Diabetic retinopathy is a leading cause of blindness that is associated with both type 1 and type 2 diabetes. It results from glycation and damage to the retinal blood vessels over time. Early stages are asymptomatic, but can progress to cause vision loss through edema, hemorrhage, or the growth of abnormal new blood vessels. Risk increases with longer duration of diabetes. Management focuses on tight glycemic control through medication and lifestyle changes, as well as regular eye exams and treatments such as laser photocoagulation or anti-VEGF injections to prevent vision loss.

1. DIABETIC RETINOPATHY
Jose M De Jesus, OD, MD, MA

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. Overview

4. 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

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

6. microvascular leakage NPDR
microvascular occlusion PDR
Glycation

7. Healthy Retina Diabetic Retinopathy

8. Epidemiology

9. Trends in Prevalence of Diabetes Worldwide
Prevalence by 2030 – 439 Million

10. Global Data on Visual Impairments WHO 2010
Accounts for Approx. 1% of Cases
of Blindness World Wide

11. Leading Cause of VL in People of Working Age (18-
65) In Developed Countries

12. Best Predictor of Diabetic Retinopathy is the
Duration of the Disease
Prevalence of Diabetic Retinopathy after 20 Years of Diagnosis

13. Risk Factors

14. Pathophysiology

15. How diabetes cause vision loss
Trajectory to Vision Loss
Glycation
CSDME
Proliferative
DR
Diabetes
NPDR
DME
Vit. Hem.
RD
NG
Vision
loss

16. Pathophysiology

17. Edema Retinal hemorrhageHard exudates
Microvascular Leakage
Microvascular Leakage

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

19. Cotton – wool spot
Retinal Neovascularization
Ischemia
Neovascular glaucoma
Microvascular Occlusion
Fibrovascular bands
Vitreous hemorrhageVitreous hemorrhage
Increased VEFG
Tractional retinal detachment
Infarction
Anterior Proliferation
Rubeosis

20. Clinical Features

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

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

23. • Capillary Microaneurysms
- earliest ophthalmoscopic detectable clinical sign
- para/extrafoveay
- wall outpouching due to pericyte loss 10-100u in diameter
- rupture - blot/dot ( INL/OPL),
flame hemorrhage (NFL) Microaneurysms

24. • Dot/blot/flame hemorrhage
• Exudation - proteinous debris
• Intraretinal edema
• Cotton wool spot
Hard exudate
edema
Cotton Wool Spots
Hemorrhages

25. • Intraretinal microvascular abnormalities (IRMA)
- tortuous dilated capillaries that
- project anteriorly
- do not leak on FA
- adjacent to CWS
- Sign of hypoxia
IRMA
IRMA
IRMA
CWS

26. • 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

27. • 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

28. Proliferative Diabetic Retinopathy (PDR)
• Increased levels VEGF
• Disc new vessels (NVD)
• Peripheral new vessels (NVE)
• Vitreous or preretinal hemorrhages
• High risk
of severe
VAL
NVDVitreous
Fibrosis
NVE

29. • DME /Clinical Significant Diabetic Macular Edema (CSDME)
- not a criterion of severity of NPDR
- leading cause of legal blindness in diabetics
- present at any stage, more in PDR
3 criteria of CSDME

30. Normal
CSDME

31. Imaging of macular edema with optical coherence tomography

32. Management

33. Blindness Prevention

34. The Best Measure for Prevention of Vision
Loss is Strict Glycemic Control

35. • Treatments exist but work best before vision
is lost
RECOMMENDED EYE EXAMINATION
SCHEDULE
Diabetes Type Recommended Time of First
Examination
Recommended Follow-up*
Type 1 3-5 years after diagnosis Yearly
Type 2 At time of diagnosis Yearly
Prior to pregnancy (type 1
or type 2)
Prior to conception and
early in the first trimester
No retinopathy to mild
moderate NPDR every 3-12
months
Severe NPDR or worse every
1-3 months.

36. Dilated Fundus Exam
Protocol
- BP
- SLE – Check angles , gonioscopy
- IOP
- Tropicamide 1%, 2.5% phenylephrine

37. Indirect Ophthalmoscopy View
Indirect View Direct View

38. Laser Photocoagulation

39. Laser Photocoagulation for CSDME

40. PRP

41. Vitrectomy
Surgical treatment to
remove extensive
vitreous
fibrovascular strands
causing retinal traction

42. Anti-VEGF Treatment
http://drcrnet.jaeb.org

43. CONCLUSIONS

44. References
• Ophthalmology Myron Yanoff MD and Jay S. Duker
• Kanski's Clinical Ophthalmology: A Systematic Approach, 8th Edition, 2015
• Proposed international clinical diabetic retinopathy and diabetic macular edema
disease, Ophthalmology Volume 110, Number 9, September 2003
• http://apps.who.int/iris/bitstream/10665/204871/1/9789241565257_eng.pdf
• http:www.who.int/bulletin/volumens/82/11/en/844.pdf
• WHO/NMH/PBD/12.01.pdf
• http://www.aao.org/newsroom/release/20091030.cfm
• http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=d0c853-219-487b-
a524-326ab3cecd9a

45. Thank You!!!
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