65 million (17%) of 387 million persons with diabetes mellitus (DM) globally reside in India.The prevalence of DR in urban areas is between 13–18% and in rural areas is 9–10%.In India, in 1970–1975 DR was the 20th cause of blindness, and today, it is the 6th cause of blindness.
65 million (17%) of 387 million persons with diabetes mellitus (DM) globally reside in India.The prevalence of DR in urban areas is between 13–18% and in rural areas is 9–10%.In India, in 1970–1975 DR was the 20th cause of blindness, and today, it is the 6th cause of blindness.
Ischemic condition affecting the eye.
The ischemia can occur secondary to systemically problem [or] particulary the eye.
Many retinal vascular disorders {like CRAO,CRVO,Diabetic retinopathy,Hypertensive Retinopathy} shows ischemic signs.
Exudative retinal detachment develops when fluid collects in the subretinal space.
The subretinal space between the photoreceptors and the retinal pigment epithelium is the remnant of the embryonic optic vesicle.
In the developed eye the subretinal space is of minimal size, but it can reopen under pathological conditions that disrupt the integrity of blood-retinal barrier.
Inflammatory, infectious, infiltrative, neoplastic, vascular, and degenerative conditions may be associated with blood-retinal barrier breakdown and the sequential development of exudative retinal detachment.
This elaborate on the pathogenesis and the differential diagnosis of exudative retinal detachment and specifically discuss the spectrum of diseases associated with exudative retinal detachment in uveitis clinics.
Ischemic condition affecting the eye.
The ischemia can occur secondary to systemically problem [or] particulary the eye.
Many retinal vascular disorders {like CRAO,CRVO,Diabetic retinopathy,Hypertensive Retinopathy} shows ischemic signs.
Exudative retinal detachment develops when fluid collects in the subretinal space.
The subretinal space between the photoreceptors and the retinal pigment epithelium is the remnant of the embryonic optic vesicle.
In the developed eye the subretinal space is of minimal size, but it can reopen under pathological conditions that disrupt the integrity of blood-retinal barrier.
Inflammatory, infectious, infiltrative, neoplastic, vascular, and degenerative conditions may be associated with blood-retinal barrier breakdown and the sequential development of exudative retinal detachment.
This elaborate on the pathogenesis and the differential diagnosis of exudative retinal detachment and specifically discuss the spectrum of diseases associated with exudative retinal detachment in uveitis clinics.
Hypertensive retinopathy is a very important topic for PG examinations of all types. Especially, the fundal changes are important; Keith and Wegner Grading is also a repeated topic in PG. This slide represents all information in a compressed fashion. Have fun!
Type 2 dm gdm new updates & guidelinesSachin Verma
Type 2 diabetes is a multifactorial disorder characterised by progressive pancreatic beta-cell dysfunction and insulin- resistance, leading to relative insulin deficiency, chronic hyperglycaemia, and various complications.
The treatment options for this disorder, which aim at correcting one or other of the two major pathophysiological mechanisms, have been hamstrung by unacceptable side-effects, lack of patient acceptability, and loss of efficacy over time.
Do T2DM drugs have CV benefit for Type 1 Diabetes ?magdy elmasry
T1D Exchange , average A1C levels have not improved .How can adjunctive therapies ( added to insulin ) can help?
The Removal Trial.Three main clinical trials :
DEPICT with dapagliflozin ,
EASE with empagliflozin , and
inTANDEM with sotagliflozin.
مدیریت و کنترل دیابت نوع دو (Management of diabetes)HalehChehrehgosha
این فایل جهت یادگیری بهتر دانشجویان پزشکی فراهم شده است.
دکتر هاله چهره گشا
فوق تخصص غدد و عضو هیات علمی دانشگاه ایران
بیمارستان حضرت رسول اکرم تهران
chehrehgosha.h@iums.ac.ir
The basics of autoregulation of Gloemrular filtration rate. This ppt deals with basic renal physiology, tubuloglomerular feedback, myogenic reflex, juxtaglomerular apparatus and renin angiotensin aldosterone system in brief. P.S.- The ppt has animations so kindly view in slide/presentation mode
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
4. Darkening cloud of DIABETES!!
438 MILLION
Current Burden DM Patients
288 million by 2030!!
6 deaths / minute attributed to Diabetic complications
Type1 Diabetics represent only 5-10% of the entire DM population
India - “Diabetes capital of the world” with approx. 32 million
Diabetics
13-15% urban population in India is Diabetic.
5. Diabetes burden – Tip of the iceberg?
Diabetic Rate of Conversion of
Population ‘PREDIABETES’ (Impaired Plasma
Glucose) to DM is 10% annually.
