Diabetic retinopathy

Contents

Diabetes
Definition
Risk factors
Pathogenesis
Classification : proliferative / non-
proliferative
Sign & symptoms
DDx & other ocular complication of DM
Treatment & follow up
Screening for DR
Apply with case study
 Diabetes mellitus
Group of common metabolic disorders

Caused by a complex interaction of genetics and environmental factors

Lack of insulin hyperglycemia

Diagnostic criteria : Fasting plasma glucose > 126 mg/dl

Type 1 DM Insulin-dependent diabetes (IDDM)

Results from pancreatic beta-cell destruction, usually leading to absolute or

near total insulin deficiency

Type 2 DM - Non-insulin-dependent diabetes (NIDDM)

Variable degrees of insulin resistance and impaired insulin secretion,

resulting in hyperglycemia and other metabolic derangements due to

insufficient insulin action.

 Diabetes mellitus
Long-standing hyperglycemia leads to multiple organ damage

Macrovascular complications

Stroke

Heart disease and hypertension

Peripheral vascular disease

Foot problems

Microvascular complications

Diabetic eye disease : retinopathy and cataracts

Renal disease

Neuropathy

Foot problems
 Diabetic retinopathy

The most severe of ocular complications of diabetes

Caused by damage to blood vessels of the retina,
leads to retinal damage
Microvascular complication of longstanding diabetes
mellitus [1]
Most prevalence cause of legal blindness between
the ages of 20 and 65 years
Common in DM type 1 > type 2
 Risk factors
Duration of diabetes
Most important
Pt diagnosed before age 30 yr
50% DR after 10 yrs
90% DR after 30 yrs
Poor metabolic control
Less important, but relevant to development and progression of
DR
HbA1c ass. with risk
Pregnancy
Ass with rapid progression of DR
Predicating factors : poor pre-pregnancy control of DM, too
rapid control during the early stages of pregnancy, pre-
eclampsia and fluid imbalance
 Risk factors
Hypertension
Very common in patients with DM type 2
Should strictly control (<140/80 mmHg)
Nephropathy
Ass with worsening of DR
Renal transplantation may be ass with improvement of
DR and better response to photocoagulation
Other
Obesity, increased BMI, high waist-to-hip ratio
Hyperlipidemia
Anemia
 Pathogenesis

Microvascular occlusion
Microvascular leakage
 Microvascular leakage

Degeneration and loss of pericytes Capillary wall weakening

Plasma leakage microaneurysm

Retinal edema

Hard exudate Intraretinal hemorrhage

(Circinate pattern)
 Non-proliferative diabetic
retinopathy

Right eye: Micro aneurysm, few flame-shaped and dot-blot hemorrhages

and hard exudate [with hard exudate in macula area] ,
neovascularization moderate non proliferative diabetic retinopathy
Left eye: Micro aneurysm, numerous flame-shaped and dot-blot
hemorrhage [more than 20 dots in 4 quadrant], hard exudate [with hard
exudate in macula area] neovascularization
severe non
proliferative diabetic retinopathy
 Microvascular occlusion
Endothelial cell damage and
proliferation
Capillary basement membrane
Decreased capillary blood
thickening
Increased plasma flow
viscosity and perfusion
Deformation of RBC Retinal hypoxia
Increased platelets
stickiness
VEGF
A-V shunt Neovascularization
IRMA* and fibrovascular proliferation

Rubeosi Proliferativ
s iridis e
retinopath
y
*intraretinal microvascular abnormalities
Vitreous hemorrhage Tractional retinal detachment
 Classification

Non-proliferative diabetic retinopathy (NPDR)

Proliferative diabetic retinopathy (PDR)

 Non-proliferative diabetic
retinopathy

Mild NPDR
Moderate NPDR
Severe NPDR
 Sign NPDR

Microaneurysm
Retinal hemorrhage
Dot or Blot Spot
Flame or Splinter shape hemorrhage
Hard exudate
Cotton wool Spot
Venous beading
Intra-retinal microvascular abnormalities
(IRMA)
 Mild NPDR

Microaneurysm
 Moderate NPDR

More microaneurysms
Scattered hard exudates
Cotton-wool spots
 Severe NPDR

4-2-1 rule
4 quadrants of severe retinal hemorrhages
2 quadrants of venous beading
1 quadrant of IRMA

Very severe NPDR more than 1 of

above
 Microaneurysm

Localized saccular outpouchings of capillary wall

red dots
Focal dilatation of capillary wall where pericytes are
absent
Fusion of 2 arms of capillary loop
Usually seen in relation to areas of capillary non-
perfusion
at the posterior pole esp temporal to fovea
The earliest signs of DR
Microaneurysm
 Scattered hyperfluorescent

Microaneurysms may
leak plasma
constituents into the
retina
 Retinal Hemorrhage
Capillary or microaneurysm is weakened rupture
intraretinal hemorrhages
Dot & blot hemorrhages
Deep hemorrhage - inner nuclear layer or outer plexiform layer
Usually round or oval
Dot hemorrhages - bright red dots (same size as large
microaneurysms)
Blot hemorrhages - larger lesions
Flame-shape or splinter hemorrhages
More superficial - in nerve fiber layer
Absorbed slowly after several weeks
Indistinguishable from hemorrhage in hypertensive retinopathy
May have co-existence of systemic hypertension BP must be checked
Dot & blot VS splinter
hemorrhage
Dot Spot VS Flame Shape
Dot Spot VS Flame Shape
Hemorrhage
 Hard exudate

