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Diabetic retinopathyTopic assignment : medical ophthalmology
D 1.1 30/3/2011
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
Contents
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
Diabetes mellitus
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
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
Risk factors
Microvascular occlusion Microvascular leakage
Pathogenesis
Microvascular leakage
Degeneration and loss of pericytes
Plasma leakage
Intraretinal hemorrhageHard exudate(Circinate pattern)
Capillary wall weakening
microaneurysm
Retinal edema
Non-proliferative diabetic retinopathy
Right eye: Micro aneurysm, few flame-shaped and dot-blot hemorrhages and hard exudate [with hard exudate in macula area] , ไมพบneovascularization เขาไดกบ 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] ไมพบ neovascularization เขาไดกบ severe non proliferative diabetic retinopathy
Microvascular occlusion
Neovascularizationand fibrovascular proliferation
VEGF
Increased plasma viscosityDeformation of RBCIncreased platelets stickiness
Decreased capillary blood flow
and perfusion
Endothelial cell damage and proliferationCapillary basement membrane
thickening
Retinal hypoxia
A-V shuntIRMA*
*intraretinal microvascular abnormalities
Proliferative
retinopathy
Rubeosis iridis
Tractional retinal detachmentVitreous hemorrhage
Classification
Non-proliferative diabetic retinopathy (NPDR)
Proliferative diabetic retinopathy (PDR)
Non-proliferative diabetic retinopathy
Mild NPDR Moderate NPDR Severe 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)
Sign NPDR
Mild NPDR
Microaneurysm
Moderate NPDR
More microaneurysms Scattered hard exudates Cotton-wool spots
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
Severe NPDR
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
Microaneurysm
Microaneurysms may leak plasma constituents into the retina
Scattered hyperfluorescent
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
Retinal Hemorrhage
Dot & blot VS splinter hemorrhage
Dot Spot VS Flame Shape
Dot Spot VS Flame Shape
Hemorrhage
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
Hard exudate
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
Cotton Wool Spot
Hard Exudate VS Cotton Wool Spot
Dilatation and beading of retinal vein Appearance resembling sausage-shaped
dilatation of the retinal veins Sign of severe NPDR
Venous beading
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
Intra-retinal microvascular abnormalities (IRMA)
Area of capillary non-perfusion
FA shows extensive areas of hypofluorescence due to capillary non-perfusion and venous beading
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
Diabetic maculopathy
Focal macular edema
Diffuse macular edema
Macular ischemia
Clinical Significant Macular Edema (CSME)
1 of 3
Retinal edema within 500 microns of
centre fovea
Hard exudates within 500
microns of fovea if ass with
adjacent retinal thickening
Retinal edema > 1 disc diameter, any part is within 1 disc diameter of centre
of fovea
microaneurysm
microaneurysm and blot dot hemorrhage
blot dot hemorrhage
IRMAs
hard exudate
Cotton wool spots
Venous beading
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,
Proliferative diabetic retinopathy
Neovascularization of disc
Fluorescein dye leakage is seen in neovascularized area
Neovascularization of elsewhere
Rubeosis iridis(neovascularisation of the iris)
Neovascular glaucoma
Vitreous changes
Tractional retinal detachment
Vitreous hemorrhage
NVE
Venous beadingIRMA
New vessels elsewhere
New vessels elsewhere
New vessels of the disc
New vessels of the disc (advanced)
Subhyaloid hemorrhage
Subhyaloid hemorrhage
Blurred or distorted vision or difficulty reading
Floaters Partial or total loss of vision
a shadow or veil across patient’s visual field Eye pain
Signs & symptoms of DR
Differential DiagnosisDiabetic retinopathy
Hypertensive retinopathy Radiation retinopathy Central retinal vein occlusion (CRVO) Branch retinal vein occlusion (BRVO) Ocular ischemic syndrome HIV-related retinopathy
Mostly miss
Hypertensive retinopathy
Radiation retinopathy
Central retinal vein occlusion (CRVO)
Branch retinal vein occlusion (BRVO)
For symptoms
Cataract Glaucoma Hypertensive retinopathy Radiation retinopathy Retinal vitreous obstruction Retinitis pigmentosa Senile macular degeneration
For cotton wool spot
Similar lesions are also caused by the alpha-toxin of Clostridium novyi
For Cotton wool spot
For Hard exudates
For Hemorrhage
Laser Photocoagulation** Vitreoretinal surgery** Intravitreal triamcinolone acetonide
Treatment
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
Medical therapy
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
Laser
Focal or Grid CSME in both NPDR and
PDR Panretinal (PRP)
PDR
Photocoagulation
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
Laser panretinal photocoagulation (PRP)
Focal photocoagulation
Grid photocoagulation
Panretinal photocoagulation (PRP)
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
Surgery
Pars plana vitrectomy (PPV) Membrane peeling (MP) Endolaser (EL) Fluid gas exchange (FGX)
SF6
C3F8
Vitreoretinal Surgery
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
Screening for DR
Retinal abnormality Follow up
Normal or rare microaneurysms
Once a year
Mild NPDR q 9 months
Mod NPDR q 6 months
Severe NPDR q 4 months or laser
CSME q 2-4 months ** or laser
PDR q 2-3 months ** or laser
Follow up
Serious vision-threatening complications of DR
persistent vitreous hemorrhage tractional retinal detachment opaque membrane formation neovascular glaucoma
Treatment : complicated vitrectomy Poor prognosis
Advanced diabetic eye disease
Case scenario
Identification data : ผปวยหญงไทยค อาย 49 ป อาชพ คาขาย ภมลำาเนา อ.สงเมน จ. แพร
Chief complaint : ตาซายมว 6 เดอน กอนมารพ.