Diagnosed Undiagnosed
DM Diabetes Study
Undiagnosed DM in India –
6.1% Chennai Urban Rural
Undiagnosed 9.1% epidemiology study
Diabetes 9% 10.5% Amrita Diabetes and
endocrine survey,
Kerala
1.9% Kashmir valley study
4.25%
6. American Diabetes Association, 2011
Diagnostic criteria for Diabetes Mellitus
Normal Glucose Impaired Glucose Diabetes
tolerance Tolerance
„PREDIABETES‟ Mellitus
Fasting plasma <100mg/dl 100-125mg/dl >/=126mg/dl
glucose
2 hr plasma glucose <140mg/dl 140-199mg/dl >/=200mg/dl
during an OGTT**
Random Blood >/= 200mg/dl
glucose + Symptoms
of diabetes*
A1C <5.6% 5.7-6.4% >/= 6.5%
*polyuria, polydispsia, weight loss
**after a glucose load of 75g anhydrous glucose dissolved in water
7. Implications of the new diagnostic criteria
A1C 6.5%
Sensitivity 99%
Specificity 24%
Signs of retinopathy seen in upto 10% individuals with Normal
Glucose Tolerance (Aus Diab study) 8% patients with Fasting Plasma
Glucose (FPG) below the diagnostic threshold for DM (Diab. Prev. Prog)
Retinopathy at baseline had 2-fold risk of developing newly
diagnosed diabetes.
A1C correlates better with likelihood of Retinopathy than FPG, and
based on incidence of DR the diagnostic criteria for DM should be
lowered to 5.3 to 5.5%(New Hoorn Study)
8. Microvascular complications of DM
Aldose Reductase forms Sorbitol -
Non enzymatic glycosylationGrowth factors
Changes in gene expression of
Advanced
Glycosylation
Pathogenesis
End products
Sorbitol
Pathway
HMP AGEs
CHRONIC Di-
Acyl-
HYPERGLYCEMIA Glycerol
Hexoseamine
Leads to activation of Protein Kinase C
pathway
9. Ocular complications in diabetes
are frequent, distressing and
destined to become one of the
challenging problems of the
future.
- Dr. Howard Root, 1935
10. Diabetic Retinopathy
DR is leading cause of legal blindness among patients aged 20- 74
yrs (CDC-US,2011)
20% patients of DM had retinopathy at diagnosis(US Report),
35 % of female and 39 % male diabetics have some level of DR at the
time of Diabetes diagnosis (UKPDS)
Early detection and timely management can prevent upto 90% of
vision loss from PDR
More frequent and severe ocular complications seen in T1DM
Prevalence of Diabetic Retinopathy
Time since onset 5yrs 15yrs 20yrs
T1Dm 25% 60-80% 100%
T2Dm 60%
12. Secondary
Primary
Prevention of Diabetic Retinopathy
Prevention of T2DM MEDICAL MANAGEMENT
Lifestyle Management Glycemic Control
(58% reduction in overall DM incidence) Risk Factor Control
Exercise Aspirin
Medical Nutrition therapy SURGICAL MANAGEMENT
Metformin Photocoagulation
(31% reduction in conversion of IGT Vitrectomy
toT2DM)
NOVEL THERAPIES
Prevention of T1DM (under active Intravitreal Anti VEGF
clinical investigation) Bevacizumab (Avastin)
Anti CD3 Monoclonal Ab Inhibitors of PKC beta
Anti B lymphocyte Mono. Ab Aldose reductase inhibitors
GAD vaccine
13. Glycemic control
ORAL AGENTS used for treatment of Diabetes Mellitus
ORAL AGENT EXAMPLES
1. Biguanides Metformin
2. Alpha Glucosidase Inhibitors Acarbose, Miglitol
3. Dipeptidyl Peptidase IV Saxagliptin, Sitagliptin, Vildagliptin
Inhibitors
4. Insulin Sulfonylureas Glimepiride, Glipizide, Glyburide
Secretagogues
Non Repaglinide, Netaglinide
Sulfonylureas
5. Thiazolidinediones Rosiglitazone, Pioglitazone
6. Bile Acid sequestrants Colesevelam
14. PARENTERAL AGENTS used for treatment of DM
PARENTERAL AGENT EXAMPLES
1. Insulin Short Acting Aspart
Glulisine
Lispro
Regular
Long Acting Detemir
Glargine
NPH
Insulin 75%Protamine lispro + 25%lispro
Combinations 70%Protamine aspart+25%aspart
50%Protamine lispro+50%lispro
70%NPH+30%regular
2. GLP1 receptor Exenatide
agonists Liraglutide
3. Amylin agonists Pramlintide
15. Newer therapies for T2DM –
Emerging Therapies 1.Sodium glucose co transporter 2
For the Treatment inhibitors
Of Diabetes dapagliflozin, canagliflozin,
ASP1941, LX4211, and B110773
2.Glucokinase activators
piragliatin, compound
14, compound 6, R1511
3.11 beta - hydroxysteroid -
dehydrogenase -1 inhibitors
INCB13739
4.Interleukin 1 Receptor antagonist
Newer therapies for T1DM –
1. Whole Pancreas transplantation
2. Pancreatic Islet transplantation
3. Closed loop pumps for continous
insulin administration
16. Lack of appropriate glycemic control is a significant risk
factor for the onset and progression of diabetic
retinopathy.
