DIABETIC RETINOPATHY

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DIABETIC RETINOPATHY

• Some pictures have been taken through Google
  Images.

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DIABETIC RETINOPATHY

• Epidemiology and risk factors
• 2. Classification and features of Diabetic
• retinopathy (DR)
• 3. Complications of DR and their prevention
• 4. Screening protocol for DR and referral to
  Ophthalmologist
• 5. Direct ophthalmoscopy and identification of
  fundus findings  

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Epidemiology of DR

• RISK of developing DR
• Type I or IDDM 70
• Type II or NIDDM - 39
• Type II on insulin 70

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• Prevalence of the type of Diabetes
• Type 2 in 90 of diabetic patients
• Hence Type 2 in most of the Diabetic
  Retinopathy patients as well
• Diabetic retinopathy - most common cause of legal
  blindness between ages 20 and 70 years.

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RISK FACTORS

• Duration of diabetes
• Poor control of Diabetes
• Pregnancy
• Hypertension
• Nephropathy
• Obesity and hyperlipidemia
• Smoking

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Pathogenesis

• Microangiopathy which has features of both
  microvascular leakage and occlusion
• Larger vessels may also be involved

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Microvascular leakage

• Loss of pericytes results in distention of weak
  capillary wall producing microaneurysms which
  leak
• Blood-retinal barrier breaks down causing plasma
  constituents to leak into the retina retinal
  oedema, hard exudates

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Microvascular occlusion

• Basement membrane thickening, endothelial cell
  damage, deformed RBCs, platelet stickiness and
  aggregation
• Vascular Endothelial Growth Factor (VEGF) is
  produced by hypoxic retina
• VEGF stimulates the growth of shunt and new
  vessels

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Classification of DR

• I. Non-proliferative DR (NPDR)
• Mild
• Moderate
• Severe
• Very severe
• Proliferative DR (PDR)
• III. Clinically significant macular oedema (CSME)
• - May exist by itself or along with NPDR
  and PDR

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Mild NPDR

• At least one microaneurysm - earliest clinically
  detectable lesion
• Retinal hemorrhages
• Hard or soft exudates

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Moderate NPDR

• Microaneurysms and/or dot and blot hemorrhages in
  at least 1 quadrant
• Soft exudates (Cotton wool spots)
• Venous beading or IRMA (intraretinal
  microvascular abnormalities)

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Mild and Moderate Non- proliferative DR was
previously known as Background DR
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Severe NPDR

• Any one of the following 3 features is present
• Microaneurysms and intraretinal hemorrhages in
  all 4 quadrants
• Venous beading in 2 or more quadrants
• Moderate IRMA in at least 1 quadrant
• Known as the 4-2-1 rule

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Very severe NPDR

• Any two of the features of the 4-2-1 rule is
  present

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Severe and Very severe Non-proliferative DR was
known as the Pre-proliferative DR
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Clinically significant Macular Oedema

• Retinal oedema close to fovea
• Hard exudates close to fovea
• Presents with dimness of vision
• By itself or along with NPDR or PDR

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CSME Hard exudates close to fovea and
associated retinal thickening
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Proliferative DR (PDR)

• Characterized by Proliferation of new vessels
  from retinal veins
• New vessels on the optic disc
• New vessels elsewhere on the retina

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Proliferative DR
NVD
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COMPLICATIONS OF DIABETIC RETINOPATHY

• Vitreous hemorrhage
• Tractional retinal detachment
• Rubeosis Iridis
• Glaucoma
• Blindness

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Vitreous Hemorrhage
SUBHYALOID HEMORRHAGE
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Tractional retinal detachment
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Rubeosis Iridis
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Neovascular Glaucoma

• Complication of rubeosis iridis
• New vessels cause angle closure
• Mechanical obstruction to aqueous outflow
• Intra ocular pressure rises
• Pupil gets distorted as iris gets pulled
• Eye becomes painful and red
• Loss of vision

