Diabetic Retinopathy

1. DIABETIC RETINOPATHY
Dr. Christina Samuel

2. DEFINITION
• DIABETIC RETINOPATHY IS A
PROGRESSIVE MICRO ANGIO PATHY
WITH CONSEQUENT BREAK DOWN
OF BLOOD RETINAL BARRIER
RESULTING IN A VARIETY OF
FUNDUS PICTURE FINALLY LEADING
TO BLINDNESS

3. DIABETIC RETINOPATHY
RISK FACTORS/PROGNOSTIC FACTOR
DURATION OF DM-type
1 4-5yrs no DR type 2 11-13yrs 23% NPDR
5-10yrs 25%-30% 3% PDR
10-15yrs 75%-95% 16yrs 60% NPDR
20-25yrs PDR in 18%-40
• TYPE OF DM
• AGE
• BLOOD GLUCOSE LEVELS
• HT
• NEPHROPATHY
• SERUM LIPIDS
• ANEMIA
• PUBERTY,PREGNANCY,BMI

4. LOCAL PROTECTIVE FACTORS
• MYOPIA
• CHORIO RETINAL SCARRING
• GLAUCOMA
• OPTIC ATROPHY
• RP

5. PATHOGENESIS
• MICROANGIOPATHY AFFECTING PRE CAPILLARIES
ARTERIOLES,CAPILLARIES & VENULES.
• FEATURES
MICROVASCULAR MICROVASCULAR
OCCLUSION LEAKAGE
RETINAL
ISCHEMIA
IRMA NV H’GES EDEMA EXUDATES
hematological loss of pericytes
vascular abn breakdown of BRB

6. HEMATOLOGICALABNORMALITIEHEMATOLOGICALABNORMALITIESS
• AABBNNOORRMMAALLIITTIIEESS OOFF PPLLAATTEELLEETT
FFUUNNCCTTIIOONN
• DDEEFFEECCTTIIVVEE FFIIBBRRIINNOOLLYYTTIICC
SSYYSSTTEEMM
• HHYYPPEERRVVIISSCCOOSSIITTYY AANNDD AABBNNOORRMMAALL
RRBBCC AAGGGGRREEGGAATTIIOONN
• AABBNNOORRMMAALL SSEERRUUMM LLIIPPIIDDSS
MMIICCRROOVVAASSCCUULLAARR AABBNNOORRMMAALLIITTIIEESS
• BBAASSEEMMEENNTT MMEEMMBBRRAANNEE TTHHIICCKKEENNIINNGG
• eeaarrlliieesstt cchhaannggee
iinnccrreeaasseedd BBMM pprrootteeiinnss
• LLOOSSSS OOFF PPEERRIICCYYTTEESS 11::11 rraattiioo--nnoorrmmaall
lloossss ooff BBRRBB
aauuttoorreegguullaattiioonn
nneeww vveesssseellss

7. PATHOGENESIS

9. •OTHER VASCULAR
ABNORMALITIES
–COAGULATION
–PERMEABILITY
–CONTRACTILITY & FLOW
–CELLULAR REGENERATION
Normally- TGF-B release by endo cells
inhibition of proliferation
In DR- loss of pericytes
prevents expression of TGF-B
endothelial cell proliferation
microaneurysms

10. ANGIOGENIC FACTORS
FGF,TGF-B,PDGF,IGF-1 & 2,VEGF
• FGF-basic
• IGF-1 &2
• VEGF-produced by retina
-induced by hypoxia
-pro angiogenic
-induces permeability
-diffusible thru out eye

11. PATHOLOGICAL LESIONS
MICRO ANUERYSMS
• Signs-tiny, round dots
• site-inner nuclear layer. Venous end of capillaries
• size-12-100mic, >30 mic
• course-hyalinization, occlusion, months -yrs
• Importance-

12. • RETINAL HEMORRHAGES
Intra retinal
“Dot –blot”
Site-inner nuclear layer
venous end of capillary
“flame shaped”
site-NFL
superficial pre-capill
arterioles

13. HARD EXUDATES
• Signs-waxy, yellow with distinct margins
• Site-outer plexiform layer
• Composition-lipoproteins, lipid laden macrophages
• Due to abnormal cap
& microanuerysms
• Circinate pattern

