DIABETIC RETINOPATHY .pptx

Dr.Nupur
Ophthalmology PG
NMCH,Patna

1. DIABETIC RETINOPATHY PRESENTER : DR NUPUR ( 1 ST YR PG) N.M.C.H PATNA

2. DIABETES MELLITUS Diabetes mellitus is a group of metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels. # American Diabetes Association. Diagnosis and classification of diabetes mellitus.  Diabetes Care.  2004;27( suppl 1):S5-S10

3. Type 1 diabetes (β-cell destruction, usually leading to absolute insulin deficiency) Type 2 diabetes ( insulin resistance with relative insulin deficiency ) Types of DM # American Diabetes Association. Diagnosis and classification of diabetes mellitus,2007

4. OPHTHALMIC COMPLICATIONS OF DIABETES COMMON RETINOPATHY IRIDOPATHY UNSTABLE REFRACTION. UNCOMMON RECURRENT STYES XANTHELASMA ACCELERATED AGE-RELATED CATARACT NEOVASCULAR GLAUCOMA (NVG) OCULOMOTOR NERVE PALSIES. REDUCED CORNEAL SENSITIVITY RARE PAPILLOPATHY, PUPILLARY LIGHT-NEAR DISSOCIATION WOLFRAM SYNDROME ACUTE- ONSET CATARACT RHINO-ORBITAL MUCORMYCOSIS. # kanski’s clinical ophthalmology, 9e

5. DEFINITION OF DIABETIC RETINOPATHY Diabetic retinopathy is a chronic progressive, potentially sight-threatening disease of the retinal microvasculature associated with the prolonged hyperglycaemia and other conditions linked to diabetes mellitus such as hypertension. https://www.rcophth.ac.uk/wp-content/uploads/2021/08/2012-SCI-267-Diabetic-Retinopathy-Guidelines-December-2012

6. What is The Retina? The retina is a multilayered, light sensitive neural tissue lining the inner eye ball. Light is focused onto the retina and then transmitted to the brain through the optic nerve. The macula is a highly sensitive area in the center of the retina, responsible for central vision.

7. #aao.org/education/topic-detail/diabetic-retinopathy- europe,oct 2016

8. Sampe size: 63,000 ; age ≥50yrs * sight-threatening diabetic retinopathy (STDR)

9. PATHOPHYSIOLOGY Diabetic Retinopathy is a microvasculopathy that causes: Retinal capillary occlusion Retinal capillary leakage https://www.aao.org/education/topic-detail/diabetic-retinopathy-europe

10. Pathophysiology https://www.aao.org/education/topic-detail/diabetic-retinopathy-europe

11. RISK FACTORS Non modifiable Duration and age at onset Puberty Modifiable Risk Factors Diabetic control/ HbA1c Hypertension Pregnancy OTHERS : Hyperlipidemia , Smoking, Obesity

12. Risk factors Diabetic Retinopathy http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=d0c853d3-219f-487b-a524-326ab3cecd9a

13. Type 1 DM DURATION (YRS) DR PDR AFTER 5 YRS 25% AFTER 10 YRS 60% AFTER 15 YRS 80% AFTER 20-30 YRS 95% 30- 50% # https://www.aao.org/education/topic-detail/diabetic-retinopathy-europe # Myron Yanoff and Jay S. Duker : Ophthalmology,5e

14. Type 2 DM DURATION (YRS) DR PDR Yanko et al. 11-13 23% 3% ≥ 16 60% Klein et al. 10 67% 10% # Myron Yanoff and Jay S. Duker : Ophthalmology,5e $ https://www.aao.org/education/topic-detail/diabetic-retinopathy-europeMyron $ PDR will develop in 2% of patients if duration of DM is < 5 years and 25% if > 25 years

15. Puberty Pre pubertal children (< 12 yrs) rarely develop complications of diabetes. Puberty is a risk factor for developing retinopathy because of the physiological increased resistance to insulin. Klein et al found that diabetes duration post menarche was associated with 30% increase risk or retinopathy compared with diabetes duration before menarche.

