Outline:

•Diabetic Retinopathy
(DR)
•Central Serous
Choroidopathy (CSC)
•Age-related Macular
Degeneration (AMD)
Diabetic Retinopathy

糖尿病视网膜病变
 Survey:
Diabetic retinopathy is the leading
cause of new cases of blindness in
the United States in patients between
the ages of 20 and 74. In the
developing Western countries, at
least 12﹪ of all blindness is due to
diabetes. In the United States, a
diabetic patient has more than a 20-
fold chance of becoming blind
compared to a nondiabetic
counterpart.
 1 、 Risk factors
• The duration of insulin-dependent
diabetes is the main factor in the
appearance of diabetic retinopathy.
When diabetes is diagnosed before
age 30 years, the risk of developing
retinopathy is about 2﹪ per year.
After 7 years and 25 years, 50% and
90% of diabetic patients,
respectively, will have some form of
retinopathy. After 25 to 50 years of
diabetes, 26% will have the
proliferative form.
 1 、 Risk factor
• Puberty (adolescence) and pregnancy
both stimulate development of retinopathy.
The 10-year rate of vision loss to less than
20/40 is about 10% in juvenile diabetics,
insulin-dependent disease, and 24% in
adult-onset, non-insulin- dependent
diabetes. The Diabetes Control and
Complications Trial (DCCT) showed that
intensive insulin treatment to control blood
sugar levels tightly decreased the risk of
developing severe nonproliferative or
proliferative retinopathy and reduced the
need for laser surgery by about 50%.
 2 、 Types of diabetes
• (1)Type 1 (juvenile onset ) diabetes
cases are autoimmune (pancreatic [ 胰
腺 ]destruction) and have a high risk
for developing severe proliferative
retinopathy.
 2 、 Types of diabetes
• (2) Type 2 (adult onset ) diabetes
cases have normal to high insulin
production but insulin-resistant
receptor cells. There are more type 2
patients with blinding sequelae( 后遗
症 ) because of the greater number of
type 2 diabetic patients.
 3 、 Medical evaluation
• Every diabetic patient deserves the benefit
of a comprehensive evaluation, with careful
attention paid to determine the presence of
symptoms of diabetic retinopathy such as
decreased vision, distortion of vision, loss
of color vision, and the presence of floaters.
The duration of diabetes and the method of
control of diabetes should be assessed. The
presence of associated systemic disease
should be noted. Hypertension is present
in 20% of insulin-dependent diabetes and in
58% of non-insulin-dependent diabetes.
Optimal （最佳） medical control is key to
minimizing ocular and systemic
complications
 4 、 Clinical appearance

• Diabetic retinopathy is classified into

four groups
• (1)Background retinopathy
(nonproliferative retinopathy)
• (2)Preproliferative diabetic
retinopathy
• (3) Proliferative diabetic retinopathy
• (4) Diabetic maculopathy
(1) Background retinopathy
(nonproliferative
retinopathy)
• The diabetic lesions （损害） of
background retinopathy are dilated
（扩大） veins, intraretinal
hemorrhages, microaneurysms, hard
exudates, edema, and CWSs (cotton
wool spots). Dot-blot hemorrhages,
retinal edema, and hard exudates
result from increased vascular
permeability. Microaneurysms cluster
around areas of capillary nonperfusion.
dot or blot haemorrhages
microaneurysms
• hard exudates forming a ring or circinate 漩涡状的
pattern around a leaking microneurysm
soft excudates in posterior fundus in moderate DR
• DR FA (fluorescein angiography )
(2)Preproliferative diabetic
retinopathy
• Preproliferative diabetic retinopathy
represents the most severe stage of
background retinopathy (nonproliferative
retinopathy). Preproliferative retinopathy is
categorized by the presence of many
intraretinal hemorrhages and
microaneurysms, intraretinal microvascular
abnormalities (dilated vessels within the
retina), and venous beading. There is wide
spread capillary closure. Approximately
10% to 50% of patients with preproliferative
retinopathy develop proliferative
retinopathy within a year.
•

