DR

1. DIABETIC
RETINOPATHY
O P H T H A L M O LO G Y D E PA R T M E N T
H O S P I TA L S E G A M AT

2. OBJECTIVES
• Differentiate clinical stage/grading of Diabetic
Retinopathy
• Criteria for referral
• Discuss regarding management approach:
–Proper examination schedule in DR patient
–Treatment modalities

3. Number of people with diabetes worldwide in 2017&2045 (20-79 years)
International Diabetes Federation; Diabetes Atlas - 8th Edition,

4. PREVALANCE OF DIABETES MELLITUS IN MALAYSIA
NATIONAL HEALTH & MORBIDITY SURVEY 2015
Highest:
Kedah:~25%
Perlis~20.6%
Johor ~19.8%
Lowest:
Sabah and WP
Labuan~14.2%
Sarawak~14.8%

5. DIABETES MELLITUS
• Highest among Indians (22.1%) followed by Malay(14.6%)
and Chinese (12.0%) (NHMS 2015)
• WHO estimates that in year 2030, Malaysia would have
2.48 million people with DM (NHMS 2015)
Prevalance of Diabetes Mellitus
Ethnic Groups
National Health & Morbidity Survey 2015

8. H O W D O W E C O M P A R E T O O U R N E I G H B O U R I N G C O U N T R I E S ?

9. DIABETIC RETINOPATHY
INTRODUCTION
• All DM patients are at risk of developing DR- prevalence
of DR worldwide ranges from 6.8 to 44.4% in patients
with diabetes mellitus
– the commonest cause of blindness and visual
disability in adults

10. DIABETIC RETINOPATHY
DEFINITION
Is a chronic progressive sight-threatening disease of
retinal microvasculature associated with prolonged
hyperglycemia.

11. RISK FACTORS
RISK
FACTOR
Obesity /
inactive
lifestyle
Duration of DM –
the longer
duration, higher
risk
Other medical
illnesses - HPT,
CKD, CVA, CVD,
hyperlipidemia,
anemia
Pregnancy
Smoking
Poor control of
DM - HbA1c/FBS

12. SIGNS AND SYMPTOMS
• Early stage – ASYMPTOMATIC
• ‘Floaters’- black spots / web-like spots in the visual
field
• Metamorphopsia (distortion of straight lines)
• Gradual or sudden blurring of vision

13. PATHOGENESIS OF DR

14. PATHOGENESIS OF DR

16. MICROVASCULAR LEAKAGE
Decompensation of endothelial blood
barrier function leads to leakage :
edema and exudates

17. NORMAL FUNDUS

18. FEATURES OF DIABETIC RETINOPATHY

20. SOURCE: WILKINSON CP, FERRIS FL III, KLEIN RE, ET AL . PROPOSED I NTERNATIONAL CLINICAL DIABETIC
RETINOPATHY AND DIABETIC MACUL AR EDEMA DISEASE SEVERIT Y SCALES. OPHTHALMOLOGY 2003;
110:1679-80
Diabetic Retinopathy Grading

21. MILD NPDR
• Microaneurysms only

22. MODERATE NPDR
• More than just microaneurysms but
less than severe NPDR

23. SEVERE NPDR
1. More than 20 intraretinal
hemorrhages in each of 4 quadrants
2. Definite venous beading in 2 or more
quadrants
3. Prominent Intraretinal Microvascular
Abnormalities (IRMA) in 1 or more
quadrants AND no signs of
proliferative retinopathy

24. PROLIFERATIVE DR

25. PDR with vireous Hemorrhage PDR with pre-retinal hemorrahge

28. • Mild
• hard exudates are located far from the center of the
fovea
• Moderate
• hard exudates or retinal thickening (no retinal
thickening) are threatening the center of the fovea
• Severe
• center of the fovea is involved with hard exudate and
thickening

29. EXAMINATION SCEDULE
Timing of first schedule
Recommendation: First for diabetic retinopathy (DR) should be done at:

30. ALGORITHM FOR SCREENING

31. WHEN TO REFER???
•Criteria for referral:
–Any level of diabetic maculopathy
–Severe NPDR
–Any PDR
–Unexplained visual loss
–If screening cannot be performed including ungradable
fundus photo

32. RECOMMENDED FOLLOW UP
SCHEDULE

33. CRITERIA FOR URGENT REFERRAL
URGENCY OF REFERRAL OCULAR FEATURES
Emergency (same day referral) • Sudden severe visual loss
• Symptoms or signs of acute retinal
detachment
Within 1 week • Presence of retinal new vessels
• Preretinal haemorrhages
• Vitreous haemorrhage
• Rubeosis iridis
Within 4 weeks • Unexplained drop in visual acuity
• Any form of maculopathy
• Severe NPDR
• Worsening retinopathy

34. TREATMENT FOR DIABETIC
RETINOPATHY
STAGE OF DR MODE OF TREATMENT
DME • Laser - focal/ grid
• Intraocular steroids
• Intraocular anti-vascular endothelial growth
factor (anti-VEGF)
Severe NPDR • No treatment, gm control
• Laser - scattered pan-retinal photocoagulation
(PRP)
PDR • Laser - PRP
ADED • Intraocular steroids
• Intraocular anti-vascular endothelial growth
factor (anti- VEGF)
• Vitrectomy

35. REFERENCE
• International Diabetes Federation; Diabetes Atlas - 8th Edition, 2017
• CPG Guideline Screening of Diabetic Retinopathy, 2011
• National Health & Morbidity Survey 2015