Diabetic retinopathy (DR)

Diabetic retinopathy (DR) & interpretasi fundus photo

Dr Nurulhuda Ariffin MD UKM, Doctor of Oph UKM

Ophthalmology Department HSAJB

Diabetic Retinopathy- DEMO JKNJ 2021 1

References

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www.drsmodule.org.my

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Table of content

Anatomy of the eye

DM and the eye

• Prevalence

• Pathogenesis

• Risk factor

• Grading

• Assessment

• Follow up

• Management

DR

Recap- fundus photos Diabetic Retinopathy- DEMO JKNJ 2021 4

AIM of today’s talk

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1. Identify patient at risk of DR

2. Schedule 1st DR assessment & interpret fundus photo

3. Decide on DR follow up & refer urgent cases

4. Create awareness & counsel DR patients

1. Anatomy of the eye

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Vitreous cavity

Fundus photography

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Right eye

Retinal vein and artery

NASAL

2. DM and the eye

Cornea

• Dry eye

• Neurotrophic keratitis

Aqueous

• Anterior uveitis

Lens

• Refractive changes

• Cataract

Retina

• DR vitreous haemorrhage retinal detachment

OD

• Glaucoma

• Diabetic papillitis

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3. Prevalence of DR1

• Worldwide 6.8-44.4%

• Malaysia 36.8% (Diabetic Eye Registry 2007)

• Singapore 35% (Singapore Malay Eye Study 2006)

• Early DR in young? New South Wales, Australia.

– 8% in children (less than 11yrs)

– 25% in adolescent (older than 11yrs)

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Sight threatening

15.6% (NED 2007)

Blind 9%

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4. Pathogenesis of DR

Intercellular sorbitol accumulation,

free radicals,

glycated end products,

disruption of ion channel function,

protein kinase C activation

HY

PER

GLY

CA

EMIA

2. Hematological & Rheological

changes

1. Microangiopathy (damage to capillary wall)

3. Direct effect on retinal cells

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Microangiopathy

(damage to capillary wall)

Intraretinal haemorrhage

Edema, Exudates Microvascular

Occlussion, Ischaemia, IRMA,

Neovascularization, Fibrosis *VEGF

Hematological & Rheological changes

*VEGF- vascular endothelial growth factor

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5. Risk factors for DR2

•Smoking •Inactive lifestyle/ obese

• HPT, CKD, CVA, CVD

• Hyperlipidaemia

• Anaemia

• Longer duration

• Poor control

DM Co-

morbid

Lifestyle Pregnancy

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6. Grading of DR1 (International Clinical Diabetic Retinopathy and Diabetic Macula Oedema Disease Severity Scale)

Dia

bet

ic R

etin

op

ath

y

Retinopathy

No apparent DR

Non proliferative DR

Mild

Moderate

Severe

Proliferative DR Advanced diabetic eye

disease (ADED)

Maculopathy

Absent

Present Diabetic Retinopathy- DEMO JKNJ 2021 14

Mild NPDR (microaneurysm only)

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Moderate NPDR

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• More than just microaneurysm • Less than severe NPDR

Microaneurysm

Severe NPDR (4:2:1 rule)

Any of the following: • more than 20

intraretinal haemorrhage in each 4 quadrant, or

• venous beading in 2 or more quadrant, or

• Intraretinal microvascular abnormality (IRMA) in 1 or more quadrant

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*IRMA is a shunt vessel

PDR Any of the following: • Neovascularization , or • vitreous/ preretinal haemorrhage

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NVD

NVE NVE

NVD: New vessel on dic, NVE: new vessel elsewhere

Preretinal haemorrhage

ADED Any of the following: – Fibrous tissue, or – dragging of retina, or – retinal detachment, tractional or rhegmatogenous

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Fibrous tissue

Fibrous tissue with tractional retinal detachment

Mild maculopathy

• Distant from centre

Moderate maculopathy

• Approaching centre

Severe maculopathy

• Involving centre

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Hard exudates at fovea

Diabetic maculopathy present:

• Hard exudates, or

• Oedema (retinal thickening)