16. HbA1c DCCT showed in T1DM: Tight control had 76% reduction in rate of developments of DR ( primary prevention cohort) and 54% reduction in progression of established DR ( secondary intervention cohort) as compared to conventional treatment group *The Diabetes Control and Complications Trial (DCCT); * tight control ( 4 measurements/day) * conventional treatment group ( one measurement per day)

17. HbA1c The DCCT : every 1% decrease in HbA1C level decrease the incidence of diabetic retinopathy by 28% . Target HbA1c value of 6 - 7% ( kanski’s clinical ophthalmology, 9e)

18. Hypertension HTN is common in patients with T2DM. Target BP <140/80 mm hg (# kanski’s clinical ophthalmology, 9e) Tight control appears to be particularly beneficial in T2DM with maculopathy . # kanski’s clinical ophthalmology, 9e

19. Gestational diabetes does not require an eye examination during pregnancy and does not increase the risk of diabetic retinopathy. Diabetic retinopathy can worsen during pregnancy Macular edema in pregnant patients can improve with delivery Diabetic retinopathy in a pregnant patient is not a contraindication for natural vaginal delivery. Pregnancy # https://www.aao.org/education/topic-detail/diabetic-retinopathy-europeMyron

20. PREGNANT DIABETIC WOMEN RISK OF DEVELOPMENT REMARKS WITHOUT DR  NPDR 10% NPDR  PDR 4% UNTREATED PDR REQUIRE - PAN RETINAL PHOTOCOAGULATION (PRP) TREATED PDR USUALLY DOES NOT WORSEN Pregnancy # Myron Yanoff and Jay S. Duker : Ophthalmology, 5e

21. Approximate equivalence of currently used alternative classification systems for diabetic retinopathy ETDRS NSE SDRGS AAO INTERNATIONAL None R0 n one R0 none No apparent retinopathy Microaneurysm only R1 background R1 mild background Mild NPDR Mild NPDR Mod NPDR Moderate NPDR R2 preproliferative R2 moderate BDR Moderately severe NPDR Severe NPDR R3 severe BDR Severe NPDR Very severe NPDR Mild PDR R3 proliferative R4 PDR PDR Moderate PDR High risk PDR Advanced PDR ETDRS = Early Treatment Diabetic Retinopathy Study; AAO = American Academy of Ophthalmology; NSC = National Screening Committee; SDRGS = Scottish Diabetic Retinopathy Grading Scheme; NPDR = non-proliferative diabetic retinopathy; BDR = background diabetic retinopathy; PDR = proliferative diabetic retinopathy; # https://www.rcophth.ac.uk/wp-content/uploads/2021/08/2012-SCI-267-Diabetic-Retinopathy-Guidelines-December-2012

22. NO DR DESCRIPTION No evidence of retinal vascular disease FOLLOW-UP Yearly with dilated funduscopic exams

23. MILD NPDR DESCRIPTION ETDRS:   ≥ 1 microaneurysm with no other findings Kanski :  Any or all : microaneurysms , retinal hemorrhages , exudates, cotton wool spots, up to the level of moderate NPDR with no IRMAs or venous beading FOLLOW-UP 6-12 months with dilated funduscopic exam There are a few cotton-wool spots and intraretinal hemorrhages in this photograph, which doesn't really fit the ETDRS/International classification for true mild NPDR.  Might still mild NPDR, because while there are multiple hemorrhages and cotton-wool spots, there are still < 20 per quadrant. Published in:  Community Eye Health Journal Vol. 24, No. 75, September 2011 (www.cehjournal.org)

24. # kanski’s clinical ophthalmology, 9e

25. MODERATE NPDR DESCRIPTION Any of the following: ≥ 20 intraretinal hemorrhages in 1-3 quadrants Venous beading in no more than 1 quadrant Presence of mild  intraretinal microvascular abnormalities (IRMAs) in no more than 1 quadrant Cotton-wool spots commonly present. FOLLOW-UP 6 months with dilated funduscopic exam PROGNOSIS PDR in up to 26% and high risk PDR in up to 8% within a year . # kanski’s clinical ophthalmology, 9e

