Diabetic retinopathyTopic assignment : medical ophthalmology

D 1.1 30/3/2011

Diabetes Definition Risk factors Pathogenesis Classification : proliferative / non-

proliferative Sign & symptoms DDx & other ocular complication of

DM Treatment & follow up Screening for DR Apply with case study

Contents

Group of common metabolic disorders Caused by a complex interaction of genetics and environmental factors Lack of insulin hyperglycemia Diagnostic criteria : Fasting plasma glucose > 126 mg/dl Type 1 DM – Insulin-dependent diabetes (IDDM)

Results from pancreatic beta-cell destruction, usually leading to absolute or near total insulin deficiency

Type 2 DM - Non-insulin-dependent diabetes (NIDDM) Variable degrees of insulin resistance and impaired insulin secretion,

resulting in hyperglycemia and other metabolic derangements due to insufficient insulin action.

Diabetes mellitus

Long-standing hyperglycemia leads to multiple organ damage Macrovascular complications

Stroke Heart disease and hypertension Peripheral vascular disease Foot problems

Microvascular complications Diabetic eye disease : retinopathy and cataracts Renal disease Neuropathy Foot problems

Diabetes mellitus

Diabetic retinopathy

The most severe of ocular complications of diabetes Caused by damage to blood vessels of the retina,

leads to retinal damage Microvascular complication of longstanding diabetes

mellitus [1]

Most prevalence cause of legal blindness between the ages of 20 and 65 years

Common in DM type 1 > type 2

Duration of diabetes Most important Pt diagnosed before age 30 yr

50% DR after 10 yrs 90% DR after 30 yrs

Poor metabolic control Less important, but relevant to development and progression

of DR HbA1c ass. with risk

Pregnancy Ass with rapid progression of DR Predicating factors : poor pre-pregnancy control of DM, too

rapid control during the early stages of pregnancy, pre-eclampsia and fluid imbalance

Risk factors

Hypertension Very common in patients with DM type 2 Should strictly control (<140/80 mmHg)

Nephropathy Ass with worsening of DR Renal transplantation may be ass with improvement of

DR and better response to photocoagulation Other

Obesity, increased BMI, high waist-to-hip ratio Hyperlipidemia Anemia

Risk factors

Microvascular occlusion Microvascular leakage

Pathogenesis

Microvascular leakage

Degeneration and loss of pericytes

Plasma leakage

Intraretinal hemorrhageHard exudate(Circinate pattern)

Capillary wall weakening

microaneurysm

Retinal edema

Non-proliferative diabetic retinopathy

Right eye: Micro aneurysm, few flame-shaped and dot-blot hemorrhages and hard exudate [with hard exudate in macula area] , ไมพบneovascularization เขาไดกบ moderate non proliferative diabetic retinopathy Left eye: Micro aneurysm, numerous flame-shaped and dot-blot hemorrhage [more than 20 dots in 4 quadrant], hard exudate [with hard exudate in macula area] ไมพบ neovascularization เขาไดกบ severe non proliferative diabetic retinopathy

Microvascular occlusion

Neovascularizationand fibrovascular proliferation

VEGF

Increased plasma viscosityDeformation of RBCIncreased platelets stickiness

Decreased capillary blood flow

and perfusion

Endothelial cell damage and proliferationCapillary basement membrane

thickening

Retinal hypoxia

A-V shuntIRMA*

*intraretinal microvascular abnormalities

Proliferative

retinopathy

Rubeosis iridis

Tractional retinal detachmentVitreous hemorrhage

Classification

Non-proliferative diabetic retinopathy (NPDR)

Proliferative diabetic retinopathy (PDR)

Non-proliferative diabetic retinopathy

Mild NPDR Moderate NPDR Severe NPDR

Microaneurysm Retinal hemorrhage

“Dot or Blot” Spot “Flame or Splinter shape” hemorrhage

Hard exudate Cotton wool Spot Venous beading Intra-retinal microvascular abnormalities (IRMA)

Sign NPDR

Mild NPDR

Microaneurysm

Moderate NPDR

More microaneurysms Scattered hard exudates Cotton-wool spots

4-2-1 rule 4 quadrants of severe retinal hemorrhages 2 quadrants of venous beading 1 quadrant of IRMA

Very severe NPDR more than 1 of above

Severe NPDR

Localized saccular outpouchings of capillary wall red dots Focal dilatation of capillary wall where pericytes are

absent Fusion of 2 arms of capillary loop

Usually seen in relation to areas of capillary non-perfusion at the posterior pole esp temporal to fovea

The earliest signs of DR

Microaneurysm

Microaneurysm

Microaneurysms may leak plasma constituents into the retina

Scattered hyperfluorescent

Capillary or microaneurysm is weakened rupture intraretinal hemorrhages

Dot & blot hemorrhages Deep hemorrhage - inner nuclear layer or outer plexiform

layer Usually round or oval Dot hemorrhages - bright red dots (same size as large

microaneurysms) Blot hemorrhages - larger lesions

Flame-shape or splinter hemorrhages More superficial - in nerve fiber layer Absorbed slowly after several weeks Indistinguishable from hemorrhage in hypertensive

retinopathy May have co-existence of systemic hypertension BP must

be checked

Retinal Hemorrhage

Dot & blot VS splinter hemorrhage

Dot Spot VS Flame Shape

Dot Spot VS Flame Shape

Hemorrhage

Intra-retinal lipid exudates Yellow deposits of lipid and protein within the retina Accumulations of lipids leak from surrounding

capillaries and microaneuryisms May form a circinate pattern Hyperlipidemia may correlate with the

development of hard exudates

Hard exudate

White fluffy lesions in nerve fiber layer Result from occlusion of retinal pre-capillary

arterioles supplying the nerve fibre layer with concomitant swelling of local nerve fibre axons