7. Assessment of DR

Diabetic Retinopathy- DEMO JKNJ 2021 21 Binocular Indirect

Ophthalmoscopy (BIO)

Slit lamp machine

Fundus camera

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8. Follow up for DR

Referral to ophthalmologist

•Unexplained visual loss

•PDR

•Diabetic maculopathy

•Severe NPDR

•Screening examination cannot be performed

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1 week

1 month

Next review? D

iab

eti

c R

etin

op

ath

y

Retinopathy

No DR

12-24 months

3 months if in pregnancy

Non proliferative DR

Mild 9-12 months

Moderate 6 months

Severe

Proliferative DR Advanced diabetic eye disease

Maculopathy Present

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OPHTHALMOLOGIST

9. Management of DR

How to manage?

Systemic

Glycaemic control

Fenofibrate

Ocular

Laser

Medical

Surgical

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Retinal Laser Photocoagulation

Pigmented: old laser mark

White: new laser mark

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Vitreoretinal surgery

Intravitreal anti-VEGF/ steroid

Case scenario

• NF, 32 M F • Type 1 DM- since 16yo • HPT

• Ophthal Hosp Batu Pahat • BE PDR, lasered • Referred to VR HSAJB in 2019

• RV 6/60 ph 6/18 • LV 6/60 ph 6/60 • RE ADED with subtotal TRD/ RRD • LE ADED with total TRD/ RRD

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• Dec 2019: LE VR surgery + SO

• June 2020: RV 6/60 ph 6/60 • Oct 2020: RE VR surgery + gas

• Nov 2020 • RV 6/60 ph 6/24 • LV 6/60 ph 6/24 • She was happy- able to see her

baby again

Unfortunately, • Mar 2021 May 2021 • RV HM HM • LV CF PL

• BE cataract L (mature) > R

• Aug 2021: LE cataract surgery + removal of SO

• # Progression from BE PDR to ADED in 2019 was likely due to her pregnancy Diabetic Retinopathy- DEMO JKNJ 2021 29

10. Recap- fundus photos

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Photo 1

• RE/ LE?

• Retina

– PDR/ NPDR?

– NPDR: mild/ moderate/ severe?

• Maculopathy

– Yes/ no?

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Diagnosis: Left moderate NPDR with

moderate maculopathy

Photo 2

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• RE/ LE?

• Retina

– PDR/ NPDR?

– NPDR: mild/ moderate/ severe?

• Maculopathy

– Yes/ no?

Diagnosis: Right

moderate NPDR, no maculopathy

Photo 3

• PDR

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• RE/ LE?

• Retina

– PDR/ NPDR?

– NPDR: mild/ moderate/ severe?

• Maculopathy

– Yes/ no?

Diagnosis: Right ADED with macular oedema,

lasered, not yet quiescent

Photo 4

• ADED

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• RE/ LE?

• Retina

– PDR/ NPDR?

– NPDR: mild/ moderate/ severe?

• Maculopathy

– Yes/ no?

Diagnosis: Right ADED with TRD threatening

macula

Photo 5

• ME

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• RE/ LE?

• Retina

– PDR/ NPDR?

– NPDR: mild/ moderate/ severe?

• Maculopathy

– Yes/ no?

Diagnosis: Left moderate NPDR with

moderate diabetic maculopathy.

Photo 5

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• RE/ LE?

• Retina

– PDR/ NPDR?

– NPDR: mild/ moderate/ severe?

• Maculopathy

– Yes/ no?

Diagnosis: Right PDR/ severe NPDR- lasered,

stable. No maculopathy

Photo 6

• CRVO

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• RE/ LE?

• Retina

– PDR/ NPDR?

– NPDR: mild/ moderate/ severe?

• Maculopathy

– Yes/ no?

Diagnosis: Left non ischaemic central

retinal vein occlussion with macular oedema

Photo 7

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• RE/ LE?

• Retina

– PDR/ NPDR?

– NPDR: mild/ moderate/ severe?

• Maculopathy

– Yes/ no?

