Management of diabetic retinopathy

Presentation simplifying the ICO guidelines for diabetic retinopathy published in 2017.

1. MANAGEMENT OF DIABETIC RETINOPATHY – ICO 2017 Bipin Bista Resident-Ophthalmology NMCTH, Birgunj , Nepal

2. Updated 2017 ICO Guidelines for Diabetic Eye Care

3. Introduction Diabetes mellitus (DM) is a global epidemic with significant morbidity. Diabetic retinopathy (DR) is the specific microvascular complication of DM and affects 1 in 3 persons with DM.

4. Introduction Optimal control of blood glucose, blood pressure, and blood lipids can reduce the risk of developing retinopathy and slow its progression. Patients with severe levels of DR are reported to have poorer quality of life and reduced levels of physical, emotional, and social well-being, and they utilize more health care resources.

5. Epidemiology Most common cause of preventable blindness in working aged- adults. A global meta-analysis showed that one in three diabetic had any form of DR. In the 2010 world diabetes population, more than 92 million adults had any form of DR, 17 million had PDR, 20 million had DME and 28 million had VTDR .

6. Epidemiology  Studies reported Diabetic Retinopathy (DR) in 19-47% of diabetic patients in Nepal. Eli Pradhan, Barsa Suwal , Govinda Paudyal.Diabetic retinopathy in Nepal: An update Comm Eye Health South Asia Vol. 28 No. 92 2016 Thapa SS, Thapa R, Paudyal I, Khanal S, Aujla J, Paudyal G, et al. Prevalence and pattern of Vitreo -retinal disorders in Nepal : the Bhaktapur glaucoma study. BMC Ophthalmology. 2013, 13, 9. doi:10.1186/1471-2415-13-9 Rizyal A. Ocular manifestations in diabetes mellitus: an experience at Nepal Medical College Teaching Hospital. Nepal Med Coll J. 2004;6:136 -138. Shrestha S, Malla OK, Karki DB, Byanju RN. Retinopathy in diabetic population. Kathmandu Univ Med J. 2007;5:204-209. Shrestha RK. Ocular manifestations in diabetes, a hospital based prospective study. Nepal Med Coll J. 2011;13:254—256.

7. Pathogenesis The exact cause of Diabetic microvascular disease is unknown . Exposure to hyperglycemia over an extended period – biochemical & physiologic changes in vascular endothelium .

8. Microvascular occlusion A . Capillary changes- loss of pericytes , thickening of BM & damage & proliferation of endothelial cells B. Haematological changes- rouleaux formation of RBC, increased platelets adhesiveness, abnormal serum lipids, abnormal VEGF, abnormalities in serum and whole blood viscosity. Result-AV SHUNTS –capillary drop-out –IRMA & NEOVASCULIZATION at retina & optic disc -VEGF

9. Microvascular leakage Microaneurysms -localized saccular outpouching of vessel wall.

10. Result a . Diffuse retinal odema –extensive capillary dilatation and leakage . b.Localized retinal odema -caused by focal leakage from microaneursyms and dilated cap. s egments. Formation of hard exudates.

11. Microaneurysms

12. Retinal hemorrhages

13. Exudates

14. Cotton wool spots

15. Intraretinal microvascular abnormalities (IRMA)

16. Diabetic maculopathy & macular oedema

17. Abbreviated Early Treatment Diabetic Retinopathy Study (ETDRS)classification of diabetic retinopathy ( The modified Airlie House classification)

18. Clinically significant macular oedema (CSMO)

19. CLASSIFICATION   Diabetic Macular Edema Findings Observable on Dilated Ophthalmoscopy No DME No r etinal thickening or ha r d exudates in the macula   Non central-involved DME Retinal thickening in the macula that does not involve the central subfield zone that is 1 mm in diameter   Central-involved DME Retinal thickening in the macula that does involve the central subfield zone that is 1 mm in diameter

20. Re-examination & referral schedules Classification Re-examination Or next sc r eening schedule Referral to Ophthalmologist   No appa r ent DR, mild non-p r oliferative DR and no DME   Re-examination in 1-2 year   Referral not r equi r ed Mild non-p r oliferative DR 6-12 months Referral not r equi r ed Moderate non-p r oliferative DR 3-6 months Referral r equi r ed Seve r e non-p r oliferative DR < 3-months Referral r equi r ed PDR < 1 month Referral r equi r ed Diabetic Macular Edema (DME) Classification Re-examination Or next sc r eening schedule Referral to Ophthalmologist Noncentral-involved DME 3 months Referral r equi r ed Central-involved DME 1 month Referral r equi r ed

