Diabetic Diabetic RetinopathyRetinopathy

St John Eye HospitalSt John Eye Hospital

Diabetic Eye Disease Diabetic Eye Disease ComponentsComponents

►Diabetic Retinopathy►Cataract►Refractive changes►Cranial nerve palsies►Glaucoma

Diabetic Eye Disease Diabetic Eye Disease significancesignificance

►10% of blind registrations are due to DR

►Commonest cause in 20-65 year old age group

►Most cases of blindness can be prevented with implementation of existing technology

Risk factorsRisk factors

►Duration of diabetes is the principle determinant of the presence of diabetes related retinopathy

►Poor glycemic control is the most critical risk factor for the development and progression of diabetes associated retinopathy

Normal RetinaNormal Retina

Classification of DRClassification of DR ► Non proliferative diabetic retinopathyNon proliferative diabetic retinopathy (NPDR)/ BDR (NPDR)/ BDR

MicroaneurysmsMicroaneurysms Dot and blot haemorrhagesDot and blot haemorrhages Hard ( intra-retinal ) exudatesHard ( intra-retinal ) exudates

► PreproliferativePreproliferative diabetic retinopathydiabetic retinopathy- CWSCWS- IRMAIRMA- Venous dilationVenous dilation- Dark blot haemorrhagesDark blot haemorrhages► Proliferative diabetic retinopathyProliferative diabetic retinopathy

Neovascularization of the retina, optic disc or irisNeovascularization of the retina, optic disc or irisLate DR-fibrovascular proliferation Late DR-fibrovascular proliferation

► MaculopathyMaculopathy Clinically significant macular oedema (CSME )Clinically significant macular oedema (CSME ) Ischaemic MaculopathyIschaemic Maculopathy Diffuse maculopathy Diffuse maculopathy

► MACULOPATHY IS LEADING CAUSE OF BLINDNESSMACULOPATHY IS LEADING CAUSE OF BLINDNESS

MicroaneurysmsMicroaneurysms

► Retinal microaneurysms are focal dilatations of retinal Retinal microaneurysms are focal dilatations of retinal capillariescapillaries

► appear as red dots.appear as red dots.► They are usually seen at the posterior pole, especially They are usually seen at the posterior pole, especially

temporal to the fovea. temporal to the fovea.

Retinal HaemorrhagesRetinal Haemorrhages► When the wall of a capillary or microaneurysm is sufficiently When the wall of a capillary or microaneurysm is sufficiently

weakened, it may rupture, giving rise to an intraretinal weakened, it may rupture, giving rise to an intraretinal hemorrhage.hemorrhage.

► If the hemorrhage is deep (i.e., in the inner nuclear layer or If the hemorrhage is deep (i.e., in the inner nuclear layer or outer plexiform layer), it usually is round or oval ("dot or blot")outer plexiform layer), it usually is round or oval ("dot or blot")

► Dot haemorrhages appear as bright red dots and are the Dot haemorrhages appear as bright red dots and are the same size as large microaneurysms same size as large microaneurysms

► Blot haemorrhages are larger lesions they are located within Blot haemorrhages are larger lesions they are located within the mid retina and often within or surrounding areas of the mid retina and often within or surrounding areas of ischaemia.ischaemia.

Hard exudatesHard exudates(Intra retinal lipid exudates)(Intra retinal lipid exudates) Hard exudates (Intra retinal lipid exudates) are Hard exudates (Intra retinal lipid exudates) are

yellow deposits of lipid and protein within the yellow deposits of lipid and protein within the sensory retina.sensory retina.

Accumulations of lipids leak from surrounding Accumulations of lipids leak from surrounding capillaries and microaneurysms, they may form a capillaries and microaneurysms, they may form a circinate pattern. circinate pattern.

Cotton Wool SpotsCotton Wool Spots Cotton wool spots result from occlusion of Cotton wool spots result from occlusion of

retinal pre-capillary arterioles supplying the retinal pre-capillary arterioles supplying the nerve fiber layer with concomitant swelling nerve fiber layer with concomitant swelling of local nerve fiber axons.of local nerve fiber axons.

Also called "soft exudates" or "nerve fiber Also called "soft exudates" or "nerve fiber layer infarctions" they are white, fluffy layer infarctions" they are white, fluffy lesions in the nerve fiber layer.lesions in the nerve fiber layer.

