49 diabetic retinopathy

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49 diabetic retinopathy

  1. 1. DIABETIC RETINOPATHY 1. Adverse risk factors 2. Pathogenesis 5. Clinically significant macular oedema 6. Preproliferative diabetic retinopathy 3. Background diabetic retinopathy 4. Diabetic maculopathies • Focal • Diffuse • Ischaemic 7. Proliferative diabetic retinopathy
  2. 2. Adverse Risk Factors 1. Long duration of diabetes • Obesity • Hyperlipidaemia 2. Poor metabolic control 3. Pregnancy 4. Hypertension 5. Renal disease 6. Other • Smoking • Anaemia
  3. 3. Pathogenesis of diabetic retinopathy
  4. 4. Consequences of retinal ischaemia
  5. 5. Consequences of chronic leakage
  6. 6. Location of lesions in background diabetic retinopathy
  7. 7. Signs of background diabetic retinopathy Microaneurysms usually temporal to fovea Intraretinal dot and blot haemorrhages Hard exudates frequently arranged in clumps or rings Retinal oedema seen as thickening on biomicroscopy
  8. 8. Focal diabetic maculopathy • Circumscribed retinal thickening • Associated complete or incomplete circinate hard exudates • Focal leakage on FA • Focal photocoagulation • Good prognosis
  9. 9. Diffuse diabetic maculopathy • Diffuse retinal thickening • Generalized leakage on FA • Guarded prognosis • Grid photocoagulation• Frequent cystoid macular oedema • Variable impairment of visual acuity
  10. 10. Ischaemic diabetic maculopathy • Macula appears relatively normal • Capillary non-perfusion on FA • Poor visual acuity • Treatment not appropriate
  11. 11. Clinically significant macular oedema Hard exudates within 500 µm of centre of fovea with adjacent oedema which may be outside 500 µm limit Retinal oedema one disc area or larger any part of which is within one disc diameter (1500 µm) of centre of fovea Retinal oedema within 500 µm of centre of fovea
  12. 12. Treatment of clinically significant macular oedema • For microaneurysms in centre of hard exudate rings located 500-3000 µm from centre of fovea Focal treatment • Gentle whitening or darkening of microaneurysm (100-200 µm, 0.10 sec) • For diffuse retinal thickening located more than 500 µm from centre of fovea and 500 µm from temporal margin of disc Grid treatment • Gentle burns (100-200 µm, 0.10 sec), one burn width apart
  13. 13. Preproliferative diabetic retinopathy Treatment - not required but watch for proliferative disease • Cotton-wool spots • Venous irregularities • Dark blot haemorrhages • Intraretinal microvascular abnormalities (IRMA) Signs
  14. 14. Proliferative diabetic retinopathy • Flat or elevated • Severity determined by comparing with area of disc Neovascularization Neovascularization of disc = NVD • Affects 5-10% of diabetics • IDD at increased risk (60% after 30 years) Neovascularization elsewhere = NVE
  15. 15. Indications for treatment of proliferative diabetic retinopathy NVD > 1/3 disc in area Less extensive NVD + haemorrhage NVE > 1/2 disc in area + haemorrhage
  16. 16. • Spot size (200-500 µm) depends on contact lens magnification • Gentle intensity burn (0.10-0.05 sec) • Follow-up 4 to 8 weeks • Area covered by complete PRP• Initial treatment is 2000-3000 burns Laser panretinal photocoagulation
  17. 17. Assessment after photocoagulation • Persistent neovascularization • Haemorrhage Poor involution • Re-treatment required • Regression of neovascularization • Residual ‘ghost’ vessels or fibrous tissue Good involution • Disc pallor
  18. 18. Indications for vitreoretinal surgery Retinal detachment involving macula Severe persistent vitreous haemorrhage Dense, persistent premacular haemorrhage Progressive proliferation despite laser therapy

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