2nd year ophthalmic assistant lecture regarding brief knowledge regarding diabetic retinopathy classification & management

1. Diabetic Retinopathy
Dr. SHARAD HEMANT MISHRA & Dr. VINITKUMAR ( FELLOW ANTERIOR SEGMENT ,SCEH,
EYE HOSPITAL, LAHAN )

2. Objectives
 Diabetic retinopathy implications as a public health
issue and a leading cause of blindness in
industrialized countries
 Discuss risk factors
 Discuss pathophysiology and the different stages
 Discuss management approach
- Prevention
- Risk factor control and annual dilated retinal
examinations
- Treatment modalities

3. Diabetes Mellitus
 Hyperglycemia resulting from body’s inability to produce and/or
utilize insulin
•Type 1
- children and young adults
- immune prone
- no insulin production
- 5% of DM pts
• Type 2
- mostly adult onset (increase incidence at earlier age)
- insulin resistance followed by decreased production
- MC
- obesity

4. Diabetic Retinopathy (DR)
• Implicated by both types of DM
• Progressive glycation on retinal blood vessel
wall
• Initially asymptomatic
• Microvascular leakage
• Microvascular occlusion

5.  Glycation
1. microvascular leakage - NPDR
2. microvascular occlusion - PDR

6. Epidemiology
 Trends in Prevalence of Diabetes Worldwide
Prevalence by 2030 – 439 Million
 Global Data on Visual Impairments WHO 2010
Accounts for Approx. 1% of Cases of
Blindness World Wide
 Leading Cause of VL in People of Working
Age (18- 65) In Developed Countries
 Best Predictor of Diabetic Retinopathy is the
Duration of the Disease Prevalence of Diabetic
Retinopathy after 20 Years of Diagnosis

7. Risk factors
 Duration
 Poor control
 Comorbidity
 Limited Access

8. Pathophysiology
 Glycation is the microvascular (capillary)
abnormality that leads to:
1. Microvascular leakage
2. Microvascular occlusion

9. Microvascular leakage
 Weakening of Endothelial cell Junctions leads
to increased Vascular Permeability
 Microvascular leakage
 Edema
 Hard exudates
 Retina hemorrhage

10. Microvascular Occlusion
• Thickening of capillary basement membranes •
Abnormal proliferation of capillary endothelium
• Increased platelet adhesion
• Increased blood viscosity

11. Symptoms
• Asymptomatic in early stages
• Blurred vision - myopic shift (lens changes)
• VA fluctuation Distorted vision
• Partial or total loss of vision

12. Non-proliferative Diabetic
Retinopathy (NPDR)
 Microaneurysms
• Dot and Blot hemorrhages
• Hard/lipid Exudates
• Cotton Wool Spots
• Venous Beading
• Intravascular Micro abnormalities (IRMA)

13.  Capillary Microaneurysms
- earliest ophthalmoscopic detectable clinical
sign
- para/extrafoveay
- wall outpouching due to pericyte loss

14.  Dot/blot/flame hemorrhage
• Exudation - proteinous debris
• Intraretinal edema

15.  Intraretinal microvascular abnormalities
(IRMA)
- tortuous dilated capillaries that
- project anteriorly
- do not leak on FA
- adjacent to CWS

16.  Venous Beading (VB)
- focal dilation of the veins
- adjacent to occluded arterioles / areas
of capillary of nonperfusion
- reflects increasing retinal ischemia
/hypoxia
- strong predictor of development of
PDR

17. Severe NPDR
 4/2/1 Rule
- > 20 intraretinal hemorrhages in each of four
quadrants
- VB in two or more quadrants
- IRMA in one or more quadrants Severe NPDR

18. Proliferative Diabetic Retinopathy (PDR)
• Increased levels VEGF
• Disc new vessels (NVD)
• Peripheral new vessels (NVE)
• Vitreous or preretinal hemorrhages

19.  DME /Clinical Significant Diabetic
Macular Edema (CSDME) or CSME
- not a criterion of severity of NPDR
- leading cause of legal blindness in
diabetics
- present at any stage, more in PDR

21. Management
 Blindness Prevention
 The Best Measure for Prevention of Vision
Loss is Strict Glycemic Control

22.  Laser photocoagulation (focal, PRP)
 Vitrectomy
 Surgical treatment to remove extensive vitreous
fibrovascular strands causing retinal traction
 Anti-VEGF Treatment