21. SCREENING FOR DR

22. Detailed ophthalmic assessment of DR Initial Patient Assessment - complete ophthalmic examination, including visual acuity and the identification and grading of severity of DR and presence of DME for each eye

23. Detailed history • Duration of diabetes • Past glycemic control (hemoglobin A1c) • Medications (especially insulin oral hypoglycemics , antihypertensives , and lipid-lowering drugs) • Systemic history (e.g., renal disease, systemic hypertension, serum lipid levels, pregnancy) • Ocular history.

24. Initial physical examination • Visual acuity • Measurement of intraocular pressure (IOP) • Gonioscopy when indicated • Slit-lamp biomicroscopy • Fundus examination

25. Fundus examination Two most sensitive methods for detecting DR are retinal photography and slit-lamp biomicroscopy through dilated pupils .

26. Ancillary Tests OCT - Most sensitive method. Quantitative assessment of DME to determine the severity. FA - T o evaluate retinal non-perfusion area, presence of retinal neovascularization, and microaneurysms or macular capillary non-perfusion in DME.

27. Patient’s education Discuss results. Encourage patients without DR but with DM for annual eye screening. Educate patients. Communicate with the general physician. Referrals for counseling, rehabilitative, or social services as appropriate.

28. Follow-up schedules Diabetic Retinopathy Severity Follow-up Schedule for management by ophthalmologists   No appa r ent DR Re-examination in 1-2 years; This may not r equi r e r e-examination by an ophthalmologist Mild nonp r oliferative DR 6-12 months; This may not r equi r e r e-examination by an ophthalmologist Moderate nonp r oliferative DR 3-6 month Seve r e nonp r oliferative DR <3 months; Consider early pan- r etinal photocoagulation.   P r oliferative DR   <1 month; Consider pan- r etinal photocoagulation.   Stable ( T r eated) PDR   6-12 months Diabetic Macular Edema severity Follow-up Schedule for management by ophthalmologists   Noncentral-involved DME   3-6 month; Consider focal laser photocoagulation   Central-involved DME   1-3 month; Consider focal laser photocoagulation or anti- VEGF therapy   Stable DME   3-6 month

29. Treatment of Diabetic Retinopathy Optimize medical treatment : If HbA1c > 58 mmol / mol (>7.5%) No DR, mild or moderate DR : Follow-up at regular interval Severe NPDR : Consider early panretinal photocoagulation for patients at high risk of progression to PDR or poor compliance with follow-up. PDR : Treat with PRP. Anti-VEGF injections.

30. Treatment for diabetic macular oedema Optimize medical treatment DME without central involvement : Observation Central-involved DME and good visual acuity (better than 6/9) careful follow-up with anti-VEGF treatment only for worsening DME; Intravitreal anti- VEGF injections laser photocoagulation with anti-VEGF, if necessary. Central-involved DME and associated vision loss (6/9 or worse) : I ntravitreal anti-VEGF treatment. DME associated with PDR : Monotherapy with anti-VEGF, re-evaluation for need of PRP. VM traction or ERM on OCT : PPV.

31. Treatment for diabetic macular oedema anti-VEGF With 8-10 in the first year 2 or 3 during the second year 1 to 2 during the third year and 0 to 1 in the fourth and fifth years of treatment P ersistent retinal thickening despite anti-VEGF therapy, consider laser treatment after 24 weeks.

32. Panretinal Photocoagulation (PRP) Fully dilated pupil & topical anaesthesia. I nitial settings on the Argon laser would be 500 μm spot size, a 0.1 second exposure and 250-270 mw power. 1 burn apart . 1600-3000 burns are placed in 1 or more sittings. B urns are placed 2 to 3 disc diameters away from the center of the macula and 1 disc diameter away from the disc extending upto the equator & beyond. S hould not be applied over major retinal veins, preretinal hemorrhages, darkly pigmented chorioretinal scars, or within 1 DD of center of macula. Favor quadrants with active new vessels or areas with intraretinal microvascular abnormalities.

