DIABETIC
RETINOPATHY
DR SRAVYA M V
SECOND YEAR
MS SALAKYATANTRA
GAVC TPRA
• Retinal changes seen in patients with diabetes mellitus
Etiopathogenesis
Risk factors
• Duration of diabetes
• After 10 years 20% type 1 & 25% type 2
• After 20 years 90% type 1 & 60% type 2
• After 30 years 95% of both
• Type of DM
• Type 1 > type 2
• PDR type 1
• DME type 2
• Age of onset – after puberty not a risk factor
• Sex F : M 4:3
• Poor metabolic control – hyperglycemia for long duration triggers the onset
• Heredity
• Pregnancy
• Hypertension
• Others – smoking, obesity, anemia, hyperlipidemia
Pathogenesis
• Hyperglycemia – in uncontrolled DM – starting point of onset of DR
• Microangiopathy - affecting retinal pre-capillary arterioles, capillaries & venules
• Mechanisms
i. Cellular damage
• Hyperglycemia produces
• Damage to the cells of retina, endothelial cells
• Loss of pericytes
• Thickening of basement membrane of capillaries
ii. Haematological & biochemical changes
• Platelet adhesiveness increases
• Blood viscosity increases
• Red blood cells deformation & Rouleaux formation
• Serum lipids get altered abnormally
• Leukostasis increases
• Fibrinolysis increases
Effects of microangiopathy producing DR
• Breakdown of blood-retinal barrier
Retinal oedema
Haemorrhages
Leakage of lipids (hard exudates)
• Weakened capillary wall
Microaneurysms
Haemorrhages
• Microvascular occlusions
Ischaemia & its effects
Cotton-wool spots (due to infarct of nerve fibre layer)
Arteriovenous shunts, i.e. intraretinal microvascular abnormalities (IRMAs)
MICROVASCULAR LEAKAGE
MICROVASCULAR OCCLUSION
Classification of DR
1. Non-proliferative diabetic retinopathy (NPDR)
• Mild NPDR
• Moderate NPDR
• Severe NPDR
• Very severe NPDR
2. Proliferative diabetic retinopathy (PDR)
3. Diabetic maculopathy
4. Advanced diabetic eye disease (ADED)
I. Non-proliferative diabetic retinopathy (NPDR)
Ophthalmoscopic features
• Microaneurysms
In the macular area & elsewhere
Due to focal dilation of capillary wall following loss of pericytes.
Appear as red dots
Leak fluid, proteins & lipids
• Retinal haemorrhages
Deep (dot & blot haemorrhages )
Superficial haemorrhages (flame-shaped)
• Hard exudates
Yellowish-white waxy-looking patches
Arranged in clumps / in circinate pattern
Common in the macular area
Due to chronic localised oedema
Composed of leaked lipoproteins & lipid filled macrophages
• Cotton-wool spots
Small whitish fluffy superficial lesions
• Venous abnormalities
Beading, looping & dilatation
Adjacent to area of capillary non-perfusion
• Intraretinal microvascular abnormalities (IRMA)
Fine irregular red lines connecting arterioles with venules
ETDRS study classification
• On the basis of severity
1. Mild NPDR
• At least one microaneurysm must be present
2. Moderate NPDR
• Microaneurysms/intraretinal hemorrhage in 2 or 3 quadrants
• Early mild IRMA
• Hard exudates & cotton-wool spots may / may not be present
Mild NPDR
Moderate NPDR
3. Severe NPDR Any one of the following (4-2-1 Rule)
• 4 quadrants of microaneurysms & extensive intraretinal hemorrhages
• 2 quadrants of venous beading
• 1 quadrant of IRMA changes
4. Very severe NPDR Any two of the following
•4 quadrants of microaneurysms & extensive intraretinal hemorrhages
• 2 quadrants of venous beading
• 1 quadrant of IRMA changes
Severe NPDR
II. Proliferative diabetic retinopathy (PDR)
• Neovascularization over the changes of very severe NPDR - hallmark of PDR
• Neovascularization at the optic disc (NVD) and/or elsewhere (NVE) in the
fundus - along the course of the major temporal retinal vessels
• These new vessels may proliferate in the plane of retina / spread into the
vitreous
PDR
• Later on results in formation of
• Fibrovascular epiretinal membrane formed due to condensation of connective tissue
around the new vessels
• Vitreous detachment & vitreous hemorrhage
NVE NVD VH
• Types
1. PDR without HRCs (Early PDR) - early NVD / NVE
2. PDR with HRCs
High-risk characteristics (HRC)
• NVD <l / 4 disc area with vitreous hemorrhage (VH) / Preretinal hemorrhage (PRH)
• NVD I /4 to 1 /3 of disc area with / without VH /PRH
• NVE > l / 2 disc area with VH / PRH
Ill. Diabetic maculopathy
• Changes in macular region