26. Haemorrhages

27. Venous changes # kanski’s clinical ophthalmology, 9e

28. Intraretinal microvascular abnormalities (IRMA) # kanski’s clinical ophthalmology, 9e

29. Cotton-wool spots Fig : Cotton-wool spots and IRMA, # kanski’s clinical ophthalmology, 9e

30. SEVERE NPDR DESCRIPTION One of the following (4-2-1 rule): 4  quadrants of ≥ 20 hemorrhages ≥  2  quadrants of venous beading ≥  1  quadrant of IRMAs FOLLOW-UP 4 months with dilated funduscopic exam PROGNOSIS PDR in up to 50% and high risk PDR in up to 15% within a year. # kanski’s clinical ophthalmology, 9e

31. VERY SEVERE NPDR DESCRIPTION ≥ 2 of the 4-2-1 criteria FOLLOW-UP 2-3 months with dilated funduscopic exam PROGNOSIS High-risk PDR in up to 45% within a year.  FIG: cotton-wool, spots, IRMA, and venous beading; Yanoff and Jay S. Duker : Ophthalmology,5e # kanski’s clinical ophthalmology, 9e

32. PROLIFERATIVE DIABETIC RETINOPATHY Proliferative diabetic retinopathy (PDR) is characterized by  neovascularization  arising from the optic disc and retina, which may cause preretinal and vitreous hemorrhage .

33. Proliferative diabetic retinopathy Mild – moderate PDR NVD <1/3 disc area or NVE <1/2 disc area (NVD or NVE :insufficient to meet high risk criteria) High risk PDR NVD > 1/3 disc area Any NVD with vitreous haemorrhage NVE > 1/2 disc area with vitreous haemorrhage *New vessels on the disc (NVD); New vessels elsewhere (NVE) # kanski’s clinical ophthalmology, 9e

34. PDR

35. PDR

36. High risk PDR

37. PDR

38. ADVANCED DIABETIC EYE DISEASE Hemorrhage : Preretinal hemorrhage ( retrohyaloid ), Intragel haemorrhage or Both Tractional retinal detachment Rubeosis iridis # kanski’s clinical ophthalmology, 9e

39. ADVANCED DIABETIC EYE DISEASE # kanski’s clinical ophthalmology, 9e

40. DIABETIC MACULAR EDEMA Diabetic macular edema is the leading cause of legal blindness in diabetics. Diabetic macular edema can be present at any stage of the disease, but is more common in patients with proliferative diabetic retinopathy.

41. Meta analysis and review on the effect on bevacizumab id diabetic macular edema Graefes Arch Clin Exp Ophthalmol (2011) 249:15-27

42. Why is Diabetic macular edema so important? The macula is responsible for central vision. Diabetic macular edema may be asymptomatic at first. As the edema moves in to the fovea (the center of the macula) the patient will notice blurry central vision. Macula Fovea

43. International Clinical Diabetic Macular Edema Disease Severity Scale Proposed disease severity level Findings observable upon dilated ophthalmoscopy DME apparently absent DME apparently present DME present No apparent retinal thickening or hard exudates in posterior pole Some apparent retinal thickening or hard exudates in posterior pole Mild DME (some retinal thickening or hard exudates in posterior pole but distant from the center of the macula) Moderate DME (retinal thickening or hard exudates approaching the center of the macula but not involving the center) Severe DME (retinal thickening or hard exudates involving the center of the macula) American Academy of Ophthalmology Retina -Vitreous Panel. Preferred Practice Pattern® American Academy of Ophthalmology; 2014

44. DME

45. Clinically Significant Macular Edema Retinal thickening located at or within 500 μm of the center of the macula Hard exudates at or within 500 μm of the center if associated with thickening of adjacent retina A zone of thickening larger than 1 disc area (1500 μm ) if located within 1 disc diameter of the center of the macula # Source: Basic and Clinical Science Course, Section 12, American Academy of Ophthalmology, 2014-2015.

