The document provides information about diabetic retinopathy including:
- It is a microvascular complication of long-standing diabetes mellitus that can cause blindness, and is the most common cause of blindness among working age adults.
- Risk factors include long duration of diabetes, poor blood glucose control, hypertension, and nephropathy.
- It is classified as non-proliferative diabetic retinopathy or proliferative diabetic retinopathy. Signs include microaneurysms, hemorrhages, cotton wool spots, hard exudates, and abnormal blood vessel growth in severe cases.
- Treatment involves tight blood glucose and blood pressure control, as well as laser photocoagulation surgery
3. Diabetic retinopathy
The most severe ocular complications of diabetes.
Caused by damage to blood vessels of the retina, leads to
retinal damage.
Microvascular complication of longstanding diabetes mellitus.
Most prevalence cause of blindness between the ages of 30
and 65 years.
Common in DM type 1 > type 2
4. Duration of diabetes
Long duration ass with increased risk of DR
Pt diagnosed before age 30 yr
50% DR after 10 yrs
90% DR after 30 yrs
Poor metabolic control
HbA1c ass. with risk
Pregnancy
Ass with rapid progression of DR
Risk factors
5. Hypertension
Very common in patients with DM type 2
Should strictly control (<140/80 mmHg)
Nephropathy
Ass with worsening of DR
Renal transplantation may be ass with improvement of DR and
better response to photocoagulation
Other
Obesity, increased BMI, high waist-to-hip ratio
Hyperlipidemia
Anaemia
Smoking
Risk factors
14. Moderate NPDR
More microaneurysm
Scattered hard exudates
Cotton-wool exudates
15. 4-2-1 rule:
4 quadrants of severe retinal hemorrhages
2 quadrants of venous beading
1 quadrant of IRMA
Very severe NPDR more than 1 of above
Severe NPDR
16. Localized outpouching of capillary wall small red dots often
in punctate pattern due to focal dilatation of capillary wall
where pericytes are absent.
The earliest signs of DR
Microaneurysm
18. Capillary or microaneurysm is weakened rupture
intraretinal hemorrhages
Dot & blot hemorrhages
Deep hemorrhage - inner nuclear layer or outer plexiform layer
Usually round or oval shape
Dot hemorrhages - bright red dots (same size as large microaneurysms)
Blot hemorrhages - larger lesions
Flame-shape or splinter hemorrhages
More superficial - in nerve fibre layer
Indistinguishable from hemorrhage in hypertensive retinopathy
Retinal Hemorrhage
23. Yellowish patches of lipid and protein within the
retina.
Accumulations of lipid leaks from surrounding
capillaries and microaneurysms or exudates.
May form a circinate pattern.
Hard exudate
25. White spots or patches composed of axoplasm and
organelles of nerve fibre.
Also called "soft exudates"
Fluorescein angiography shows no capillary perfusion in
the area of the soft exudate
More common in pt with hepertensive retinopathy
Cotton Wool Spot
30. Dilatation ,beading,looping of retinal vein.
Appearance resembling sausage-shaped
dilatation of the retinal veins.
Sign of severe NPDR.
Venous beading
31. Intraretinal neovascularization arising from
either major arteries or veins .
Indicate severe NPDR rapidly progress to
PDR.
Intra-retinal Microvascular
Abnormalities (IRMA)
33. Macular ischemia or exudates
Macular haemorrhage
Macular edema
Increased retinal vascular permeability
Seen in both NPDR and PDR
Focal or diffuse or mixed
Cause of visual loss in DR
Ass with planning for treatment
Diabetic Maculopathy
Means lesions in and around the macula
58. Blurred or distorted vision or difficulty in reading
Partial or total loss of vision
Eye pain
Signs & symptoms of DR
59. I. Medical treatment
II. Surgical Intervention:
1. Panretinal photocoagulation(PRP)
2.Vitreoretinal Haemorrhage
Treatment
60. Prevention by
Control blood sugar – HbA1c < 7
Control blood pressure – SBP < 130 mmHg
Control lipid profile – TG, LDL
Correct anemia
Control diabetic nephropathy
Stop smoking
Aldose reductase inhibitor can be use
Medical therapy
61. Panretinal photocoagulation (PRP):
High-risk PDR
Vitreous or preretinal hemorrhage
Iris or angle neovascularization
Reduce the rate of progression to blindness by about 50%
Laser
62. I. Focal or Grid :
NPDR and PDR
II. Panretinal
photocoagulation(PRP):PDR
Photocoagulation
65. Pars plana vitrectomy (PPV)
Membrane peeling (MP)
Endolaser (EL)
Fluid gas exchange (FGX)
Vitreoretinal Surgery
66. Juvenile onset DM - 5 years after diagnosis or earlier
then annually.