Intra-retinal lipid exudates

Yellow deposits of lipid and protein within the retina
Accumulations of lipids leak from surrounding
capillaries and microaneuryisms
May form a circinate pattern
Hyperlipidemia may correlate with the
development of hard exudates
 Cotton Wool Spot

White fluffy lesions in nerve fiber layer

Result from occlusion of retinal pre-capillary
arterioles supplying the nerve fibre layer with
concomitant swelling of local nerve fibre axons
Also called "soft exudates" or "nerve fiber layer
infarctions"
Fluorescein angiography shows no capillary
perfusion in the area of the soft exudate
Very common in DR, esp if pt with HT
Hard Exudate VS Cotton Wool
Spot
 Venous beading

Dilatation and beading of retinal vein

Appearance resembling sausage-shaped
dilatation of the retinal veins
Sign of severe NPDR
 Intra-retinal microvascular
abnormalities (IRMA)

Abnormal dilated retinal capillaries or may

represent intraretinal neovacularization
which has not breached the internal limiting
membrane of the retina
Indicate severe NPDR rapidly progress to
PDR
 Area of capillary non-
perfusion

FA shows extensive areas of hypofluorescence due to

capillary non-perfusion and venous beading
 Diabetic maculopathy

Macular ischemia
Retinal capillary non-perfusion
Progressive NPDR
Macular edema
Increased retinal vascular permeability
Seen in both NPDR and PDR
Focal or diffuse or mixed
Cause of visual loss in DR
Ass with planning for treatment
Focal macular edema

Diffuse macular edema

Macular ischemia
 Clinical Significant Macular Edema
(CSME)
1 of 3

Retinal edema Hard exudates Retinal edema > 1

within 500 within 500 disc diameter, any
microns of microns of fovea part is within 1 disc
centre fovea if ass with diameter of centre
microaneurysm
microaneurysm and
blot dot hemorrhage
blot dot hemorrhage
IRMAs
hard exudate
Cotton wool spots
Venous beading
 Proliferative diabetic
retinopathy

5% of DM pt.
Finding
Neovascularization : NVD, NVE
Vitreous changes
Advanced diabetic eye disease
Final stage of Uncontrolled PRD
Glaucoma (neovascularization)
Blindness from persistent vitreous hemorrhage,
tractional RD, opaque membrane formation,
Neovascularization of disc
 Neovascularization of
elsewhere

Fluorescein dye
leakage is seen in
neovascularized area
 Rubeosis iridis Neovascular glaucoma
(neovascularisation of the iris)
Vitreous
changes
 Vitreous Tractional retinal
hemorrhage detachment
NVE

Venous
beadin
g
IRMA
New vessels elsewhere
New vessels elsewhere
New vessels of the disc
New vessels of the disc
(advanced)
Subhyaloid hemorrhage
Subhyaloid hemorrhage
 Signs & symptoms of DR

Blurred or distorted vision or difficulty

reading
Floaters
Partial or total loss of vision
a shadow or veil across patients visual field
Eye pain
Hypertensive retinopathy
Radiation retinopathy
 Treatment

Laser Photocoagulation**
Vitreoretinal surgery**
Intravitreal triamcinolone acetonide
 Medical therapy

Prevention
Treat underlying conditions
Control blood sugar HbA1c < 7
Control blood pressure SBP < 130 mmHg
Control lipid profile TG, LDL
Correct anemia
Control diabetic nephropathy
Pregnancy makes DR worsen
 Laser

Panretinal photocoagulation (PRP)

High-risk PDR (3/4)
Vitreous or preretinal hemorrhage
New vessels
New vessels on optic disc or within 1,500 microns
from optic disc rim
Large new vessels
Iris or angle neovascularization
CSME
Photocoagulation

Focal or Grid
CSME in both NPDR and
PDR
Panretinal (PRP)
PDR
Laser panretinal photocoagulation
(PRP)

Inducing involution of new vessels

Preventing vitreous hemorrhage and preventing
visual loss
Limitations :
Patient must have clear lens and vitreous
If cataract treat before laser PRP
If vitreous hemorrhage vitrectomy + laser
photocoagulation
 Surgery

Indications for pars plana vitrectomy (PPV) in

DR
Severe persistent vitreous hemorrhage
Progressive tractional RD (threatening or
involving macula)
Combined tractional and rhegmatogenous RD
Premacular subhyaloid hemorrhage
Recurrent vitreous hemorrhage after laser PRP
 Vitreoretinal
Surgery

Pars plana vitrectomy (PPV)

Membrane peeling (MP)
Endolaser (EL)
Fluid gas exchange (FGX)
SF6
C 3F 8
 Screening for DR

Juvenile onset DM > 5 years then every year

Adult onset DM at diagnosis (> 30) then every
year
DM with pregnancy in first trimester then every
trimester
Follow up
 Advanced diabetic eye
disease

Serious vision-threatening complications of

DR
persistent vitreous hemorrhage
tractional retinal detachment
opaque membrane formation
neovascular glaucoma
Treatment : complicated vitrectomy
Poor prognosis