2. Objectives
By the end of the session participants will
be able to:
• Define & classify diabetic retinopathy
• List signs and symptoms of diabetic
retinopathy
• State why signs & symptoms occur
• When referral to an ophthalmologist is
required.
• Treatment options available
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5. When Does Retinopathy Arise
Prevalence of DR
• At diagnosis 20%
• 10 years after diagnosis 40-50%
• 20 years after diagnosis
– Type I 100%
– Type II 60%
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6. With strict control of DM:
• Risk of developing retinopathy was
reduced by 75%
• Reduction in the rate of progression of
retinopathy in existing retinopathy 50%
• Diabetes Control and Complications Trial
Research Group N Engl J Med 1993;
329:977-986.
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10. Microaneurysm
• Small protuberances on the retinal blood
vessels. The first sign of eye damage.
Microaneurysms are reversible if the blood
glucose control is improved
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11. Hard Exudates
• Yellow spots seen in the
retinaThey are lipid
break-down products
that are left behind
after localized edema
resolves. You can kind
of think of them like the
dirt-ring that gets left
behind after the
bathwater drains out.
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12. IRMA
• Intraretinal microvascular abnormalities
(lRMA) : Dilated, tortous retinal
capillaries that act as a shunt between
arterioles and venules. frequently seen
adjacent to areas of capillary closure.
IRMA may resemble focal areas of flat
NVE . But in IRMA : intraretinal location.
absence of profuse leakage on fluorescein
angiography. failure to cross over major
retinal blood vessels. www.DivyaPrabha.in
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13. • A) cotton-wool
spot
• B) venous
beading
• C) intraretinal
microvascular
abnormalities;
• D) intraretinal
hemorrhages.
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14. NVD
• New Vessels: Unlike IRMA, they arise on
the retinal surface and may extend or be
pulled into the vitreous cavity.
• NVD : NV appears on or within one DD of
disc margin .
• NVE : any other location .
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16. • Fibrous Glial
proliferation :
Accompained
growth of new
vessels. It is
proliferation
between the
posterior
vitreous gel and
the ILM. Derived
from retinal
glial cells and
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21. OCT
• Optical Coherence Tomography OCT
creates cross section of retina. It
demonstrates 3 basic structural changes
of the retina from diabetic macular
edema (DME), that is, retinal swelling,
cystoid edema, and serous retinal
detachment
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23. Risk Factors for dr
• Duration of diabetes : is the most
important factor.
• In patients diagnosed as having diabetes
before the age of 30 years, the incidence
of DR :
• after 10 years is 50%
• after 30 years is 90%
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24. RISK FACTORS for dr
• Age at diagnosis of diabetes
• Duration
• Poor control of diabetes
• Pregnancy
• Hypertension
• Nephropathy
• Hyperlipidemia
• Obesity
• Anemia
• Smoking
• Cataract surgery
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25. Stages of Retinopathy
• No DR • No Macular Edema
• Mild NPDR • Macular Edema
• Mod NPDR Present
• Severe NPDR
• PDR
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27. Macular edema types
• Focal ME :which has
identifiable leakage
source.
• Cystoid ME : in which
fluid accumulate in OPL
and INL to form cystoid
spaces.
• Diffuse ME : which has
multiple unidentifiable
source of leakage.
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29. CSME (ETDRS):definition
• retinal thickening 500
from fovea
• HE within 500 microns
from fovea with
thickening
• 1500 of thickening with
any part within 1 DD of
fovea
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30. DME: Pathophysiology
• DME is the result of microvascular
changes in diabetes leading to
incompetence of vessels
• Hypoxic state stimulate VEGF causing
more CME
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31. DME: Morbidity
• DME is the leading cause of new blindness
in the US .
• Untreated , 25-30 % of CSME double their
visual angle within 3 years
• Treated the risk drops by 50%
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33. Treatment Modalities
LASER Photocoagulation
CSME – Focal & Grid PDR–
Pan Retinal Photocoagulation
INTRA VITREAL
anti VEGF – Bevacizumab, Ranibizumab
steroids – Triamcinolone acetonide
PARS PLANA VITRECTOMY
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34. Focal/grid laser
• Significant visual improvement is uncommon.
Photocoagulation reduced the risk of moderate
visual loss from diabetic macular edema by 50%,
from 24% to 12%, 3 years after initiation of
treatment.
• Laser treatment is most effective when initiated
before visual acuity is lost. Laser treatment of
diabetic macular edema should precede panretinal
photocoagulation (PRP) by at least 6 weeks because
PRP before has been known to worsen diabetic
macular edema. PRP should not be delayed in
patients with very severe nonproliferative diabetic
retinopathy or high-risk proliferative diabetic
retinopathy
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35. Deferral of focal laser
• Hypertension or fluid retention associated with
heart failure, renal failure, pregnancy, or any
other causes that may aggravate macular edema.
• when the center of the macula is not involved,
visual acuity is excellent, and the patient
understands the risks
• Treatment of lesions close to the foveal avascular
zone may result in damage to central vision and
with time laser scars may expand and cause
further vision deterioration.
