Diabetes and Eye Disorders by Dr Shahjada Selim

1. Diabetes and the Eye
Dr Shahjada Selim
Associate Professor
Department of Endocrinology
Bangabandhu Sheikh Mujib Medical University, Dhaka
Email: selimshahjada@gmail.com,
info@shahjadaselim.com

2. Diabetes and the Eye
Diabetic Retinopathy
Diabetic retinopathy is the leading cause of new blindness in persons aged
25-74
Diabetic Macula Oedema
Glaucoma
Iris Neovascularisation
Neuropathies
Corneal Anomalies
Hyperopic /Myopic Prescription Changes
Extra-ocular Muscle Palsy
Dry Eye Disease (50%) (reduced corneal sensitivity)

3. DIABETIC RETINOPATHY

4. DIABETIC RETINOPATHY
1. Epidemiology and risk factors
2. Classification and features of Diabetic
retinopathy (DR)
3. Complications of DR and their prevention
4. Screening protocol for DR and referral to Ophthalmologist
5. Direct ophthalmoscopy and identification of fundus
findings

5. Epidemiology of DR
RISK of developing DR:
• Type 1 DM – 70%
• Type 2 - 39%
• Type 2 on insulin – 70%

6. Prevalence of the type of Diabetes
 Type 2 – in 90% of diabetic patients
Diabetic retinopathy - most common
cause of legal blindness between
ages 20 and 70 years.

7. All people with Type 1 or Type 2 diabetes
are at risk of developing diabetic
retinopathy.
• Over the same duration, type 1 may
result in worse diabetic retinopathy
• The longer a person has diabetes,
the greater the risk. (25% for 15
years)
• Poor control of blood sugar levels
can increase the risk
Access Economics Pty Ltd. Clear Insight – The Economic Impact and Cost of Vision Loss in Australia, 1.2 Diabetic Retinopathy, August 2004,
Who is at risk?

8. • Systemic Hypertension
• Hyperlipidaemia
• Renal disease
• Pregnancy (with prior Type 1 or Type 2
diabetes)
• Family History of DR
• Smoking
Other Risk Factors

9. Intensive glucose therapy
Reduces the onset of new DR by 75%
Reduces the progression of DR by 50%
HbA1c 6-7%
1% decrease in HbA1c associated with lowering
the
◦risk of retinopathy 40%
◦progression to sight threatening DR 25%
◦risk for laser 24%
◦risk for blindness 5%
Controlling Diabetic Retinopathy Risk

10. Tight BP control associated with lower risk
of
Retinopathy progression 35%
Need for laser 35%
Risk for vision loss 50%
 Others: Hyperlipidemia(lipidil) / Smoking and
Alcohol consumption / Pregnancy / Body Mass
Index / Inflammation
Controlling Diabetic Retinopathy Risk

11. • It is estimated only ½ the Australians with diabetes have a
regular eye exam and 1/3rd have never been checked.
• Often there are no symptoms of diabetic retinopathy until
serious damage has occurred.
• Early diagnosis and treatment can prevent severe vision
loss
• Eye examination every Year is recommended for people
with diabetes.
Evidence indicates that early detection of Diabetic
Retinopathy by regular eye examination, is key to
reducing vision loss and blindness from diabetes.

12. Pathogenesis
Microangiopathy which has features of
both microvascular leakage and occlusion
Larger vessels may also be involved

13. Microvascular leakage
Loss of pericytes results in distention of
weak capillary wall producing
microaneurysms which leak.
Blood-retinal barrier breaks down causing
plasma constituents to leak into the retina
– retinal oedema, hard exudates

14. Microvascular occlusion
Basement membrane thickening,
endothelial cell damage, deformed RBCs,
platelet stickiness and aggregation
Vascular Endothelial Growth Factor
(VEGF) is produced by hypoxic retina
VEGF stimulates the growth of shunt and
new vessels

15. Classification of DR
I. Non-proliferative DR (NPDR)
• Mild
• Moderate
• Severe
• Very severe
II. Proliferative DR (PDR)
III. Clinically significant macular oedema
(CSME)
- May exist by itself or along with NPDR and PDR

16. • At least one microaneurysm - earliest clinically detectable
lesion
 Retinal hemorrhages
 Hard or soft exudates
Mild NPDR

17. Moderate NPDR
• Microaneurysms
and/or dot and blot
hemorrhages in at
least 1 quadrant
• Soft exudates
(Cotton wool spots)
• Venous beading or
IRMA (intraretinal
microvascular
abnormalities)
IRMA

