DIABETIC
RETINOPATHY-
MANAGEMENT
INTRODUCTION
• DR is the retinal changes seen in pts with
DM
• High chance in DM 1
• Raised HbA1c is a risk factor
• Other risk factors:-
• smoking,HTN,obesity,anemia,Hyperlipidaemi
a
MANAGEMENT
• Includes:-
• Screening
• investiaions
• treatment
SCREENING
• To prevent visual loss occurring from diabetic retinopathy a
periodic follow-up is very important for timely intervention.
Recommendations for periodic fundus examination:
• First examination, 3 years after diagnosis of type l DM and
at the time of diagnosis in type 2 DM.
• Every year, till there is no diabetic retinopathy 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
INVESTIGATIONS
• Urine examination
• Blood sugar estimation
• Renal function tests: serum creatinine, blood urea,
and 24 hour urinary protein
• Lipid profile
• Haemogram
• Glycosylated haemoglobin (HbAlC)
• Fundus fluorescein angiography -to elucidate
areas of neovascularization, leakage and
capillary nonperfusion.
• Optical coherence tomography (OCT) to study
detailed structural changes in diabetic
maculopathy.
METABOLIC CONTROL OF DM &
ASSOCIATED RISK FACTORS
• First stabilize DM metabolically. Not only the blood
glucose levels but other biochemical parameters
should also be normal. lfderanged, consultation from
an internist/ endocrinologist should be
sought .Targeted values:-
• Control of glycaemia. Target blood glucose level:
fasting <120 mg% post-prandial <180 mg%, HbAlc
<7%.
• Control of dyslipidaemia. Target lipid profile (fasting):
• Renal function tests. Target level are serum
creatinine 1.0 mg%, blood urea 20-40 mg%, and
24-hour urinary protein <200 mg%.
• • Control of associated anaemia. Target
haemoglobin >10mg%.
• • Control of associated hypertension. Target blood
pressure levels:130/80 mm Hg.
• • Lifestyle changes. Stop smoking and alcohol
consumption, and take regular exercises.
TREATMENT
• intravitreal anti-VEGF drugs, intravitreal
• steroids,
• laser therapy,
• pars plana vitrectomy
INTRAVITEAL ANTI VEGF DRUGS
• VEGF-pivotal role in etiopathogenesis of DR&D
maculopathy
• Bevacizumab ( 1.25 mg)
• Ranibizumab (0.5 mg)
• given intravitreally in 0.1 mL vehicle
lead to improvement in vision in>40% cases and
stabilize vision in another >40% cases
• preferred over laser therapy particularly in patients
with:
• • Focal CME involving centre of fovea,
• • Diffuse DME
• • DME with neurosensory detachment
• • Anti-VEGFs are also recommended before pan-retinal
photocoagu lation (PRP) in patients with PDR and
diffuse DME.
• Effects of the anti-VEGFs last for 4-6 weeks and
frequent injections are warranted.
INTRAVITREAL STEROIDS
• TRIAMCINOLONE ACETONIDE(IVTA)-20mg
• restores inner retinal barrier +some anti-VEGF
effects .
• risk of glaucoma, steroid induced cataract, &
increased vulnerability to endophthalmitis -restrict
its use.
• Hence, anri-VEGFs are preferred over IVTA these
days. However, in recalcitrant cases IVTA may be
given along with anti-VEGFs. Intravitreal
dexamethasone slow release implant (Ozurdex) -
alternative to triamcinolone (which needs to be
LASER THERAPY
• ETDRS had recommended focal laser for focal
DME and grid laser for diffuse DME.
• Laser - stimulate the RPE pump mechanism &
inhibit VEGF release.
• Before the advert of anti-VEGFs, laser therapy,
which only stabilizes the vision, was the
mainstay in the treatment of DME. Now laser is
limited
• Laser therapy is performed using double
frequency YAG laser 532 run or argon green
• Present indicate on protocols for laser therapy:-
• FOCAL MACULAR GRID
PHOTOCOA
• for focal DME GULATION not
for diffuse DME for
• not involving the centre recalcitrant cases
not responding
• of fovea to anti-VEGF
&intravitreal steroids.
PANRETINAL PHOTOCOAGULTION
• (PRP) or scatter laser consists of 1200-1600 spots,
each 500 µm in size and 0.1 sec duration. Laser
burns are applied outside the temporal arcades and
on nasal side one disc diameter from the disc up to
the equator. The burns should be one burn width
apart
• In PHP inferior quadrant of retina is first coagulated.
• PRP produces destruction of hypoxic retina which is
responsible for the production of vasoformative
factors.
INDICATIONS FOR PRP ARE:
• • PDR with HRCs,
• • Neovascularization of iris ( NVI),
• • Severe NPDR associated with:
• • Poor compliance for foUow-up,
• • Before cataract surgery/YAG capsulotomy,
• • Renal failure,
• • One eyed patient,
• • Pregnancy.-
SURGICAL T/T INDCATIONS
• Tractional DME with NPDR.-pars plana vitrectomy
(PPV) with removal of posterior hyaloid.
• • Advanced PDR with dense vitreous
haemorrhage.-PPV along with removal of opaque
vitreous gel and endophotocoagulation at an
early stage
• . • Advanced PDR with extensive fibrovascular
epirelinal membrane -PPV along with removal of
fibrovascular epiretinal membrane and
endophotocoagulation.
• • Advanced PDR with tractional retinal
detachment- by PPV with endophotocoagulation
and reattachment of detached retina alongwith
other methods like scleral buckling and internal
tamponade using i11travitreal silicone oil or
gases like sulphur hexafluoride (SF6) or
perfluoropropane (C3F8 ).
THANK YOU