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36. Intravitreal triamcinolone
acetonide
IVTA has been shown to significantly reduce
macular edema and to improve visual
acuity, particularly. Action is maximal at 1
week, lasting 3-6 months. Patients should be
counseled about the risk (30-40%) of
increased intraocular pressure, of which
virtually all can be medically controlled.
Other adverse effects include a less than 1%
chance of retinal detachment, cataract, and
endophthalmitis
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37. Rx Intravitreal anti-VEGF
agents
• Ocular VEGF increases retinal vascular
permeability, causes breakdown of the
blood-retina barrier, and results in retina
edema. VEGF is up-regulated in diabetic
retinopathy. Three currently available
anti-VEGF agents are pegaptanib sodium,
ranibizumab, and bevacizumab
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39. CSME: Conclusion
• Untreated, 25-30% of patients with CSME
exhibit a doubling of the visual angle
within 3 years. Treated, the risk drops by
50%.
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40. Ocular Risk Factors Removal of
cataract
• DR may progress after cataract surgery.
Patient who have CSME, SNPDR or PDR
should undergo photocoagulation if the
media is sufficiently clear.
• If the cataract preclude retina evaluation
and treatment, prompt postoperative
retinal evaluation and treatment should
considered
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42. Follow up of dr
• Annually Normal
• Every 9 months Mild NPDR
• Every 6 months Moderate NPDR
• Every 6 months CSME
• Every 4 months Sever NPDR
• Every 2- 4 months CSME
• Every 2-3 months PDR
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44. Panretinal photocoagulation
• The benefit of early panretinal photocoagulation
at the severe nonproliferative or worse stage of
retinopathy is greater in patients with type 2
diabetes than in those with type 1.
• Other factors, such as poor compliance with
follow-up, impending cataract extraction or
pregnancy, and status of fellow eye will help in
determining the timing of the panretinal
photocoagulation.
• It is preferable to perform the focal
photocoagulation first, prior to panretinal
photocoagulation to prevent laser-induced
exacerbation of the macular edema
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46. DCCT 1993
• 1441 subjects with IDDM followed for 6.5
years. Randomized into strict and
conventional treatment. Strict control
group had average hbA1c 7.2%
Conventional 8.8%
• Strict control resulted in reduction of
retinopathy by 76%
• Reduced risk of progression by 54%
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47. Glycemic Control
• Total lifetime exposure to glycemia
was the principal determinant of the risk
of retinopathy
• There is no level ofglycemic control
below which a reduction in risk does not
occur. Improved control always reduced
risk of retinopathy retinmopathy
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48. Role of BP
• Hypertension is an independsant risk
factor for DR and its progression.
• UKPDS 1998:
– Tighter control of BP resulted in 34%
reduction in progression of DR.
– 47% reduced risk of loss 3 lines VA
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49. Role of cholesterol
• WESDR 19914: Higher serum cholesterol
increased risk of HE in type I
• ETDRS 1996: Higher serum lipids
increased risk of HE and loss of VA
• Elevated lipids may increase the
morbidity of diabetic macular edema.
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50. Pregnancy : DR
DR accelerate during pregnancy and
improve postpartum. Do not hesitate
to treat with laser when indicated.
FFA should be avoided in all but the
most difficult cases of macular
edema.
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51. Quiz #1 True of False
• People with diabetes are more likely than
people without diabetes to develop
certain eye diseases
True
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52. #2 True or False
• Diabetes eye diseases has early warning
signs
• FALSE
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53. #3 True or False
• People with diabetes should have yearly
eye examinations
• TRUE
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54. #4 True or False
• Diabetic retinopathy is caused by changes
in the blood vessels in the eye.
• TRUE. In some people, blood vessels in
the retina may swell and leak fluid. In
other people, abnormal new blood
vessels grow on the surface of the
retina.
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55. #5 True or False
• People with diabetes are at low risk for
developing glaucoma.
• FALSE
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56. #6 True or False
• Laser surgery can be used to halt the
progression of diabetes retinopathy
• TRUE. In laser surgery, laser light is used
to shrink the abnormal vessels or seal
leaking blood vessels. Laser surgery has
been proven to reduce the 5 year risk of
vision loss from advanced retinopathy by
more than 90%
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57. #7 True or False
• People with diabetes should have regular
eye examination through dilated pupils.
• TRUE
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58. #8 True or False
• Cataract are common among people with
diabetes.
• TRUE
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59. #9 True or False
• People who have good control of their
diabetes are not at high risk for diabetic
eye disease.
• FALSE. Even with good control of blood
glucose, there is still a risk of developing
diabetic eye disease. However studies
have shown that careful management of
blood sugar levels slows the onset and
progression of diabetic retinopathy.
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60. #10 True or False
• The risk of blindness from diabetic eye
disease can be reduced.
• TRUE. With early detection and timely
treatment, the risk of blindness from
diabetic eye disease can be reduced.
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61. “We choose our joys and
sorrows long before we experience
them.”
― Kahlil Gibran
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Notas del editor
OCT is not currently required to establish a diagnosis and is not prescribed by current practice guideline; however, OCT has gained widespread acceptance as an additional modality to help identify and evaluate macular pathology. Quantitative measurement of macular thickness and subjective analysis of the foveal architecture allow a precise and reproducible way to monitor macular edema.