Case
6 เดอน กอนมารพ. ผปวยมอาการตาซายมว อาการคอยๆ เปน และเปนมากขนเรอยๆ ตาขวามองเหนปกตด ไมมปวดตา ปวดศรษะ ไมมตาแดง นำาตา-ขตาปรมาณเทาเดม อาการตาซายมว มองใกลมวพอๆ กบ มองไกล กลางวนมวพอๆ กบกลางคน ไมมแสงรอบดวงไฟ
1 สปดาหกอนมารพ. ตาซายมวมาก ประกอบกบ
เหนภาพซอน มวตถลอยไปมา ปดตาแลวมไฟกระพรบเปนบางครง ไมมปวดตา ปวดศรษะ จงมารพ.แพร ไดรบการรกษา แตอาการไมดขน จงสงตวมารกษาตอทรพ. มหาราช
Present illness
Underlying diseases : DM (poor controlled), HT (poor controlled)
Current medicationmetformin 500 mg 2*1 o pcNifedipine 20 mg 1*2 o pcAmlopine 10 mg 1*1 o pc
ไมเคยตรวจตามากอน ปฏเสธประวตการผาตดทตามากอน และอบตเหตท
ตาFamily history : แมเปน DM, ปฏเสธโรคตาใน
ครอบครว
Past history
GA : a middle aged woman with normal consciousness, good co-operation
V/S : T 36.9 BP 157/83 mmHg P 94/min RR 16/min
HENT : no discharge per ears, nose, no bleeding per gum, cervical LN cant’ be palpable
Heart : normal S1S2, no murmurs Lungs : clear & equal breath sounds
both lungsAbdomen : soft, not tenderExt : no pitting edema
Physical examination
OD OSVA c C 6/9 -2 PjVA c PH 6/9 -Lids & Lashes & Conjunctiva
Normal Normal
Cornea Clear ClearIrisLens Clear ClearAnterior chamber Normal depth, clear Normal depth, clearPupil 3 mmRTLBE RAPD -EOM Full FullIOP 20 20
Ocular examination
OD OSRed reflex Normal Normal Vessels Normal 2:3 Normal 2:3Background & Macula
Dot & blot hemorrhageNVE
dot blot hemorrhage ,
NVE , old hemorrhage
Fibrous and retinal break involve macula
Disc No NVD , C:D 0.3 No NVD , C:D 0.3
Fundus examination
Problem lists
Unilateral chronic painless visual loss Flashing and Floaters Poor controlled DM, poor controlled HT Dot & blot hemorrhages with NVE BE Fibrous & Retinal break involve macula LE
Problem list
Right eye : PDR Left eye : PDR with TRD+RRD
Provisional diagnosis
Hypertensive retinopathy Central retinal vein occlusion (CRVO) Branch retinal vein occlusion (BRVO) Ocular ischemic syndrome
Differential diagnosis
LE Pars plana vitrectomy membrane peeling Endolaser silicone oil injection
Management in this case
Indications for PPV in DRSevere persistent VHProgressive tractional RDCombined TRD & RRDPremacular subhyaloid hemorrhageRecurrent VH after laser PRP
DR รายนจำาเปนตองผาตด PPV
หรอไม?
Closed observe (q 2-3 months) Laser PRP PPV + MP + EL + SOI
จะทำาอะไรกบตาขางขวาตอไป??
เคยตรวจตาหรอยง?ตรวจตาครงลาสดเมอไหร?
คำาถามทตองตดปากเมอเจอคนไขเบาหวาน
ควรตรวจตาทนททวนจฉยเปนเบาหวานชนดท 2 ควรตรวจตาทกป
การควบคมเบาหวานใหด ชวยชะลอการเกดภาวะแทรกซอนทางตาได
Thank you