Approach to a case of DIABETIC RETINOPATHY.pptx

This PPT is about "How to approach a case of Diabetic Retinopathy?"

1. APPROACH TO A CASE OF DIABETIC RETINOPATHY Presented by:- Dr. Ranjita Amanatya Presented by:-Dr. Ranjita Amanatya

2. INTRODUCTION:- DIABETIC RETINOPATHY(DR) is the “disease of the retina” caused by microangiopathy d/t long term effect of diabetes. It leads to progressive damage of the retina & blindness. M.C.C. of severe B/L visual loss in working age groups. Microangiopathy primarily affects :-Precapillary arterioles Capillaries Venules Postcapillary venules

3. PREVALANCE OF DIABETIC RETINOPATHY:- Prevalence of any diabetic retinopathy:- 35.4% PDR:- 7.2% DME:- 7.4% Vision-threatening diabetic retinopathy:- 11.7% 537 MILLION PEOPLE ARE DIABETIC . Overall,12-19% of people with Type-2DM have DR at diagnosis.

4. DIABETES DIAGNOSIS :- Person must have symptoms of diabetes Causal plasma glucose >200 Fasting blood glucose of >126mg/dl 2-hour plasma glucose >200 mg/dl on oral glucose test RISK FACTORS Obesity First degree relative with diabetes Hypertension Belongs to a high-risk ethnic group Was diagnosed with gestational diabetes HDL level <35 mg% or TG >250 mg% EFFECT OF DURATION ON DIABETIC RETINOPATHY:- IDDM NIDDM 4-5yrs :- 0% 11-13yrs :- 23% 5-10yrs :- 25-50% 14-16yrs :- 43% 10-15yrs:- 75-95% >16yrs :- 60%

5. HISTORY :- History of present illness :- k/c/o diabetes mellitus often referred by general physician Chief complaint Gradual loss of vision Acute loss of vision History of floaters Acute pain , redness & loss of vision ASYMPTOMATIC

6. HISTORY Cont. :- History of past illness:- H/O DM:- Type of DM Duration of DM DM control Insulin use Associated nephropathy History of retinal laser for DR H/O prior t/t with intra- vitreal injections Hypertension Hyperlipidemia Anemia Pregnancy Cardiac disease & Neurological disease H/O frequent change of glasses

7. EXAMINATION:- General Examination/Specific Systemic Examination:- To r/o other complications of DM Neuro pathy Nephro pathy Diabetic foot

8. OCULAR EXAMINATION:- Eyeball Conjunctiva Cornea Lid Visual Acuity :- Reversible refractive errors with change in glycemic levels should be kept in mind BCVA is helpful in deciding t/t modality in presence of macular edema Pupil sparing 3 rd & 6 th CN palsy are sign of reversible ischemic mono neuropathy Xanthelasma Recurrent hordeola Blepharitis Increased risk of developing bacterial infections Corneal hypoesthesia Decreased corneal healing Tear film abnormalities 3 rd CN Posterior communicating artery

9. OCULAR EXAMINATION Cont. :- Iris IOP Pupil Lens Vitreous Neovascularization of iris (NVI) in PDR Ectropion uvea Increase pigment at angles Difficulty in dilating pupils Can be a/w POAG & NVG Nuclear & Cortical cataract in chr. & progressive cases Acute cortical cataract with profound elevation in blood glucose Snowflake cataract in young Type-1 diabetics Precocious liquefaction Posterior Vitreous Detachment(PVD) Asteroid hyalosis

10. Neo-vascularization NVD NVE NVA NVI (rubeosis iridis) Pre-retinal Hge Sub-hyaloid Hge Vitreous Hge Fibro-vascular proliferation Traction on retina TRD NVG Secondary Angle Closure Glaucoma Optic atrophy PATHOGENESIS

11. FUNDUS CHANGES (Nerve fiber layer ischemic necrosis) (Secondary to capillary wall outpouching d/t pericyte loss) (Microaneurysms rupture in the deeper layers of retina) (Splinter hemorrhages in superficial nerve fiber layer) (Breakdown of BRB) Leakage of serum protein & lipids from vessels Intra retinal microvascular abnormality(IRMA):- Abnormal dilated, tortuous retinal capillaries(forming A-V shunt) <8a :- Moderate NPDR, >8a :-Severe NPDR Venous changes:- beading , looping& severe segmentation(d/t venous stagnation)

12. Early Treatment Diabetic Retinopathy Study(ETDRS) CLASSIFICATION OF DIABETIC RETINOPATHY(DR):- Non-proliferative diabetic retinopathy(NPDR) Proliferative Diabetic Retinopathy (PDR) MA, retinal hge , hard exudates Cotton wool spots Venous changes IRMA Moderate NPDR + MA, retinal hge in all 4 quadrants Venous changes in 2/more quadrants IRMA at least in 1 quadrant 2/more of above features on severe NPDR NVD ¼ to 1/3 disc area ±VH/PRH NVD <1/4 disc area + VH/PRH NVE >1/2 disc area + VH/PRH