14. SOFT EXUDATES
• cotton wool spots
• signs-whitish, fluffy,obscure blood vessels
• composition-axoplasmic stasis
• course- in wks to mths
• importance –focal infarcts
8 or more-PDR in 6-18mths

15. IRMA
• Shunts from arterioles to venules
• close to areas of capillary closure
• signs-fine red lines, focal areas of flat new
vessels
• distinguishing feature-intra retinal , do not
cross major vessels, absence of leak
RETINAL EDEMA
• site-all layers
• signs-retinal thickening, transparency lost
cystoid appearance

16. CAPILLARY ABNORMALITIES
• occlusion –focal, perifoveal, regional
• dilatation
• microaneurysm
• abnormal permeability
ARTERIOLAR ABNORMALITIES
• obstruction
• sheathing
VENOUS ABNORMALITIES
• general dilatation
• beading & sausaging
• venous kinks & loops
• reduplication
• CRVO
• BRVO

17. DIABETIC MACULOPATHY
MACULAR EDEMA- S/L examination ( Bimicroscopy),
 Absence of foveal reflex
 Cystoid appearance
TYPES
 Focal
 Diffuse
 Ischemic
 Mixed
 Detachment of macula

18. Diabetic maculopathy
FOCAL- well circumscribed retinal thickening
Rings of perifoveal exudates
around discrete foci of capillary abnormalities
DIFFUSE- thru out post pole
diffuse capillary abn.
ISCHEMIC-VA decreased but normal appearance
CWS +
focal cap drop outs
enlargement of FAZ
occl. of art in the macula
MIXED
MACULAR DETACHMENT

19. ABBREVIATIONS
• CWS-COTTON WOOL SPOTS
• VA-VISUAL ACUITY
• FAZ-FOVEAL AVASCULAR ZONE
• MA-MICRO ANEURYSM

20. MODERN ETDRS CLASSIFICATION
NPDR ( Non-Proliferative Diab Retinopathy)
• MILD- at least 1 micro aneurysms
Hard exudates
Intra retinal h’ges
Macular edema
FAZ abnormalities
• MODERATE-Venous beading
CWS
IRMA
Intraretinal h’ges
• SEVERE- Intraretinal h’ges in 4 quadrants
Venous beading in 2 quadrants
IRMA in 1 quadrant
• VERY SEVERE- Any 2 of the above

21. MILD NPDR:
•ATLEAST ONE Ma /HGE
ANY QUADRANT

22. MODERATE NPDR:
MODERATE AMT OF Ma/HGES
WITH HARD /SOFT EXUDATES

23. SEVERE NPDR:
ATLEAST ONE OF THE FOLLOWING—
• HGES/Ma --- ALL 4 QUADRANTS
• VENOUS BEADING IN TWO
QUADRANTS
• INTRA RETINAL MICROVASCULAR
ABNORMALITIES- ONE QUADRANT

24. VERY SEVERE NPDR:
TWO OF THE ABOVE CRITERIA

25. PROLIFERATIVE Diab Retinopathyhy-PDR
• EARLY-NVD
( neovascularisation of the disc)
NVE ( neovascularisation elsewhere)
Vitreous/Preretinal h’ge &NVE >1/2DD
• HIGH RISK PDR-NVD
>1/4-1/3 DD
NVD & vitreous/preretinal h’ge
NVE>1/2DD & vitreous/preretinal h’ge
• ADVANCED PDR –
Tractional RD inv macula
Vitreous h’ge obscuring grade

26. PROLIFERATIVE DR:
NEW VESSELS ON THE DISC ( NVD )

27. NEW VESSELS ELSEWHERE ( NVE ):

28. ADVANCED
PROLIFERATIVE DR
FIBROVASCULAR BANDS
PRE RETINAL HGE

29. CLINICALLY SIGNIFICANT MACULAR EDEMA
THREE CRITERIA:criteria 1
• RETINAL THICKENING
WITHIN 500 MICRONS
FROM THE FOVEA

30. CLINICALLY SIGNIFICANT MACULAR EDEMA
criteria-2
HARD EXUDATES
WITHIN 500 MICRONS
OF FOVEA WITH
ADJACENT RETINAL
THICKENING

31. CLINICALLY SIGNIFICANT MACULAR EDEMA
Criteria-3
•RETINAL THICKENING
OF > 1 D.D. EVEN IF PARTLY
WITHIN 500 MICRONS OF FOVEA