Non proliferative diabetic retinopathy by phaneendra akana

non-proliferative diabetic nephropathy overview

1. NON-PROLIFERATIVE DIABETIC RETINOPATHY MOHAN PHANEENDRA AKANA Final M.B.B.S Part-1 7 th SEMESTER NOV 11,2015

2. 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. The macula is needed for reading, recognizing faces and executing other activities that require fine, sharp vision.

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4. RETINA

5. Diabetic Retinopathy (DR) Definition Progressive dysfunction of the retinal blood vessels caused by chronic hyperglycemia. DR can be a complication of diabetes type 1 or diabetes type 2. Initially, DR is asymptomatic, if not treated though it can cause low vision and blindness.

6. Healthy Retina Diabetic Retinopathy

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

8. Risk factors Duration of diabetes Poor Blood Sugar control HTN Hyperlipidemia

9. How diabetes cause vision loss Mechanism of VISION LOSS Preclinical changes Macular edema Proliferative DR Diabetes Background DR Clinical significant macular edema Vitreous hemorrhage and/or Retinal detachment and/or neovascular glaucoma Preproliferative DR Vision loss

10. Pathophysiology Diabetic Retinopathy is a microvasculopathy that causes: Retinal capillary ( microvascular ) occlusion Retinal capillary ( microvascular ) leakage

11. Microvascular Occlusion Microvascular occlusion is caused by: Thickening of capillary basement membranes Abnormal proliferation of capillary endothelium Abnormalities in platelet function (Increased adhesion) Increased blood viscosity Defective fibrinolysis

12. Cotton – wool spots Neovascularization Ischemia Neovascular glaucoma Microvascular Occlusion Fibrovascular bands Vitreous hemorrhage Increased VEFG Tractional retinal detachment Infarction

13. Microvascular leakage Microvascular leakage is caused by: Impairment of endothelial tight junctions Loss of pericytes Weakening of capillary walls Elevated levels of vascular endothelial growth factor (VEGF)

14. Edema Retinal hemorrhage Hard exudates Microvascular Leakage

15. Ophthalmic features of non-proliferative diabetic retinopathy Microaneurysms (inner nuclear) Retinal hemorrhages(dot and blot) Oedema (macular) Hard ( retnal lipid)exudates Cotton-wool spots(nerve fiber layer) Venous abnormalities Intraretinal microvacular abnormalities Dark-blot hemorrhages

16. Hyperglycemia Damage to retinal capillaries Weakens capillary walls Small outpouchings leaky,fluid seep into retina of vessel lumen fluid deposition under macula rupture Macular edema hemorrhage Resolution of fluid lakes Sediments of lipid byproducts

17. Glucose galactose Sorbitol galacitol Can’t diffuse out of the cells(lens epithelial,pericytes,schwann cells) Incr. intracellular conc. Inc. osmotic forces Water diffuse into cell Electrolyte imbalance Damage to pericytes on vessel wall loss of contraction & relaxation of vessel wall Cotton wool spots

18. Associate features : Vitreous hemorrhage Retinal detachment Neovascular glaucoma Premature cataract Cranial nerve palsies

19. ETDRS study classification: Mild NPDR Moderate NPDR Severe NPDR Very severe NPDR

20. Findings Obsd International Clinical Diabetic Retinopathy Disease Severity Scale Proposed Disease Severity Level Findings Observable upon Dilated Ophthalmoscopy No apparent retinopathy No abnormalities Mild nonproliferative diabetic retinopathy Microaneurysms only Moderate nonproliferative diabetic retinopathy More than just microaneurysms but less than severe NPDR Severe nonproliferative diabetic retinopathy Any of the following: More than 20 intraretinal hemorrhages in each of four quadrants Definite venous beading in two or more quadrants Prominent IRMA in one or more quadrants and no signs of proliferative retinopathy. Proliferative diabetic retinopathy One or both of the following: Neovascularization Vitreous/preretinal hemorrhage

21. Mild NPDR Atleast one microaneurysm (Ma)

22. MILD NONPROLIFERATIVE DIABETIC RETINOPATHY Microaneurysms

23. Moderate NPDR Microaneurysms or intraretinal hemorrhages(Ma/H) in 2 or 3 quadrants Soft exudates Venous beading(VB) Intraretinal micro vascular abnormalities(IRMA) defenitely p resent

24. Moderate Nonproliferative Diabetic Retinopathy (NPDR) Hard exudates Flamed shaped hemorrhages Microaneurysm

25. Moderate Nonproliferative Diabetic Retinopathy ( NPDR) Hard exudates microaneurysm

26. Severe NPDR H/Ma(>20) in all 4 quadrants VB in ≥2 quadrants IRMA in ≥1 quadrant No signs of proliferative retinopathy “4-2-1 rule.”

27. Severe Nonproliferative Diabetic Retinopathy (NPDR) Venous beading

28. Very severe NPDR Any 2 of the severe NPDR (4 – 2 - 1)

29. Diabetic Eye Disease Key Points Treatments exist but work best before vision is lost RECOMMENDED EYE EXAMINATION SCHEDULE Diabetes Type Recommended Time of First Examination Recommended Follow-up* Type 1 3-5 years after diagnosis Yearly Type 2 At time of diagnosis Yearly Prior to pregnancy (type 1 or type 2) Prior to conception and early in the first trimester No retinopathy to mild moderate NPDR every 3-12 months Severe NPDR or worse every 1-3 months. *Abnormal findings may dictate more frequent follow-up examinations

30. Treatment of NPDR No ocular intervention is warrented,until disease reaches the proliferative stage. As proliferative stage arouses,the treatment is carried out through various measures like…. Pan retinal Laser photocoagulation Intra- vitreal anti VEGF injections Anti-platelet theraphy Anti hypertensive agents Anti-angiogenesis agents

31. DIABETIC RETINOPATHY TREATMENT Once DR threatens vision treatments can include:

32. Pan retinal Laser Photocoagulation Laser Photocoagulation is recommended for eyes with: Clinical significant macular edema CSME High risk Proliferative diabetic retinopathy Lasers named for active medium Choice of optimal wavelength depends on absorption spectrum of target tissues Used for retinal & choroidal abnormalities Recent appplications have exploited the subthreshold effects of laser.

33. DIABETIC RETINOPATHY TREATMENT NEWER DEVELOPMENTS:

34. CONCLUSIONS Diabetic Retinopathy is preventable through strict glycemic control and annual dilated eye exams by an ophthalmologist.

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