COTTON WOOL SPOTS (“SOFT EXUDATES”)
  • 15. Venous Loop Venous Beading Venous Segmentation Retinal arteriole obliteration
  • 16. PROLIFERATIVE DR NEO VASCULARIZATION : DISC
  • 17. PROLIFERATIVE DR NEO VASCULARIZATION : ELSEWHERE
  • 18. ADVANCED DIABETIC EYE DISEASE • Pre retinal hemorrhage • Vitreous hemorrhage • Traction RD • Rubeosis Iridis • Neovascular Glaucoma
  • 19. DIABETIC MACULOPATHY FOCAL DIFFUSE ISCHEMIC DIFFUSE FOCAL
  • 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. CLINICALLY SIGNIFICANT CONCEPTS FROM MACULAR EDEMA DRS & ETDRS
  • 23. Work Up - History Duration of diabetes Past glycemic control (hemoglobin A1c) Medications Systemic history (e.g., obesity, renal disease, systemic hypertension, serum lipid levels, pregnancy) Ocular history
  • 24. Workup : Examination Visual acuity Measurement of IOP Gonioscopy when indicated (for neovascularization of the iris or increased IOP) Slit-lamp biomicroscopy Dilated funduscopy including stereoscopic examination of the posterior pole Examination of the peripheral retina and vitreous, best performed with indirect ophthalmoscopy or with slit-lamp biomicroscopy, combined with a contact lens
  • 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. INTERNATIONAL CLINICAL DIABETIC RETINOPATHY DISEASE SEVERITY SCALE
  • 27. INTERNATIONAL CLINICAL DIABETIC MACULAR EDEMA DISEASE SEVERITY SCALE
  • 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.
  • 30. 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).
  • 31. 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.
  • 32. • Screening of all cases above the age of 40 years irrespective of status of diabetes