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Blindness

• Non-clearing vitreous hemorrhage
• Neovascular glaucoma
• Tractional retinal detachment
• Macular ischemia

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PREVENTION OF COMPLICATIONS

• By early institution of appropriate treatment
• This requires early detection of DR in its
• asymptomatic treatable condition
• By routine fundus examination of all Diabetics
  (cost effective screening)
• And appropriate referral to ophthalmologist

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Mild and Moderate NPDR

• - No specific treatment for retinopathy
• Good metabolic control to delay progression
• Control of associated Hypertension, Anemia and
  Renal failure

• Severe and very severe NPDR

• Close follow up by Ophthalmologist

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Clinically significant macular oedema

• Laser photocoagulation to minimise risk of visual
  loss

• Proliferative DR

• Retinal laser photocoagulation as per the
  judgment of ophthalmologist (in high risk eyes)
• It converts hypoxic retina (which produces
  ANGIOGENIC factors) into anoxic retina (which
  cant)

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Screening protocol for Diabetic retinopathy

• Screening once in a 1 year
• Diabetics with normal fundus
• Mild NPDR
• Screening once in 6 months
• Moderate NPDR

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Referral to Ophthalmologist

• Visual Symptoms
• Diminished visual acuity
• Seeing floaters
• Painful eye
• Fundus findings
• - Macular oedema/hard exudates close to fovea
• - Proliferative DR
• - Vitreous hemorrhage
• - Moderate to severe and very severe NPDR
• Retinal detachment
• Cataract obscuring fundus view

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Referral to Ophthalmologist

• Presence of Risk Factors
• - Pregnancy
• - Nephropathy

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Simulation of defective vision as experienced by
a Diabetic whose vision has been affected by
Diabetic retinopathy
Normal
Defective
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DIRECT OPHTHALMOSCOPY

• Examination of the fundus of the eye
• To screen for Diabetic Retinopathy
• After dilatation of both eyes with 0.5
  tropicamide
• Flashlight test, prior to dilatation to detect
  eyes with shallow AC
• Procedure will be demonstrated

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Aim the ophthalmoscope light at the pupil at an
angle 15-200 lateral to the visual axis, along
the white line shown in the figure, 10-12 inches
in front of the patients eye. A red reflex
should fill the pupil. Keeping red reflex in
view move closer to about 1 inch in front of
patient when the retina (optic disc) comes into
focus. From this position slightly tilt the
ophthalmoscope to examine other areas around the
optic disc, to trace the blood vessels and view
the macula.
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The optic disc is seen first as the fundus is
observed along an axis 15-20o lateral to the
visual axis. The macula is viewed by moving the
ophthalmoscope nasally into the visual axis of
the subject, so that the beam of light sweeps the
retina temporal to the disc to fall on the
macula, which is placed lateral to disc.
Left Eye
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View of the retina through an ophthalmoscope
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Normal fundus views of Right and left eye
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NPDR
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Mild NPDR Microaneurysms, Dot and Blot
hemorrhages
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(No Transcript)
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Moderate NPDR
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Moderate NPDR with CSME
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Circinate retinopathy Hard exudates in a ring
around leaking aneurysms
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Age related Macular degeneration Note the
drusen. Not to be confused with Hard exudates.
There are no microaneurysms or dot/blot
hemorrhages.
DRUSEN
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• Moderate Severe NPDR
• Cotton wool patches
• Hemorrhages - 4 quadrants

With CSME
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Severe NPDR
Very severe NPDR

• Venous beading, - scars of laser spots,
• Absorbing hemorrhages

Cotton-wool patches, venous segmentation
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CSME in Different Stages of NPDR
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Proliferative DR New vessels elsewhere on the
retina along the supero-temporal vessels
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PDR New vessels on disc
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PDR New vessels on disc and New vessels
elsewhere on retina
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PDR with vitreous hemorrhage
Vitreous bleed
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Vitreous Hemorrhage
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Tractional retinal detachment
Fibro-vascular proliferation
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Thank you!
Any doubts?