DIABETIC RETINOPATHY

PRESENTED BY

DR.MOSTAFA ZAHIR RAIHANI EYE SPECIALIST

Diabetic retinopathy is a complication of diabetes that is caused by changes in the blood vessels of the retina. When blood vessels in the retina are damaged, they may leak blood and grow fragile, brush-like branches and scar tissue. This can blur or distort the vision images that the retina sends to the brain.

Pathogenesis of diabetic retinopathy Micro-vascular occlusion Micro-vascular leakage

Micro-vascular occlusion

Consequences of retinal ischaemia

MICROVASCULAR LEAKAGE

PATHOGENESIS : BREAK DOWN OF INNER BLOOD RETINAL BARRIER

MICROANEURYSMS

CONSEQUENCE:

DIFFUSE RETINAL OEDEMA

LOCALIZED RETINAL OEDEMA

Micro-vascular leakage & its Consequences

RISK FACTORS :

DURATION OF DM POOR METABOLIC CONTROL PREGNANCY HYPERTENSION NEPHROPATHY

OTHERS: OBESITY SMOKING HYPERLIPIDAEMIA

Based on dilated fundus examination

Signs of background diabetic retinopathy

Microaneurysms usually temporal to fovea

Intraretinal dot and blot haemorrhages

Hard exudates frequently arranged in clumps or rings

Retinal oedema seen as thickening on biomicroscopy

Location of lesions in background diabetic retinopathy

Focal diabetic maculopathy

Circumscribed retinal thickening Associated complete or incomplete circinate hard exudates

Focal leakage on FA Focal photocoagulation Good prognosis

Diffuse diabetic maculopathy

Diffuse retinal thickening Frequent cystoid macular oedema Variable impairment of visual acuity

Generalized leakage on FA Grid photocoagulation Guarded prognosis

Ischaemic diabetic maculopathy

Macula appears relatively normal Poor visual acuity

Capillary non-perfusion on FA Treatment not appropriate

Clinically significant macular oedema

Retinal oedema within 500 m of centre of fovea Hard exudates within 500 m of centre of fovea with adjacent oedema which may be outside 500 m limit

Retinal oedema one disc area or larger any part of which is within one disc diameter (1500 m) of centre of fovea

Preproliferative diabetic retinopathy

Signs

Cotton-wool spots Venous irregularities

Dark blot haemorrhages Intraretinal microvascular abnormalities (IRMA)

Cotton wool spots

Represent focal infarcts of the retinal NFL, due to occlusion of precapillary arterioles. Small whitish, fluffy superficial lesions which obscure underlying blood vessels.

IRMA
Represent shunts that run from retinal arterioles to venules thus by passing the capillary bed.
Seen adjacent to areas of capillary closure.

Dark blot hemorrhage

Represent hemorrhagic retinal infarcts Located within the middle retinal layers.

Beading

Venous looping

Preproliferative diabetic retinopathy Treatment - not required but watch for proliferative disease

Proliferative diabetic retinopathy

Affects 5-10% of diabetics IDD at increased risk (60% after 30 years)

Flat or elevated Severity determined by comparing with area of disc

Neovascularization

Neovascularization of disc = NVD

Neovascularization elsewhere = NVE

Laser panretinal photocoagulation

Area covered by complete PRP

Initial treatment is 2000-3000 burns

Gentle intensity burn (0.10-0.05 sec) Follow-up 4 to 8 weeks

Spot size (200-500 m) depends on contact lens magnification

Assessment after photocoagulation

Poor involution Good involution

Persistent neovascularization Haemorrhage Re-treatment required

Regression of neovascularization Residual ghost vessels or fibrous tissue Disc pallor

50% stable of Vision 50% decreased of vision

If PDR not treated by PRP complications develops

Advanced Diabetic eye disease

Serious vision threatening complication of DR.

Pre-retinal hemorrhage

Tractional retinal detachment

Opaque membrane

Rubeosis iridis

Advanced Diabetic eye disease treatment is mainly vitreoretinal surgery

Surgery often slows or stops the progression of diabetic retinopathy, but it's not a cure. Because diabetes is a lifelong condition, future retinal damage and vision loss is possible. Even after treatment for diabetic retinopathy, patient need regular eye exams. So there is safe pathway of management is..

People with type 1 or type 2 diabetes should have a dilated eye exam every year. The American Diabetes Association (ADA) recommends that anyone who's over 10 years old with type 1 diabetes have his or her first eye exam within five years of being diagnosed with diabetes. For people with type 2 diabetes, the ADA advises getting the initial eye exam soon after diagnosed with diabetes, because may have had diabetes for some time without knowing it.

Women with diabetes who become pregnant need to have an eye exam during the first trimester of pregnancy and possibly again later in the pregnancy, depending on the results of the first exam. The reason for this is that pregnancy can sometimes worsen diabetic retinopathy.

Patient of diabetes, reduce risk of getting diabetic retinopathy by doing the following: Make a commitment to managing diabetes. Make healthy eating and physical activity part of daily routine. Take oral diabetes medications or insulin as directed.

Monitor blood sugar level. Patient need to check and record blood sugar level as requered more frequent measurements may be required if patient are ill or under stress. Careful monitoring is the only way to make sure that blood sugar level remains within target range.

Glycosylated hemoglobin test. The glycosylated hemoglobin test or hemoglobin A1C test reflects average blood sugar level for the two- to three-month period before the test. For most people, the HbA1C goal is to be under 7 percent. Perform this test twice a year. But, if it is higher than goal, more frequent testing is recommended. So, blood sugar level as close to normal as possible slows the progression of diabetic retinopathy and reduces the need for surgery.

Keep blood pressure and cholesterol under control. High blood pressure and high cholesterol increase the risk of vision loss. Eating healthy foods, exercising regularly and losing excess weight can help. Sometimes medication is needed, too.

Stop smoking & other types of tobacco. Pay attention to vision changes. Urgent contact to eye doctor right away if experience sudden vision changes or vision becomes blurry, spotty or hazy.

Diabetes doesn't necessarily lead to poor vision. Taking an active role in diabetes management can go a long way toward preventing complications

Thanks for attention