Splinter 片 haemorrhages and intraretinal microvascular abnormalities

 (3) Proliferative diabetic
retinopathy
• Proliferative diabetic retinopathy
occurs in 5% of patients with diabetic
retinopathy. In the proliferative stage,
vascular abnormalities appear on the
surface of retina or within the vitreous
cavity, starting postequatorially. Visual loss
can be severe. New blood vessels grow on
the surface of the retina and the optic nerve
and are usually attached to the posterior
hyaloid （透明） surface of the vitreous body
causes traction on the retinal
neovascularization, resulting in vitreous
hemorrhage and/or traction retinal
detachment .
• Retinal Detachment
(4) Diabetic maculopathy
• Diabetic maculopathy may result
from increased vascular permeability
with or without intraretinal lipoprotein
deposits (hard exudates), or, less
commonly, from ischemia due to
closure of foveal capillaries. Diabetic
maculopathy may be seen in any
phase of retinopathy except for very
early background disease.
• DR macular
 5 、 Pathology
Histology of eyes with diabetic retinopathy
shows loss of intramural 壁内的 pericytes 外膜细
胞 and extensive capillary closure in trypsin 胰
岛素 -digest flat preparations of the retina. The
blood-retinal barrier is compromised mainly by
defects in the junctions between abnormal
vascular endothelial cells. The most widely
accepted working hypothesis for the
pathogenesis 发病机理 of proliferative
retinopathies such as diabetes, retinopathy
of prematurity (ROP 早产儿视网膜病 ), and CRVO
is that retina rendered ischemic by widespread
capillary closure elaborates VEGF, which
stimulates retinal neovascularization and/or
rubeosis 潮红 of the iris.
 6 、 Management
• Diabetic retinas are best examined using a binocular
viewing system which provides moderate
magnification such as a slitlamp at 10× in conjunction
with a 90-D （ diopter ） lens to allow the
stereoscopic 立体 vision. It is important to have the
patient look in various fields of gaze so the more
peripheral retina to the equator can be inspected,
because approximately 27% of retinal abnormalities
are found outside the central 45-degree area. Indirect
ophthalmology provides a view of the retina at, and
anterior to, the equator. Color photography is used to
document the progress or regression of retinopathy
following treatment. Fluorescein angiography defines
areas of leakage and ischemia, and confirms the
presence of neovascularization of the retina or disk.
• DR neovascularization of disc
• DR neovascularization
 6 、 Management
• Diabetic eyes should be inspected for
rubeosis with a slitlamp before the
pupil is dilated because fine vessels
on the iris are almost impossible to
see once mydriasis 瞳孔扩大 is induced.
Gonioscopy 前房角镜检查 is necessary if
new vessels are seen on the surface of
the iris with the slitlamp. To properly
inspect the retina, wide pupillary
dilation is needed.
 6 、 Management
• (1)Three major clinical trials have
been carried out by the National Eye
Institute to determine the retinal
history of nonproliferative and
proliferative diabetic retinopathy, as
well as guidelines for treatment.
 6 、 Management
• (a) The Diabetic Retinopathy Study (DRS)
showed that scatter argon laser
photocoagulation (panretinal photocoagulation
激光光凝 <PRP>) reduced the incidence of
severe visual loss (vision less than or equal to
5/200) by half or more in eyes with
neovascularization on the disk or within one
disk diameter of the disk. A similar reduction in
the rate of severe visual loss was obtained in
eyes with neovascularization elsewhere
associated with vitreous hemorrhage.
• laser pan-retinal photocoagulation
 6 、 Management
• (b) The Early Treatment Diabetic
Retinopathy Study showed that
eyes with clinically significant
macular edema benefited from focal
argon laser to discrete 不连续 areas
of leakage and grid 格子
photocoagulation to areas of
nonperfusion or diffuse leakage.
Moderate visual loss was defined as
a doubling of the visual angle: e.g.,
going from 20/20 to 20/40.
 6 、 Management
• Laser treatment reduced the risk of such
visual loss by 50% or more, increased the
chance of improved vision, and had only
minor visual field effect. Focal
photocoagulation for vision-threatening
macular edema should be given before
scatter photocoagulation (PRP) for
approaching high-risk proliferative
retinopathy. Aspirin had no clinical effect.
Observation only was indicated for eyes
with mild to moderate nonproliferative
retinopathy
 6 、 Management
• (c) The Diabetic Retinopathy Vitrectomy
Study showed that type 1 diabetic patients with
recent, severe vitreous hemorrhage associated
with vision equal to or more than 5/200
undergoing early vitrectomy 玻璃体切除 (within 6
months) had a notably better chance of attaining
20/40 or better vision than those whose
vitrectomy was deferred a year. Type 2 or mixed
diabetic patients did not benefit from early
vitrectomy for severe vitreous hemorrhage.
Patients with severe proliferative retinopathy with
vision equal to or greater than 10/200 had a better
chance of attaining 20/40 or better vision if they
had early vitrectomy than those managed with
conventional therapy.
 6 、 Management
• (2) Follow-up and management guidelines for
diabetic retinopathy, as recommended by
American Academy of Ophthalmology .