46. CSME

47. DIABETIC MACULOPATHY (DM) DM is further classified as: Focal maculopathy Diffuse maculopathy Ischaemic maculopathy Mixed # kanski’s clinical ophthalmology, 9e

48. Focal maculopathy DESCRIPTION Well circumscribed Retinal thickening Complete/incomplete ring of exudates FA : Late, focal hyperfluorescence Good macular perfusion # kanski’s clinical ophthalmology, 9e

49. Diffuse maculopathy DESCRIPTION Diffuse Retinal thickening Cystoid changes Scattered microaneurysms Small hemorrhages FA : Mid to Late, diffuse hyperfluorescence # kanski’s clinical ophthalmology, 9e

50. Ischaemic maculopathy DESCRIPTION Macula may look relatively normal Reduced visual acuity PPDR may be present FA : Capillary non-perfusion at fovea, posterior pole and periphery # kanski’s clinical ophthalmology, 9e

51. Diabetic Eye Disease Key Points Treatments exist but work best before vision is lost RECOMMENDED EYE EXAMINATION SCHEDULE Diabetes Type Recommended Initial Evaluation Recommended Follow-up* Type 1 5 years after diagnosis Yearly Type 2 At time of diagnosis Yearly pregnancy (type 1 or type 2) Soon after conception and early in the first trimester No retinopathy to mild or moderate NPDR : every 3-12 months Severe NPDR or worse: every 1-3 months. * Abnormal findings may dictate more frequent follow-up examinations h ttp://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=d0c853d3-219f-487b-a524-326ab3cecd9a

52. SYMPTOMS Asymptomatic Decreased vision Floaters Metamorphopsia Symptoms of retinal detachment https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ

53. OCULAR EXAMINATION Visual acuity Intraocular pressure Slit lamp biomicroscopy Gonioscopy before dilating pupils Funduscopic examination of the posterior pole under dilated pupil Examination of peripheral retina and vitreous under dilated pupil  https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ

54. IMAGING Digital photography Fluorescein angiography optical coherence tomography ( oct )

55. TREATMENT OF DIABETIC RETINOPATHY Effective in 90% of cases to prevent severe visual loss Good glycemic control  Adequate control of hypertension Encourage changes in lifestyles Treatment options Laser therapy Anti-VEGF drugs ( ranibizumab , aflibercept , bevacizumab ) Surgery https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ

56. Treatment of diabetic retinopathy HbA1c target (6.5-7.5%). NPDR with T2DM : Add fenofibrate with statin Macular edema : No pioglitazone Systolic BP ≤130mmHg : Retinopathy and/or nephropathy Systolic BP < 140mmHg : Without retinopathy, Pregnancy : No statin ( Diabetic patients planning pregnancy should be informed on the need for assessment of diabetic retinopathy before and during pregnancy; Tropicamide alone should be used if mydriasis is required during pregnancy ) https://www.rcophth.ac.uk/wp-content/uploads/2021/08/2012-SCI-267-Diabetic-Retinopathy-Guidelines-December-2012

57. Treatment of diabetic retinopathy DIABETIC PREGNANT WOMEN 1 ST ANTENATAL VISIT 2 ND VISIT AT (FOLLOW UP) NO DR 28 WEEKS DR 16-20 WEEKS PPDR DURING PREGNANCY AT LEAST 6 MONTHS FOLLOWING DELIVERY (Macular edema in pregnant patients can improve with delivery, no intravitreal anti-VEGF is recommended. Consider intravitreal steroids.) https://www.rcophth.ac.uk/wp-content/uploads/2021/08/2012-SCI-267-Diabetic-Retinopathy-Guidelines-December-2012

58. Treatment of diabetic macular edema Laser Therapy Focal laser : FDA approved based on ETDRS findings Micropulse laser Anti-VEGF Drugs Aflibercept Ranibizumab Bevacizumab https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ *Anti-VEGF injections are considered the new gold standard of therapy for eyes with centre-involving macular oedema and reduced vision

59. Treatment of diabetic macular edema Steroids Intravitreal Injections Intravitreal implants Ozurdex ( Dexamethasone ) Iluvien ( Flucinolone Acetonide ) Surgery Consider in cases of vitreomacular traction Tractional retinal detachment https://www.aao.org/education/topic-detail/diabetic-retinopathy-europ

60. INITIAL MANAGEMENT RECOMMENDATIONS FOR PATIENTS WITH DIABETES * Adjuncttive treatments that may be considered include intravitreal corticosteroids or anti-VEGF agents. Source: American Academy of Ophthalmology Retina -Vitreous Panel. Preferred Practice Pattern® Guidelines

61. DIABETIC RETINOPATHY