Diagnosis: Left hypertensive

retinopathy grade 4

Take home messages

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1. Serial DR screening- must be done for all diabetic patients

2. Metabolic control- slow down DR progression, avoid recurrent of treated DR

3. Educate patient on blinding DR consequences- asymptomatic even reach PDR state

Thank you

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MCQ 1

1. These are the eye complications of uncontrolled Diebetes Mellitus, EXCEPT

a) Glaucoma

b) Macular Oedema

c) Lens Dislocation

d) Neurotropic keratitis

Answer: C.

Cataract is a known complication of DM through several mechanism but it does not cause lens dislocation

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MCQ 2

2. False statement about Diabetes complicating pregnancy

a) Arrange DR screening prior to a planned pregnancy b) Patient with no DR during 1st trimester can be followed

up yearly c) In no DR or mild NPDR, DR screening should be repeated

every 3 months d) Risk of DR progression expected during pregnancy

Answer: B Due to increase metabolic demand during pregnancy, DR may progress. Even without DR changes, patient need to be followed up 3 monthly.

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MCQ 3

3. Diagnosis of severe NPDR includes any of the following criteria except:

a) more than 20 intraretinal haemorrhage in each 4 quadrant, or

b) venous beading in 2 or more quadrant, or c) Intraretinal microvascular abnormality (IRMA) in 1

or more quadrant d) Presence of hard exudates at the macula

Answer: D Hard exudates is not a criteria to diagnose severe NPDR

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MCQ 4

4. DR progression can be reduced by these management except:

a) Oral steroid prescription b) Oral fenofibrate prescription c) Panretinal photocoagulation laser d) Treatment of anaemia

Answer: A Systemic steroid leads to uncontrolled DM thus DR may progress. Local steroid has less systemic effect. It is used in diabetic macula oedema (given through intravitreal injection) and to control intraocular inflammation e.g. post cataract surgery (topical form- eyedrops)

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MCQ 5

5. False statement about diabetic maculopathy a) Only occurs in patient with severe NPDR or worse

b) Presence of hard exudates or oedema (retinal thickening) at macula area

c) Need to be referred to an ophthalmologist within 4 weeks

d) Can be observed if visual acuity is good (6/12 or better)

Answer: A

Diabetic maculopathy can be present/ absent at any DR stage

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MCQ 6

6. True statement about moderate NPDR, except a) Panretinal Photocoagulation laser need to be given b) Can be followed up 6 monthly under primary care setting c) Optimization of metabolic comorbidities reduce DR

progression d) Presence of of LESS than than 20 intraretinal

haemorrhage in each 4 quadrant

Answer: A Laser PRP will be initiated in severe NPDR if close monitoring unable to be performed. In DR less than severe NPDR, systemic medical optimization is the key management.

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MCQ 7

7. True statement about PDR, except a) Define as presence of neovascularization

b) Vascular endothelial growth factor (VEGF) play a role in the pathogenesis

c) Preretinal haemorrhage or vitreous haemorrhage occurs due to ruptured new vessel

d) All patient has poor visual acuity

Answer: D

PDR patient may be asymptomatic

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MCQ 8

8. 1st DR assessment, except

a) Up to 3 years after diagnosis of type 1 DM in adult

b) Up to 3 years after diagnosis of type 2 DM in children

c) 2-5 years after diagnosis of type 1 DM in children (at age of 10 or at onset of puberty if this is earlier)

d) At the time of diagnosis for GDM diagnosed in 1st trimester

Answer: B

All type 2 DM need to be screen at the time of diagnosis

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MCQ 9

9. Pathogenesis of DR, except a) Intravascular changes includes deformation of red

blood cell, leukostasis and increase platelet stickiness b) Capillary changes includes pericyte loss, endothelial

cell dysfunction and basement membrane thickening c) Retinal neural cells are not affected d) Vascular endothelial growth factor (VEGF) increase

vascular permeability and stimulates new vessels formation

Answer: C Retinal neurodegeneration is part of the DR pathogenesis

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MCQ 10

10. Management of PDR, except a) Laser panretinal photocoagulation

b) Vitreoretinal surgery if patient has persistent vitreous haemorrhage

c) Systemic diabetic control

d) Intravitreal steroid

Answer: D

Intravitreal steroid is a treatment option for centrally involved diabetic macular oedema (1st line treatment is intravitreal antiVEGF).

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