Diabetic retinopathy-screening training program for nurses St John Eye Hospital - UNRWA

1. DIABETIC RETINOPATHY
Dr. Riyad Banayot
St. John of Jerusalem Eye Hospital
Diabetic Retinopathy Screening

3. Diabetic eye disease Lids
Recurrent styes, xanthalesma
& blepharitis

4. Diabetic eye disease
Conjunctiva & Cornea
Conjunctivitis & Keratitis

5. Diabetic eye disease Iris
 Rubeosis iridis (complication
of PDR)
 Spontaneous Hyphema
 Bleeding also occurs during
cataract surgery & iridectomy
 Diabetic iritis
 Pupillary dysfunction

6. Diabetic eye disease
 Angle Neovascularization
 IOP
 Secondary glaucoma (neovascular or
Hemorrhage)
 Hypotony in diabetic coma

7. Diabetic eye disease Lens
 True diabetic cataract below 30 years
 Pre-senile cataract above 40 years
 Hyperglycemia = index myopia
 Hypoglycemia = index hypermetropia

8. Diabetic eye disease
Vitreous
Hemorrhage

9. Diabetic eye disease Retina
 Diabetic retinopathy
 Lipemia retinalis due to high
blood level in uncontrolled
cases. Fundus appears pale
&retinal vessels are milky

10. Diabetic eye disease
Optic nerve
 Retrobulbar neuritis
 Acute papillitis

11. Diabetic eye disease
6th nerve
Paralytic squint

12. Diabetic eye disease
 Post operative complication
 Hemorrhage
 Infection
 Delayed wound Healing

13. Diabetic retinopathy
 A silent complication with no initial
symptoms (until they have a bleed in the
eye)
 When symptoms occur, treatment is more
complicated and often difficult with poorer
outcome
 Screening for retinopathy is of the utmost
importance

14. When to screen for
retinopathy
 Type 1 diabetes: within 5 years of
diagnosis
 Type 2 diabetes: at time of diagnosis
(30% already have complications)
Thereafter, every 1 to 2 years,
depending on the status of the retina

15. Diabetic eye disease
 Blurred vision: common symptom of
hyperglycaemia. Osmotic changes in the lens
due to fluctuating blood glucose levels (lens
changes shape)
 Blurred vision may also be due to other eye D
 Epidemiology:
 Some form of retinopathy: 21-36%
 vision-threatening retinopathy: 6-13%

16. Risk factors
 Poor glycemic
control
 Long duration
 Hypertension
 Dyslipidemia
 Nephropathy
 Pregnancy

17. Intensive therapy
DCCT – type 1 diabetes receiving intensive therapy:
 Patients without retinopathy:
reduced risk of developing retinopathy by
76%
 Patients with some retinopathy:
reduced risk of progression of retinopathy by
54%
DCCT 1993

18. Intensive therapy
UKPDS – type 2 diabetes:
 Good glyaemic control:
reduced progression of retinopathy by
20-30%
 Tight blood pressure control: reduced
progression of retinopathy by 34%
UKPDS 1998

19. Screening tests
 Visual acuity (OnceVA decreases to 6/24
the chance of saving the sight using laser
therapy is significantly reduced)
 Direct fundoscopy (through dilated
pupils)
 Retinal photography (FFA & OCT)
 Testing intra-ocular pressure

20. Diabetic retinopathy
 Non-proliferative diabetic retinopathy:
minimal, mild, moderate, severe
 Proliferative Diabetic Retinopathy
(PDR): high-risk PDR, advanced PDR
 Macular oedema, clinically significant
macular oedema

21. Normal retina
Macula
Optic disc

22. Non-proliferative diabetic
retinopathy
Hard exudates

23. Severe non-proliferative
retinopathy
Haemorrhage
Cotton wool
spot

24. Proliferative retinopathy
New vessels
Pre-retinal
haemorrhage

25. Advanced proliferative
retinopathy
Scar tissue

26. Vitreous haemorrhage
 See a black mark across the vision
 Some blood will be reabsorbed
 Vitrectomy may be necessary

27. Early macular oedema

28. Investigations
 Fluorescein angiogram:
provides more detailed information

29. Investigations: FFA
Dot
haemorrhage
Blot
haemorrhage

30. Fluorescein leakage

31. Treatment
 Laser therapy:
 Pan-retinal for proliferative
retinopathy
 Focal or grid for macular edema

32. Pan-bombing for proliferative
retinopathy

33. Grid laser for macular
oedema

34. Laser therapy
Side effects
 Loss of peripheral vision, tunnel vision,
night blindness
 Colour blindness
 Vision can get worse but “laser saves
sight” in long term

35. Treatment
 Blood pressure: reduces macular edema
 Blood glucose control: slows progression
 Control lipids
 Use of aspirin does not increase the risk
of retinal bleeding.

36. Pregnancy
 Pregnancy can cause transient
deterioration of diabetic retinopathy
but generally not permanent damage
 Baseline retinal assessment should be
performed before pregnancy
 Retinopathy is not a problem in
gestational diabetes

37. Summary
 100% of people with diabetes will
develop some retinopathy
 The higher the blood glucose level the
greater the risk
 Different grades of retinopathy
 Laser therapy saves sight
 Timely treatment is most effective
 Regular screening is a must