Diabetic retinopathy

Opthalmologists view.

1. DIABETIC RETINOPATHY

2. Progressive dysfunction of the retinal blood vessels caused by chronic hyperglycaemia . Definition

3. Hyperglycaemia Duration of diabetes - 50% develop DR after 10 yrs 70 % after 20 yrs 90 % after 30 yrs 2. Hypertension 3. Hyperlipidaemia 4 . More in females than males 5. Pregnancy may accelerate DR 6. Smoking, Obesity, Anaemia 7. Poor metabolic control 8. Hereditary – more on proliferative DR Risk Factors

4. Classification of Diabetic Retinopathy Non-proliferative diabetic retinopathy Mild nonproliferative retinopathy Moderate nonproliferative retinopathy Severe nonproliferative retinopathy Very severe nonproliferative retinopathy Proliferative diabetic retinopathy Diabetic maculopathy Advanced diabetic eye disease

5. No retinopathy

6. Mild nonproliferative retinopathy Atleast one microaneurysm or intraretinal haemorrhage Hard/ Soft exduates may or may not be present

7. II. Moderate nonproliferative retinopathy Micro aneurysms / intraretinal haemorrhages in 2 or 3 quadrants Early mild IRMA Intra retinal Microvascular abnormalities Hard / Soft exudates may or may not be present

8. III. Severe nonproliferative retinopathy Four quadrants of severe micro aneurysms / intraretinal haemorrhages Two quadrants of venous bleeding One quadrant of IRMA changes Any one of the following :

9. IV. Very severe nonproliferative retinopathy Four quadrants of severe micro aneurysms / intraretinal haemorrhages Two quadrants of venous bleeding One quadrant of IRMA changes Any two of the following :

10. P roliferative diabetic retinopathy NVD ¼ to 1/3 of disc area with or without VH or PRH NVD < ¼ disc area with VH o r PRH NVD < ¼ disc area with VH o r PRH

11. E xtensive vitreous haemorrhage obscuring most of fundus (white circle)

12. Diabetic Maculopathy On Slit lamp examination with 90D lens : Thickening of retina at or within 500 micron of the centre of fovea Hard exudates at or within 500 micron of the centre of fovea associated with adjacent retinal thickening Development of a zone of retinal thickening one disc diameter or larger in size, at least a part of which is within one disc diameter of foveal centre .

13. Maculopathy within 1 disc diameter of the fovea.

14. Advanced diabetic eye disease Persistent vitreous haemorrhage Tractional retinal detachment Neovascular glaucoma

15. Investigations Urine examination Blood sugar estimation 24 hour urinary protein Renal function tests Lipid profile Haemogram Glycosylated Haemoglobin ( HbA1C) Fundus Fluorescein angiography – to elucidate areas of neovascularisation , leakage and capillary nonperfusion Optical Coherence Tomography to study detailed structural changes in diabetic maculopathy

16. Prevention Primary Prevention – Strict glycemic control, Blood pressure control, correction of dyslipidaemia , control of associated anaemia , control of hypoproteinemia Secondary Prevention – Annual eye exams Tertiary Prevention – Retinal laser photocoagulation , Vitrectomy

17. Treatment of Diabetic Retinopathy Anti – vascular endothelial growth factors Others under evaluation – Protein Kinase C inhibitors, Aldose reductase , ACE inhibitors, Antioxidants such as vitamin E Role of intravitreal steroids – Flucinolone acetonide intravitreal implant, Inj. Triamcinolone intravitreal

18. Laser Photocoagulation

19. Vitrectomy

20. September 16, 2014 Eylea Granted Breakthrough Therapy for Diabetic Retinopathy Food and Drug Administration (FDA) has granted  Eylea  ( afilbercept ) Injection Breakthrough Therapy designation for the treatment of diabetic retinopathy in patients with diabetic macular edema (DME ) . Eylea is a vascular endothelial growth factor (VEGF) inhibitor designed to block the growth of new blood vessels and decreases vascular permeability in the eye by blocking VEGF-A and placental growth factor ( PlGF ), two growth factors involved in angiogenesis. Eylea helps prevent VEGF-A and PlGF from interacting with their natural VEGF receptors as shown in preclinical studies . Eylea is already approved for the treatment of neovascular (wet) age-related macular degeneration (AMD) and macular edema following central retinal vein occlusion (CRVO). Latest Treatment modalities for Diabetic Retinopathy

21. Human trials are set to begin for a new  medication , currently called KVD001, which treats  diabetic macular edema , a form of  diabetic retinopathy . Human trials begin for promising diabetic retinopathy treatment Fri, 05 Sep 2014 KVD001 is an intravitreal plasma kallikrein inhibitor drug that is given by injection  into  the eye . Whilst injections into the eye may sound painful, in practice they are not as eye-watering as they sound. There is currently only one medication,  Lucentis , has been officially licensed for treatment of diabetic macular edema. Having another  medication  such as KVD001 would give doctors more choice over which treatment to give and, because it works in a different way to Lucentis , it means that it could help save the sight  of people for whom Lucentis is not effective. KVD001 has been developed by KalVista Pharmaceuticals, a company in Hampshire. The  clinical trials , which will be run across five different centres within the United States, are being funded by the  type 1 diabetes  charity, the  JDRF .

22. Conclusion Diabetic Retinopathy is preventable through strict glycemic control and annual dialated eye exams by an opthalmologist .