• Diabetic macular oedema (DME) occurs due to increased permeability of the
retinal capillaries
Clinico-angiographic classification of diabetic maculopathy
l. Focal exudative maculopathy
• Microaneurysms
• Hemorrhages
• Well-circumscribed macular oedema
• Hard exudates - circinate pattern
2. Diffuse exudative maculopathy
• Diffuse retinal oedema
• Thickening throughout the posterior pole
• Relatively few hard exudates
3 . Ischaemic maculopathy
• Due to microvascular blockage
• Marked visual loss
• Microaneurysms
• Hemorrhages
• Mild/no macular oedema
• A few hard exudates
4. Mixed maculopathy
• Combined features of ischemic & exudative maculopathy
• OCT-based classification of diabetic macular edema
I. Non-tractional DME
a. Spongy thickening of macula (>290 µ)
b. Cystoid macular oedema (CME)
c. Neurosensory detachment with / without (a) / (b) above
2. Tractional DME
d. Vitreo-foveal traction (VFT)
e. Taut/thickened posterior hyaloid membrane
NEUROSENSORY RETINAL DETACHMENT
CME
VITREO FOVEAL TRACTION
IV. Advanced diabetic eye disease
• End result of uncontrolled PDR
Complications
• Persistent vitreous hemorrhage
• Tractional retinal detachment
• Neovascular glaucoma
MANAGEMENT
Includes its screening, investigations & treatment
A. Screening –
- To prevent visual loss
- For a timely intervention
• First examination, 3 years after diagnosis of type l DM & at the time of diagnosis in type 2 DM
• Every year, till there is no DR or there is mild NPDR
• Every 6 months, in moderate NPDR
• Every 3 months, in severe NPDR
• Every 2 months, in PDR with no high-risk characteristics
B. Investigations
• Urine examination
• Blood sugar estimation
• Renal function tests: serum creatinine, blood urea,24 hour urinary protein
• Lipid profile
• Hemogram
• Glycosylated haemoglobin (HbA1C)
• FFA should be carried out to elucidate areas of neovascularization, leakage & capillary
nonperfusion
• OCT to study detailed structural changes in diabetic maculopathy
C. Metabolic control of diabetes mellitus & associated risk factors
• Control of glycaemia
Target blood glucose level: fasting 50 mg%, & LDL 10mg%
• Control of associated hypertension
Target blood pressure levels:130/80 mm Hg
• Lifestyle changes
Prohibit smoking & alcohol consumption, take regular exercises
D. Treatment of diabetic retinopathy
I . Intravitreal anti-VEGF drugs
Bevacizumab ( 1.25 mg) & Ranibizumab (0.5 mg)
Preferred over laser therapy particularly
• Focal CME involving centre of fovea
• Diffuse DME
• DME with neurosensory detachment
•Before pan retinal photocoagulation (PRP) in patients with PDR & diffuse DME
II. Intravitreal steroids
Risk of glaucoma, steroid induced cataract & increased vulnerability to
endophthalmitis restrict its use
Ill. Laser therapy
• Focal laser for focal DME & grid laser for diffuse DME
• Laser helps possibly by stimulating the RPE pump mechanism & by inhibiting
VEGF release
• Laser therapy is performed using double frequency YAG laser 532 run / argon
green laser / diode laser
i. Macular photocoagulation
• Focal photocoagulation
- Focal DME not involving the center of fovea
• Grid photocoagulation
- Diffuse DME
- In cases not responding to anti-VEGFs & intravitreal steroids
ii. Pan retinal photocoagulation (PRP) / scatter laser
• Consists of 1200-1600 spots, each 500 µm in size & 0.1 sec duration
• Laser burns are applied outside the temporal arcades & on nasal side one
disc diameter from the disc up to the equator
• The burns should be one burn width apart
• PRP produces destruction of hypoxic retina
Indications
• PDR with HRCs
• Neovascularization of iris ( NI)
• Severe NPDR associated with
• Poor compliance for follow-up
• Before cataract surgery/YAG capsulotomy
• Renal failure
• One eyed patient
• Pregnancy
IV. Surgical treatment
• Tractional DME with NPDR
Pars plana vitrectomy (PPV) + removal of posterior hyaloid
• Advanced PDR with dense vitreous haemorrhage
PPV + removal of opaque vitreous gel + endo photocoagulation
• Advanced PDR with extensive fibrovascular epiretinal membrane
PPV + removal of fibrovascular epiretinal membrane + endo photocoagulation
• Advanced PDR with tractional retinal detachment
PPV + endo photocoagulation + reattachment of detached retina
THANK YOU