Adult onset DM -at diagnosis then annually.
DM with pregnancy in first trimester then every
trimester.
Screening for DR
70. Introduction:
Bilateral
Symmetrical
Small blood vessel disease
Caused by systemic hypertension
Acute or chronic
Systolic or diastolic
End organ disease manifestation
71. Prevalence:
The second most common retinal vascular disease
Malignant hypertension (240/140mmhg) 0.5-0.75%
Hypertensive retinopathy 4-10%
72. Risk factor:
Afro-Caribbeans = relative risk factor 2x
Age
Family history
Obesity
Smoking
Alcohol consumption
Stress
Lack of exercise
84. Classification
Keith-Wagener-Barker classification
Grade Description
Grade 1 Mild generalised narrowing, sclerosis, and tourtuosity of the retinal
arterioles(Silver wiring) mild asymptomatic hypertension.
Grade 2
G 1+Definite focal narrowing ,constriction, sclerosis at the site of AV
crossing (AV nipping); blood pressure is higher and sustained.
Grade 3 G 2+Retinopathy (cotton-wool spots, flame shape haemorrhages); blood
pressure is higher and more sustained; headaches, vertigo, and
nervousness; mild impairment of cardiac, cerebral, and renal function
Grade 4 G 3+Neuroretinal oedema, including pappilloedema, blood pressure
persistently elevated; severe impairment of cardiac, cerebral, and renal
function
85. Diagnosis:
Diagnosis is made by thorough history of the
patient, ophthalmoscopy (direct or indirect)
and also physical examination.
History
May reveal decrease of patient vision, occipital
headache and high blood pressure.
Physical examination
May detect elevation of blood pressure
Ophthalmoscopy
86. Management:
A major aim of treatment is to prevent, limit, or
reverse such target organ damage by lowering the
patient's high blood pressure.
Lifestyle changes Promote Healthy lifestyle;
exercise, healthy foods
Advice patient to reduce the Blood Pressure
Taking the medication accordingly
Referral to medical team
87. Differentiation of retinopathy:
Hypertensive Retinopathy Diabetic Retinopathy
Dry retina
Rare oedema
Few haemorrhages
Multiple cotton wool spots
Flame-shaped haemorrhages
AV nipping present
Copper and silver wiring
Venous beading absent
IRMA usually absent
Macular star present
Wet retina
Extensive oedema
Multiple dot blot haemorrhages
Few cotton wool spots
Rare flame-shaped
haemorrhages
AV nipping absent
Wiring absent
Venous beading present
IRMA may present
Macular star absent
1. The cardinal funduscopic feature of malignant hypertension is disk swelling, which appears as blurring and elevation of disk margins. The top image also shows a characteristic star-shaped macular lesion caused by leaking retinal vessels; the bottom image also shows a characteristic flame-shaped hemorrhage and dilated veins.
2. Moderate hypertensive retinopathy is characterized by thinned, straight arteries; intraretinal hemorrhages; and yellow hard exudates (top). Cotton-wool spots (bottom) are an additional feature of moderate hypertensive retinopathy. They are caused by focal axonal swelling of the retinal nerve fiber layer as a result of small-vessel occlusion.
Retinal arteriolar narrowing due to thickening and opacification of arteriolar walls (copper wiring) caused by hypertensive arteriosclerosis. Image also shows macular edema.