Proliferative diabetic Proliferative diabetic retinopathyretinopathy

Retinal ischaemia due to Retinal ischaemia due to widespread capillary non widespread capillary non perfusion results in the perfusion results in the production of production of vasoproliferative substances vasoproliferative substances and to the development of and to the development of neovascularizationneovascularization

Neovascularization can Neovascularization can involve the retina, optic disc involve the retina, optic disc or the iris (or the iris (rubeosis iridis)rubeosis iridis)

Proliferative diabetic Proliferative diabetic retinopathyretinopathy

► Rubeosis iridisRubeosis iridis is a sign of severe is a sign of severe proliferative disease, it may cause proliferative disease, it may cause intractable glaucoma.intractable glaucoma.

► Bleeding from fragile new vessels Bleeding from fragile new vessels involving the retina or optic disc can involving the retina or optic disc can result in result in vitreous or retinal vitreous or retinal hemorrhagehemorrhage. Retinal damage can . Retinal damage can result from persistent vitreous result from persistent vitreous hemorrhage.hemorrhage.

► Pre retinal haemorrhages are often Pre retinal haemorrhages are often associated with retinal associated with retinal neovascularization, they may neovascularization, they may dramatically reduce vision within a dramatically reduce vision within a few minutes.few minutes.

Proliferative diabetic Proliferative diabetic retinopathyretinopathy

Late DiseaseLate Disease

Contraction of Contraction of associated fibrous associated fibrous tissue formed by tissue formed by proliferative disease proliferative disease tissue can result in tissue can result in deformation of the deformation of the retina and tractional retina and tractional retinal detachment retinal detachment

Macular OedemaMacular Oedema

►Macular oedema is an important Macular oedema is an important manifestation of DR because it is now the manifestation of DR because it is now the leading cause of legal blindness in diabetics.leading cause of legal blindness in diabetics.

► The intercellular fluid comes from leaking The intercellular fluid comes from leaking microaneurysms or from diffuse capillary microaneurysms or from diffuse capillary leakage leakage

Flourescein AngiographyFlourescein Angiography

OCTOCT

►Mainly for macular edemaMainly for macular edema

Good Control of DMGood Control of DM

Laser TherapyLaser Therapy

► Laser Laser photocoagulation photocoagulation causes a retinal burn causes a retinal burn which is visible on which is visible on fundoscopy.fundoscopy.

► Retinal and optic Retinal and optic disc disc neovascularization neovascularization can regress with the can regress with the use of retinal laser use of retinal laser photocoagulation photocoagulation

Panretinal laser Panretinal laser photocoagulation for photocoagulation for

proliferative DRproliferative DR► The mainstay of treatment The mainstay of treatment

of diabetic retinopathy is of diabetic retinopathy is retinal laser retinal laser photocoagulation.photocoagulation.

► Laser therapy is highly Laser therapy is highly effective; the rate of effective; the rate of severe visual loss at 2 severe visual loss at 2 years due to proliferative years due to proliferative disease can be reduced by disease can be reduced by 60%.60%.

► Rubeosis iridis requires Rubeosis iridis requires urgent panretinal urgent panretinal photocoagulation to photocoagulation to prevent ocular pain and prevent ocular pain and blindness from glaucoma.blindness from glaucoma.

Panretinal laser Panretinal laser photocoagulationphotocoagulation

Macular laser therapyMacular laser therapy

► The indications for laser therapy now include CSME The indications for laser therapy now include CSME which is treated with a macular laser grid or which is treated with a macular laser grid or treatment of focal lesions such as microaneurysms.treatment of focal lesions such as microaneurysms.

► Early referral and detection of disease is important Early referral and detection of disease is important as treatment of maculopathy is far more successful as treatment of maculopathy is far more successful if undertaken at an early stage of the disease if undertaken at an early stage of the disease processprocess

Anti VEGFAnti VEGFVascular endothelial growth

factor (VEGF)

► A protein called vascular endothelial growth factor A protein called vascular endothelial growth factor (VEGF) is one reason why weak (VEGF) is one reason why weak abnormal blood vessels may grow under the retina abnormal blood vessels may grow under the retina and lead to vision loss.and lead to vision loss.

► Anti-VEGF medicines block the effects of VEGF. Anti-VEGF medicines block the effects of VEGF.

► Treatment of macular oedeme, PDRTreatment of macular oedeme, PDR

► Treatment of ARMDTreatment of ARMD

VITRECTOMY IN DIABETIC VITRECTOMY IN DIABETIC PATIENTSPATIENTS

► Vitrectomy, plays a vital Vitrectomy, plays a vital role in the management role in the management of severe complications of severe complications of diabetic retinopathy.of diabetic retinopathy.

► The major indications The major indications are non-clearing vitreous are non-clearing vitreous hemorrhage, traction hemorrhage, traction retinal detachment, and retinal detachment, and combined traction combined traction /rhegmatogenous retinal /rhegmatogenous retinal detachment.detachment.

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