13. Diabetic maculopathy Increased permeability of retinal capillaries Clinically Significant Macular Edema (CSME) Advanced diabetic eye disease End result of uncontrolled PDR In patients in whom t/t has been inadequate/unsuccessful. C/F:- PVH TRD Rubiosis iridis

14. DIFFERENTIAL DIAGNOSIS:-

15. MANAGEMENT 1 . Screening :- 1 st Examination:- 5yr after diagnosis of Type-1DM At the time of diagnosis of Type-2DM Every yr :- Till there is no retinopathy Every 6 months:- in Moderate NPDR Every 3 months:- in Severe NPDR Every 2 months:- in PDR with no HRC SCREENING INVESTIGATIONS TREATMENT

16. 2.INVESTIGATION SYSTEMIC INVESTIGATIONS FUNDUS PHOTOGRAPHY OPTICAL COHERENCE TOMOGRAPHY FUNDUS FLUORESCENE ANGIOGRAPHY ULTRA-WIDE FIELD IMAGING RED-FREE IMAGING OCT ANGIOGRAPHY ELECTRORETINOGRAM USG B-SCAN

17. INVESTIGATION:- a . b . SYSTEMIC INVESTIGATIONS :- FBS/PPBS Glucose tolerance test HbA1c Renal function test ,Lipid profile, Urine examination FUNDUS PHOTOGRAPHY:- For tracking disease progression

18. c . Optical Coherence Tomography:- DME (Pearl necklace sign) Biomarker :-Disorganization of Retinal Inner Layers(DRIL) Use in DR:- Investigate cases with unexplained V.A. loss Detect areas of VMT Evaluate difficult/questionable examinations for DME r/o other causes of macular edema Screen patients with NO/Minimal DR Haemorrhage Retinal vessels OCT findings Hyper-reflective Hypo-reflective Shadow effect Hard exudates Cotton wool spots Intra-retinal edema CME

19. d . Fundus Fluorescein Angiography:- DIAGNOSIS Areas of capillary nonperfusion r/o other causes of macular swelling Differentiate new vessels from IRMA Aid in t/t Guide Laser t/t of CSME Delineate fovea & FAZ Delineate area of leakage Detect areas of untreated retinal capillary nonperfusion Asymmetric DR:- Carotid artery occlusion Ocular ischemic syndrome One eye CRVO

20. DME grades on FFA :- Focal exudative maculopathy Diffuse exudative maculopathy Ischemic maculopathy Mixed maculopathy

21. e . OCT Angiography:- f .Ultra wide field imaging:- g .Red-free imaging:- h .Electroretinogram:- Imaging micro-aneurysms & FAZ changes For monitoring NPDR Helpful in identifying new vessels Full field & multifocal ERG in diagnosing Diabetic neuroretinopathy Wide field OCTA B-OCTA

22. No DR. Very mild DR Review in 12months Mild NPDR Review in 6-12months Moderate NPDR Review in 6months PDR in 26% & high-risk PDR in 8%(Within a year) Severe NPDR Review in 4 months 3.TREATMENT:- Diabetic control Other risk factors Fenofibrate 200mg daily DME GOOD VISION POOR VISION Centre involved DME Do FFA Focal leak Diffuse leak Anti-VEGF +Laser Anti-VEGF Improved Worse Observe Anti-VEGF+Steroid Worse VITRECTOMY Normal Normal Worse Centre involved Centre not involved OBSERVE Normal Worse Laser/Anti-VEGF PDR with/without HRC PRP Argon Laser Diode Laser Double frequency NdYAG Laser

23. TREATMENT OF DME Intra- vitreal Anti-VEGF preferred over Laser:- Focal CME involving centre of fovea DME Diabetic CME Risk of :- Glaucoma Steroids-induced cataract Vulnerable to endophthalmitis Macular photocoagulation Panretinal photocoagulation AVASTIN LUCENTIS Aflibercept (EYLEA)

24. Pars Plana Vitrectomy:- Indications:- Tractional DME with NPDR Advanced PDR with dense V.H. Advanced PDR with TRD Premacular retrohyaloid haemorrhage A.S. neovascularization & media opacities

25. DR & PREGNANCY:- DM affect 17% of pregnancies worldwide. Diabetes duration in predicting the progression of PDR:- DM with >15 yrs duration :- 38% progressed to PDR DM with <15 yrs duration :- 18% progressed to PDR T/T:- PRP ,ideally before the onset of pregnancy The use of intravitreal injections of Anti-VEGF drugs in pregnancy is not recommended .

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