Diabetic Retinopathy.pdf internal medicine

diabetic retinopathy

1. PRESENTED BY: Kamel Ahmed Atef
Group:- 15-3-19
Diabetic Retinopathy

2. Retinopathy is the most important ocular
complication of diabetes. DR is more
common in type 1 DM than type 2 DM.
Proliferative Diabetic Retinopathy (PDR)
affects 5-10% of diabetic population. Type 1
Diabetes are at particular risks, with an
incidence of upto90% after 30 years.

3. RISKFACTORS of DR
Duration of diabetes
-Most important
•Patient diagnosed before age 30 years
•50% DR after 10 years
•90% DR after 30 years
Poor metabolic control
•Less important, but relevant to development and
progression of DR
•Increased HbA1c associated with increased risk.

4. Pregnancy
•Associated with rapid progression of DR
•Predicating factors : poor pre-pregnancy control
of DM, too rapid control during the early stages
of pregnancy, pre-eclampsiaand fluid imbalance.
Hypertension
•Very common in patients with DM type 2
•Should strictly control (<140/80 mmHg)

5. Nephropathy
•Associated 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

6. Pathogenesis
Here microangiopathyoccurs and it
leads to:
Microvascularocclusion
Microvascularleakage

7. SYMPTOMS
Diabetic retinopathy is asymptomatic in early stages of the
disease. As the disease progresses symptoms may include –
•Blurred vision
•Floaters and flashes
•Distorted vision
•Dark areas in the vision
•Poor night vision
•Impaired color vision
•Partial or total loss of vision

9. SIGNS OF DIABETIC
RETINOPATHY
Microaeurysm
Retinal hemorrhage
Hard exudates
Cotton wool spot
Venous beading
Intraretinalmicrovascular
abnormalities (IRMA)
Macular oedema

10. Microaneurysm
Localized saccularoutpouchingsof capillary wall red dots
•Focal dilatation of capillary wall where pericytesare absent
•Fusion of 2 arms of capillary loop
Usually seen in relation to areas of capillary non-perfusion
•at the posterior pole in temporal to fovea
It is the earliest signs of DR

12. Scattered hyperfluorescent
Microaneurysmsmay leak plasma
constituents into the retina

13. Retinal Hemorrhage
Capillary or microaneurysmis weakened rupture intraretinal
hemorrhages
Dot & blot hemorrhages
•Deep hemorrhage -inner nuclear layer or outer plexiformlayer
•Usually round or oval
•Dot hemorrhages -bright red dots (same size as large microaneurysms)
•Blot hemorrhages -larger lesions

15. Hard exudate
Intra-retinal lipid exudates
Yellow deposits of lipid and protein within the retina
Accumulations of lipids leak from surrounding capillaries and
microaneuryisms
 Hyperlipidemia may correlate with the development of hard

exudates

17. Cotton Wool Spot
White fluffy lesions in nerve fiber layer
Result from occlusion of retinal pre-capillary arterioles
supplying t he nerve fiber l ayer with accompaying swelling
oof local nerve fiber axons
Also called "soft exudates" or "nerve fiber layer infarctions“
 Very common in DR, specially if patient with hypertension.

19. Venous beading
Dilatation and beading of retinal vein
Appearance resembling sausage-shaped dilatation of the
retinal veins
Sign of severe NPDR

20. Intraretinalmicrovascular
abnormalities
(IRMA)
Abnormal dilated retinal capillaries or may represent
intraretinalneovacularizationwhich has not breached the
internal limiting membrane of the retina.
Severe NPDR indicate rapidly progress to PDR

21. Diabetic maculopathy
Macular ischemia
•Retinal capillary non-perfusion
•Progressive NPDR
Macular edema
Focal or diffuse or mixed
Increased retinal vascular permeability
Seen in both NPDR and PDR
Cause of visual loss in DR
Important in planning for treatment

23. Focal macular edema
Diffuse macular edema

24. Macular ischemia

25. CLASSIFICATION
Non-proliferativeDiabetic Retinopathy(NPDR):
•No DR
•Very MildNPDR
•Mild NPDR
•ModerateNPDR
•Severe NPDR
•Very SevereNPDR
Proliferative Diabetic Retinopathy (PDR):
•Mild to Moderate PDR
•High Risk PDR

26. Nonproliferativediabeticretinopathy
Very Mild:
Indicated by the presence of at
least 1 micro aneurysm.
Mild:
Microaneurysms, retinal
haemorrhage, exudates, cotton
wool spots.

27. Moderate:
•Includes the presence of
hemorrhages(1-3 quadrants), micro -
aneurysms,hardexudatesand
Cotton woolspot.
Microaneurysm
Exudate
Cottonwool

28. Severe:
The (4-2-1) rule; one or more of:
•Hemorrhages and microaneurysms
in 4 quadrants.
•Venous beading in at least 2
quadrants.
•Intraretinalmicrovascular
abnormalities in at least 1 quadrant
IRMA
Beading

29. Proliferative diabetic
retinopathy
 5% of DM .
Findings-
• Neovascularization
•Vitreous changes
Advanced diabetic eye disease
• Final stage of Uncontrolled PDR
•Glaucoma (neovascularization)
• Blindness from persistent vitreous hemorrhage, retinal
detachment,.

30. Diagnostic Testing
Fundus Fluorescein Angiography:
To i dentify Ischemic maculopathy
Intraretinal microvascular
abnormalities vs Neovascularization

31. Fundus Photography:
•For documentation purpose

33. Screening for DR
Patients withType1 diabetes should have an
ophthalmologic examination within 5 years
after onset.
Patients with Type 2 DM should have an
ophthalmologic examination at the time of the
diabetes diagnosis.
If there is no DR then one annual examination
required.
If any level of DR, progression and sight
threatening, then examination will be required
more frequently

34. Screening for DR
Women with pre existing type 1 or type 2 DM
who are planning pregnancy or pregnant
should be counseled on risk of development &/
or progression of DR.
Eye examinations should be started from 1
st
trimsterand monitored every trimsterand for 1
year of postpartum period.

35. Management
Medical treatment.
Observation.
Laser therapy.
AntiVEGFAgents
Vitrectomy.

36. Medicaltreatment:
Glucosecontrol:
controllingdiabetes.
maintaining the HbA1Clevel in the 6-7% range.
Levelofactivity:
Maintainingahealthylifestylewithregularexercisecan
helpreducethecomplicationofdiabetesandDR.
Blood pressurecontrol.
Lipid-loweringtherapy.

37. Lasertherapy
Panretinalphotocoagulation (PRP)
(a) before and (b) after focal laser photocoagulation

38. Vitrectomy

39. Aspirin in diabetic
eye
Aspirinusedidnotalterprogressionofdiabetic
retinopathy.
Aspirinusedidnotincreaseriskofvitreous
hemorrhage.
Aspirinusedidnotaffectvisualacuity.
Aspirin reducesrisk of cardiovascular morbidity
andmortality.

40. Followup:
Retinalfinding Suggestedfollow-up
Normal Annually
MildNPDR 1year
ModerateNPDR 6 months-1yearor referto
ophthalmologist.
SeverNPDR Every 4months
Diabetic macular edema'DME'Every 2 -4months
PDR Every 2-3months