Two of the landmark trials with
respect to glycemic control in
DR were –
DCCT and UKPDS
17. The Diabetes Control and
Complications trial
(DCCT)
Intensive Glycemic control was associated with a decrease in all
microvascular complications
76% in the risk of onset of Diabetic Retinopathy
63% in the progression of pre existing Diabetic Retinopathy
56% in the need for laser surgery
predicted gain of 7.7 addditional years of vision
18. The United Kingdom Prospective
Diabetes Study
(UKPDS)
In the Intensive Glycemic control group -
For every 1% in A1C 35%approx. in the incidence of
microvascular complications
17% in the progression of DR
29% in the need for laser photocoagulation
23% in the development of Vitreous Hemorrhage.
16% in incidence of legal blindness
With respect to control of HTN , with intensive BP control –
34% reduction in risk of DR progression
47% reduction in moderate visual acuity loss independent of
19. Risk factors for Diabetic Retinopathy
It is critical for optimal ocular health of
diabetic patients that several other systemic
considerations be optimized.
1. Hypertension
2. Nephropathy
3. Hyperlipidemia
4. Pregnancy
5. Puberty
6. Anemia
20. Hypertension and DR
Diabetes often coexists with Hypertension
Uncontrolled Hypertension is related to
Increased development of DR
Increased progression of DR
Increased risk of developing Proliferative DR
Increased incidence of diffuse macular edema
(EUCLID, UKPDS)
Acc. to Wisconsin study –
Systolic BP Onset of Non Proliferative DR
Diastolic BP Progression of NPDR
21. Diabetic Nephropathy and
DR
PDR
Gross Proteinuria Presence and Severity of DR
PROTEINURIA
Diabetic nephropathy accelerates the
progression of retinopathy, especially macular
oedema.
The visual prognosis is often better if the
nephropathy is treated by renal transplantation
rather than by dialysis
The presence of Retinopathy itself suggests the
need for renal evaluation
22. Hyperlipidemia and DR
Increased serum lipids
Extravasted lipids in Retina
Hard exudates
Vision loss
Statins are well recognized to be of benefit in
23. Pregnancy and DR
Pregnancy may accelerate the progression of
diabetic retinopathy by 1.63 fold (DCCT)
Women who begin a pregnancy with no
retinopathy, the risk of developing diabetic
retinopathy is about 10%.
Women who begin pregnancy with poorly
controlled diabetes and who are suddenly
brought under strict control frequently have
severe deterioration of their retinopathy and
do not always recover after delivery .
(Diabetes in Early pregnancy Study)
24. Cataract Surgery and DR
Cataract surgery may lead to progression of
pre-existing macular oedema and proliferative
diabetic retinopathy.
Cataracts may impede fundoscopy and
therefore interfere with the treatment of
diabetic retinopathy.
If possible, diabetic retinopathy should be
treated prior to cataract surgery
25. Anemia and DR
Low hematocrit is related to the dvelopment of
high risk PDR and severe vision loss (ETDRS)
In a cross sectional study of 1691 patients with,
Hb <12g/dl
Showed a 2-fold increase in the risk of
development of retinopathy
5-fold increase in the risk of development of
26. Puberty and DR
The onset of vision-threatening
retinopathy is rare in children prior to
puberty, regardless of the duration of
diabetes
Significant retinopathy can arise within
6 years of disease if diabetes is
diagnosed between the ages of 10 and
30 years.
27. Surgical Management - Overview
Focal Proliferative DR
Macular Photocoagulation
Proliferative DR
Non laser Edema
Pan RetinalPhotocoagulation
ProphylacticPhotocoagulation
Diagnosed Diabetic Retinopathy
28. Surgical Management of DR
Dramatic strides have been made in treating diabetic retinopathy
and macular edema through the effective use of scatter
(panretinal) laser and other surgical techniques.
The value of these techniques has received strong support from
the findings of three major nationwide, randomized, and
controlled clinical trials in the United States:
1. Diabetic Retinopathy Study (DRS)
2. Early Treatment Diabetic Retinopathy Study (ETDRS), and
3. Diabetic Retinopathy Vitrectomy Study (DRVS)
29. Early detection of diabetic retinopathy through regularly
scheduled ocular examination is critical
Type of diabetes mellitus Recommended initial eye Routine follow up*
examination
Type 1 5 years after onset Yearly
or during puberty
Type 2 At time of diagnosis Yearly
Pregnancy with Prior to pregnancy •Early in first
preexisting diabetes for counseling trimester
•Each trimester or
more frequently as
indicated
•6 weeks postpartum
*Abnormal findings will dictate more frequent follow-up examinations
30. Conclusions
EXERCISE CAUTION
Diabetic Retinpathy at the time of diagnosis
Assymptomatic, with good visual acuity
initiate Education, Medical and Ocular follow up
MONITOR CAREFULLY
Appropriate observation of level of ocular disease
Prompt laser, other interventions (when indicated)
Patients retain excellent vision
31. “Diabetes can be controlled and does not have to keep people
from achieving their dreams”
- Michael Hunter
- World’s only insulin-dependent air show stunt pilot
-First diabetic person to receive the
Federal Aviation Administration
Low altitude airshow license