18. Mild and Moderate Non- proliferative DR
was previously known as Background DR

19. Severe NPDR
Any one of the following 3 features is present
• Microaneurysms and intraretinal
hemorrhages in all 4 quadrants
• Venous beading in 2 or more quadrants
• Moderate IRMA in at least 1 quadrant
Known as the 4-2-1 rule

20. Very severe NPDR
Any two of the features of the 4-2-1
rule is present

21. Severe and Very severe Non-proliferative
DR was known as the Pre-proliferative DR

22. Clinically significant Macular
Oedema
• Retinal oedema close to fovea
• Hard exudates close to fovea
• Presents with dimness of vision
• By itself or along with NPDR or PDR

23. CSME – Hard exudates close to fovea and
associated retinal thickening

24. Proliferative DR
(PDR)
Characterized by
Proliferation of
new vessels from
retinal veins
• New vessels on
the optic disc
• New vessels
elsewhere on the
retina

25. Proliferative DR
NVD

26. COMPLICATIONS OF DIABETIC
RETINOPATHY
• Vitreous hemorrhage
• Tractional retinal detachment
• Rubeosis Iridis
• Glaucoma
• Blindness

27. Vitreous Hemorrhage
SUBHYALOID HEMORRHAGE

28. Tractional retinal detachment

29. Rubeosis Iridis

30. Neovascular Glaucoma
• Complication of rubeosis iridis
• New vessels cause angle closure
• Mechanical obstruction to aqueous outflow
• Intra ocular pressure rises
• Pupil gets distorted as iris gets pulled
• Eye becomes painful and red
• Loss of vision

31. Blindness
• Non-clearing vitreous hemorrhage
• Neovascular glaucoma
• Tractional retinal detachment
• Macular ischemia

32. PREVENTION OF COMPLICATIONS
• By early institution of appropriate treatment
• This requires early detection of DR in its
asymptomatic treatable condition
• By routine fundus examination of all
Diabetics (cost effective screening)
• And appropriate referral to ophthalmologist

33. Mild and Moderate NPDR
- No specific treatment for retinopathy
- Good metabolic control to delay
progression
- Control of associated Hypertension,
Anemia and Renal failure
Severe and very severe NPDR
– Close follow up by Ophthalmologist

34. Clinically significant macular oedema
- Laser photocoagulation to minimise risk of
visual loss
─ Retinal laser photocoagulation as per the
judgment of ophthalmologist (in high risk eyes)
─ It converts hypoxic retina (which produces
ANGIOGENIC factors) into anoxic retina (which
can’t)
Proliferative DR

35. Screening protocol for Diabetic
retinopathy
1. Screening once in a 1 year
• Diabetics with normal fundus
• Mild NPDR
2. Screening once in 6 months
• Moderate NPDR

36. Referral to Ophthalmologist
• Visual Symptoms
– Diminished visual acuity
– Seeing floaters
– Painful eye
• Fundus findings
- Macular oedema/hard exudates close to fovea
- Proliferative DR
- Vitreous hemorrhage
- Moderate to severe and very severe NPDR
- Retinal detachment
- Cataract obscuring fundus view

37. Referral to Ophthalmologist
• Presence of Risk Factors
- Pregnancy
- Nephropathy

38. Simulation of defective vision as experienced by a
Diabetic whose vision has been affected by Diabetic
retinopathy
Normal Defective

39. DIRECT OPHTHALMOSCOPY
• Examination of the fundus of the eye
• To screen for Diabetic Retinopathy
• After dilatation of both eyes with 0.5%
tropicamide

40. View of the retina through an
ophthalmoscope

41. Normal fundus views of Right
and left eye

42. Mild NPDR – Microaneurysms, Dot and
Blot hemorrhages

43. Moderate NPDR

44. Moderate NPDR with CSME

45. Circinate retinopathy – Hard exudates in a
ring around leaking aneurysms

46. DRUSEN
Age related Macular degeneration: Note the
drusen. Not to be confused with Hard exudates. There
are no microaneurysms or dot/blot hemorrhages.

47. Severe NPDR
• Cotton wool patches
• Hemorrhages - 4 quadrants
With CSME

48. Very severe NPDR
-Venous beading
- scars of laser spots
- Absorbing hemorrhages
Cotton-wool patches,
venous segmentation

49. CSME –
in
Different
Stages of
NPDR

50. Proliferative DR – New vessels elsewhere on
the retina along the supero-temporal vessels

51. PDR – New vessels on disc

52. PDR – New vessels on disc and new vessels
elsewhere on retina

53. PDR – with vitreous hemorrhage
Vitreous bleed

54. Vitreous Hemorrhage

55. Tractional retinal
detachment Fibro-vascular
proliferation

56. Thank you!
Any doubts?