33. Lenses for PRP Lens Field of V ision Axial magnification Spot magnification Spot Size Setting for ~500 um Mainster W ide-Field 125° 0.46 1.50x 300µm V olk T ransEquator 120-125° 0.49 1.43x 300µm V olk Quad/Aspheric 130-135° 0.27 1.92x 200 to 300µm Mainster PRP 165 160° 0.27 1.96x 200 to 300 µm

34. Burn characteristics of PRP Size (on r etina): 500 µm Exposu r e 0.05 to 0.1 seconds r ecommended. 0.02 or 0.03 seconds can be conside r ed for use in High Resou r ce Settings (in certain laser machines, whe r e applicable). Intensity mild white (i.e. 2+ to 3+ burns) Distribution Mild and moderate PDR : Edges 1 burn width apart Seve r e PDR : Edges 0.5 to 0.75 burn width apart Number of sessions/sittings 1 to 3 Nasal p r oximity to disk No closer than 500 µm T emporal p r oximity to center No closer than 3000 µm Superior/inferior limit No further posterior than 1 burn within the temporal a r cades Extent A r cades (~3000 µm f r om the macular center) to at least the equator

35. Burn characteristics of PRP T otal number of bu r ns 1200 – 1600   Guide for 20ms PRP and 100ms PRP:   Mild PDR: 20ms PRP ETDRS laser 100ms 2400-3500 burns 1200-1800 burns   Moderate PDR: 20ms PRP ETDRS laser 100ms 4000-5000 burns 2000-2500 burns   Seve r e PDR: 20ms PRP ETDRS laser 100ms 5500-6000 burns 2000-2500 W avelength G r een or yellow ( r ed can be used if vit r eous hemorrhage is p r esent)

36. PRP TECHNIQUE

37. Complications of PRP

38. Lasers in DME Focal di r ect laser t r eatment Di r ectly t r eat all leaking mic r oaneurysms in a r eas of r etinal thickening between 500 and 3000 µm f r om the center of the macula (but not within 500 µm of disc). Change in mic r oaneurysms color with di r ect t r eatment is not r equi r ed, but at least a mild gray-white burn should be evident beneath all mic r oaneurysms . Burn size 50-100 µm Burn duration 0.05 to 0.1 sec W avelength G r een to yellow wavelengths Grid laser t r eatment Applied to all a r eas with di f fuse leakage or non-perfusion a r ea . T r eat the a r ea 500 to 3000 µm superiorl y , nasally and inferiorly f r om the center of the macula, and 500 to 3500 µm temporally f r om macular cente r . No burns a r e placed within 500 µm of disc. Aim ba r ely visible (light gray) laser burn and each burn should be at least two visible burn widths apart. Burn size 50-100 µm Burn duration 0.05 to 0.1 sec W avelength G r een to yellow wavelengths

39. Indications for Vitrectomy Severe vitreous hemorrhage of 1–3 months duration or longer that does not clear spontaneously. Advanced active proliferative DR that persists despite extensive PRP. Traction macular detachment of recent onset. Fovea-threatening or progressive macula-involving traction detachments benefit from surgical management. Combined traction- rhegmatogenous retinal detachment. Tractional macular edema or epiretinal membrane involving the macula.

40. Complications of Vitrectomy

41. Management of Diabetic Retinopathy in Special Circumstances Pregnancy I nformed on the need for assessment of DR before and during pregnancy . R etinal assessment : F irst antenatal clinic appointment and again at 28 weeks if the first assessment is normal. If any DR is present, additional retinal assessment should be performed at 16-20 weeks . S hould not be considered a contraindication to vaginal birth.

42. Management of Diabetic Retinopathy in Special Circumstances Management of Cataract Mild cataract - carefully assess DR status. Patients without vision loss with clear fundus view may not require cataract surgery . Moderate cataract - carefully assess DR status. Attempt to treat any severe NPDR with laser PRP, and/or DME with focal/grid laser or anti-VEGF therapy, before cataract surgery. Once DR/DME is stable, consider cataract surgery to improve vision . Severe to advanced cataract with poor fundus view - consider early cataract surgery followed by assessment and treatment as necessary. If DME is present, consider anti-VEGF before surgery, at the time of surgery, or after surgery if DME is discovered when the media is cleared.

43. Bibliography Jack J Kanski , Brad Bowling, Clinical Ophthalmology, A Systemic Approach. 8 th Edition. International council of Ophthalmology . Guidelines for Diabetic eye care. Updated 2017. Internet Sources.

44. Every human being is the author of his own health or disease. Thank you.