• (a) Normal or rare microaneurysms: annual
examination, good diabetic control.
• (b) Mild nonproliferative diabetic retinopathy
(NPDR ) (few hemorrhages and
microaneurysms in one field or several
fields, but no macular edema or exudates):
examination every 9 months, good diabetic
control.
 6 、 Management
• (c) Moderate NPDR (hemorrhages and/or
exudates in all fields, intraretinal
microvascular abnormalities [IRMAS] or
CWSs): examination every 6 months, good
diabetic control.
• (d) Severe NPDR (one or more of the
following: severe number of retinal
hemorrhages and microaneurysms,
moderate IRMAs, venous beading):
examination every 4 months.
• (e) Macular edema at any time: examination
every 3 to 4 months, focal laser if clinically
significant edema develops.
splinter haemorrhages and intraretinal
microvascular abnormalities
 6 、 Management
• (4) Non-high-risk proliferative
diabetic retinopathy occurs when
there are any new vessels but the eye
does not yet have high-risk
characteristics (HRC) as defined by
the DRS. These eyes should be
followed every 2 to 3 months. In
patients with bilateral non-high-risk
proliferative retinopathy, PRP should
be considered in one eye.
 6 、 Management
• (3) Clinically significant macular edema
includes any of the following features:
• (a) Thickening of the retina at or within
500μm of the center of the macula.
• (b) Hard exudates at or within 500μm of the
center of the macula.
• (c) Zones of retinal one disk area or lager,
any part of which is within one diameter of
the center of the macula.
Appropriate argon laser photocoagulation
reduces the risk of visual loss substantially.
 6 、 Management
• (5) Proliferative retinopathy with HRC.
• Panretinal laser photocoagulation is the
treatment of choice for this stage, which is
characterized by one or more of the
following.
• (a) Neovascularization on or within one disk
diameter of the disk greater than one-fourth
to one-third of the disk area.
• (b) Vitreous or preretinal hemorrhage
associated with less extensive
neovascularization of the disk (NVD) or
neovascularization elsewhere (NVE) one-
half disk area or more in size.
 6 、 Management
• (6) Laser application.
• The risk of severe visual loss in patients with HRC
is substantially reduced by means of panretinal
laser photocoagulation done with the argon
green laser. If nuclear sclerotic cataract or
vitreous hemorrhage is present, there is less
wavelength absorption with yellow or red lasers,
such as the Krypton. The goal is to achieve
regression of exiting vessels and inhibition of new
vessel growth. Treatment is commonly done in two
to four stages separated by 1 or more weeks.
Typically, 400 to 600 burns of 500μm diameter are
placed in the retinal periphery in one session. They
come to within 500μm of the disk on the nasal side.
 6 、 Management
• To preserve central vision, none are place
within two disk diameters of the center of
the macula. To preserve peripheral field,
burns are placed one to one-half burn width
apart. The duration of each burn is 0.1 to 0.2
Seconds and the power is adjusted to
achieve definite retinal whitening. Flat new
vessels away from the disk receive
confluent 融合性的 ; burns. Areas of significant
fibrosis, traction retinal detachment, and
vitreous or preretinal hemorrhage are
avoided. If proliferative diabetic retinopathy
continues to be active despite panretinal
laser photocoagulation in all quadrants 象限 ,
additional laser spots may be added
between, or anterior to, the old laser scars.
 6 、 Management
• Panretinal cryoablation 冷冻消融 [ 术 ] is useful in
selected patients. If a blinding vitreous
hemorrhage occurs despite these measures or
before laser can be given, pars plana 睫状体扁平部
vitrectomy should be performed within 6 months in
type 1 diabetics. Intraoperative laser
photocoagulation is often performed when these
patients undergo pars plana vitrectomy. If B-scan
ultrasonography suggests an underlying traction
retinal detachment of the macula, vitrectomy
should be done in all patients. Of course, when a
recent traction macular detachment or a
combination traction and rhegmatogenous 孔源性的
retinal detachment is present even when there
is no vitreous hemorrhage, vitreous surgery is
indicated.
rhegmatogenous 孔源性的 retinal detachment
 6 、 Management
• PRP is not necessary in phakic 人工晶体
eyes if there is peripupillary rubeosis 红变
but no abnormal new vessels on the
trabecular meshwork 小梁网 . Such eyes
should be followed every 3 months. If there
are new vessels in the angle, the eye is
aphakic 无晶体眼 , or the eye is pseudophakic
eye 人工晶状体眼 with a broken posterior
capsule, prompt PRP is needed to prevent
neovascular glaucoma even when
proliferative diabetic retinopathy with HRC
is absent.
 6 、 Management
• Focal macular laser therapy for clinically
significant macular edema commonly uses
100 to 200 μm spot sizes and 0.1 seconds
duration. The goal is to change the color of
leaking microaneurysms through direct
treatment; grid treatment （核）栅极治疗 is
given to areas of diffuse leakage and
ischemia. Leaks within 500μm of the center
of the macula are usually not treated with
the laser unless previous treatment has
failed, vision is less than 20/40, and
treatment will not damage the perifoveal 中
心凹周的 capillary network on the edge the
foveal avascular 无血管 zone.