diabetic retinopathy
TRANSCRIPT
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DIABETIC RETINOPATHY
Dr Paavan Kalra
Department of Ophthalmology,
S P Medical College,
Bikaner
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• Diabetic retinopathy is a disorder of the retinal vessels that eventually develops to some degree in nearly all patients with long-standing diabetes mellitus.
• Contributes 4.8% of the 37 million cases of blindness throughout the world
• Most Common cause of bilateral severe visual loss in working age group in US
• A recent study in urban population in south India estimates prevalence of DM in adult population as high as 28% & the prevalence of DR in diabetics to 18%
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RISK FACTORS
• Age at diagnosis of diabetes• Duration• Poor control of diabetes• Pregnancy• Hypertension• Nephropathy• Hyperlipidemia• Obesity• Anemia• Smoking• Cataract surgery
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PATHOGENESIS Hyperglycemia
Intracellular sorbitol accumulation
Free radicals
Glycated end products
Disruption of ion channel function
Protein kinase C activation
Microangiopathy (damage to
capillary wall)
Direct effect on retinal cells
Hematological & Rheological changes
Edema Exudates
Microvascular OcclusionIschemia
IRMA Neovascularization
Fibrosis
Intra retinal hemorrhages
hemorrhageTraction
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• Angiogenic stimulators
Vascular Endothelial Growth Factor – A
Platelet Derived Growth Factor
Hepatocyte Growth Factor
• Angiogenesis inhibtors
Endostatin
Angiostatin
Pigment Epithelium Derived Factor
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CLASSIFICATION
Acc to Kanski 7th ed ( 2011)
Background Diabetic Retinopathy
Diabetic Maculopathy
Preproliferative Diabetic Retinopathy
Proliferative Diabetic Retinopathy
Advanced Diabetic Eye Disease
Most detailed classification was given by ETDRS study
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PERICYTE LOSS
MICRO ANEURYSM THROMBOSED MICRO ANEURYSM
NORMAL CAPILLARIES
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MICRO ANEURYSMS
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INTRARETINAL
HEMORRHAGES
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NORMAL EDEMA : CYSTOID
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EXUDATES(HARD)
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NORMAL ISCHEMIA
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COTTON WOOL SPOTS
(“SOFT EXUDATES”)
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INTRA RETINAL MICROVASCULAR ABNORMALITIES
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Retinal arteriole obliterationVenous Segmentation
Venous BeadingVenous Loop
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PROLIFERATIVE DR
NEO VASCULARIZATION
: DISC
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NEO VASCULARIZATION
: ELSEWHERE
PROLIFERATIVE DR
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ADVANCED DIABETIC EYE DISEASE
• Pre retinal hemorrhage
• Vitreous hemorrhage
• Traction RD• Rubeosis
Iridis• Neovascular
Glaucoma
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DIABETIC MACULOPATHY
FOCAL
DIFFUSEISCHEMIC
DIFFUSE FOCAL
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ISCHEMIC MACULOPATHY
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HIGH RISK PDR
NVD > 1/4 - 1/3 disc area
NVD < 1/4-1/3 disc area with pre retinal or vitreous
hemorrhage
NVE >1/2 disc area
with pre retinal or vitreous hemorrhage
CONCEPTS FROM DRS & ETDRS
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CLINICALLY SIGNIFICANT MACULAR EDEMA
CONCEPTS FROM DRS & ETDRS
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Work Up - History
Duration of diabetes
Past glycemic control (hemoglobin A1c)
Medications
Systemic history (e.g., obesity, renal disease, systemic hypertension, serum lipid levels, pregnancy)
Ocular history
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Workup : Examination
Visual acuity
Measurement of IOP
Gonioscopy when indicated (for neovascularization of the iris or increased IOP)
Slit-lamp biomicroscopy
Dilated funduscopy including stereoscopic examination of the posterior pole
Examination of the peripheral retina and vitreous, best performed with indirect ophthalmoscopy or with slit-lamp biomicroscopy, combined with a contact lens
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Work up : Ophthalmic Investigations
• Fundus Photography• Fluorescein Angiography
to guide treatment of CSME
to identify Ischemic maculopathy
IRMA vs NV
evaluation in hazy media
not a screening modality
not a routine investigation• Optical Coherence Tomography
Retinal thickening
assessment & Monitoring of edema
vitreo macular traction•USG – B scan
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INTERNATIONAL CLINICAL DIABETIC RETINOPATHY
DISEASE SEVERITY SCALE
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INTERNATIONAL CLINICAL DIABETIC MACULAR EDEMADISEASE SEVERITY SCALE
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Treatment Modalities
• LASER Photocoagulation (ARGON)
CSME – Focal & Grid
PDR with HRC – Pan Retinal Photocoagulation•Other LASERS for CSME – Frequency doubled Nd YAG
Micro pulse Diode•INTRA VITREAL anti VEGF – Bevacizumab, Ranibizumab•INTRA VITREAL steroids – Triamcinolone acetonide•PARS PLANA VITRECTOMY
Strict Glycemic Control delays the onset and progression
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Deferral of focal photocoagulation
• hypertension or fluid retention associated with heart failure, renal failure,pregnancy, or any other causes that may aggravate macular edema.
• when the center of the macula is not involved, visual acuity is excellent, and the patient understands the risks
• Treatment of lesions close to the foveal avascular zone may result in damage to central vision and with time laser scars may expand and cause further vision deterioration.
• Adjunctive treatment may be considered- intravitreal corticosteroids or antivascular endothelial growth factor agents (off-label use).
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Panretinal photocoagulation • may be considered as patients approach
high-risk PDR.• The benefit of early panretinal
photocoagulation at the severe nonproliferative or worse stage of retinopathy is greater in patients with type 2 diabetes than in those with type 1.
• Other factors, such as poor compliance with follow-up, impending cataract extraction or pregnancy, and status of fellow eye will help in determining the timing of the panretinal photocoagulation.
• It is preferable to perform the focal photocoagulation first, prior to panretinal photocoagulation to prevent laser-induced exacerbation of the macular edema.
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• Screening of all cases above the age of 40 years irrespective of status of diabetes
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THANK YOU