Also called "soft exudates" or "nerve fiber layer infarctions"

Fluorescein angiography shows no capillary perfusion in the area of the soft exudate

Very common in DR, esp if pt with HT

Cotton Wool Spot

Hard Exudate VS Cotton Wool Spot

Dilatation and beading of retinal vein Appearance resembling sausage-shaped

dilatation of the retinal veins Sign of severe NPDR

Venous beading

Abnormal dilated retinal capillaries or may represent intraretinal neovacularization which has not breached the internal limiting membrane of the retina

Indicate severe NPDR rapidly progress to PDR

Intra-retinal microvascular abnormalities (IRMA)

Area of capillary non-perfusion

FA shows extensive areas of hypofluorescence due to capillary non-perfusion and venous beading

Macular ischemia Retinal capillary non-perfusion Progressive NPDR

Macular edema Increased retinal vascular permeability Seen in both NPDR and PDR Focal or diffuse or mixed Cause of visual loss in DR Ass with planning for treatment

Diabetic maculopathy

Focal macular edema

Diffuse macular edema

Macular ischemia

Clinical Significant Macular Edema (CSME)

1 of 3

Retinal edema within 500 microns of

centre fovea

Hard exudates within 500

microns of fovea if ass with

adjacent retinal thickening

Retinal edema > 1 disc diameter, any part is within 1 disc diameter of centre

of fovea

microaneurysm

microaneurysm and blot dot hemorrhage

blot dot hemorrhage

IRMAs

hard exudate

Cotton wool spots

Venous beading

5% of DM pt. Finding

Neovascularization : NVD, NVE Vitreous changes

Advanced diabetic eye disease Final stage of Uncontrolled PRD Glaucoma (neovascularization) Blindness from persistent vitreous hemorrhage,

tractional RD, opaque membrane formation,

Proliferative diabetic retinopathy

Neovascularization of disc

Fluorescein dye leakage is seen in neovascularized area

Neovascularization of elsewhere

Rubeosis iridis(neovascularisation of the iris)

Neovascular glaucoma

Vitreous changes

Tractional retinal detachment

Vitreous hemorrhage

NVE

Venous beadingIRMA

New vessels elsewhere

New vessels elsewhere

New vessels of the disc

New vessels of the disc (advanced)

Subhyaloid hemorrhage

Subhyaloid hemorrhage

Blurred or distorted vision or difficulty reading

Floaters Partial or total loss of vision

a shadow or veil across patient’s visual field Eye pain

Signs & symptoms of DR

Differential DiagnosisDiabetic retinopathy

Hypertensive retinopathy Radiation retinopathy Central retinal vein occlusion (CRVO) Branch retinal vein occlusion (BRVO) Ocular ischemic syndrome HIV-related retinopathy

Mostly miss

Hypertensive retinopathy

Radiation retinopathy

Central retinal vein occlusion (CRVO)

Branch retinal vein occlusion (BRVO)

For symptoms

Cataract Glaucoma Hypertensive retinopathy Radiation retinopathy Retinal vitreous obstruction Retinitis pigmentosa Senile macular degeneration

For cotton wool spot

Similar lesions are also caused by the alpha-toxin of Clostridium novyi

For Cotton wool spot

For Hard exudates

For Hemorrhage

Laser Photocoagulation** Vitreoretinal surgery** Intravitreal triamcinolone acetonide

Treatment

Prevention Treat underlying conditions

Control blood sugar – HbA1c < 7 Control blood pressure – SBP < 130 mmHg Control lipid profile – TG, LDL Correct anemia Control diabetic nephropathy

Pregnancy makes DR worsen

Medical therapy

Panretinal photocoagulation (PRP) High-risk PDR (3/4)

Vitreous or preretinal hemorrhage New vessels New vessels on optic disc or within 1,500 microns

from optic disc rim Large new vessels

Iris or angle neovascularization CSME

Laser

Focal or Grid CSME in both NPDR and

PDR Panretinal (PRP)

PDR

Photocoagulation

Inducing involution of new vessels Preventing vitreous hemorrhage and preventing

visual loss Limitations :

Patient must have clear lens and vitreous If cataract treat before laser PRP If vitreous hemorrhage vitrectomy + laser

photocoagulation

Laser panretinal photocoagulation (PRP)

Focal photocoagulation

Grid photocoagulation

Panretinal photocoagulation (PRP)

Indications for pars plana vitrectomy (PPV) in DR Severe persistent vitreous hemorrhage Progressive tractional RD (threatening or

involving macula) Combined tractional and rhegmatogenous RD Premacular subhyaloid hemorrhage Recurrent vitreous hemorrhage after laser PRP

Surgery

Pars plana vitrectomy (PPV) Membrane peeling (MP) Endolaser (EL) Fluid gas exchange (FGX)

SF6

C3F8

Vitreoretinal Surgery

Juvenile onset DM > 5 years then every year Adult onset DM at diagnosis (> 30) then every

year DM with pregnancy in first trimester then every

trimester

Screening for DR

Retinal abnormality Follow up

Normal or rare microaneurysms

Once a year

Mild NPDR q 9 months

Mod NPDR q 6 months

Severe NPDR q 4 months or laser

CSME q 2-4 months ** or laser

PDR q 2-3 months ** or laser

Follow up

Serious vision-threatening complications of DR

persistent vitreous hemorrhage tractional retinal detachment opaque membrane formation neovascular glaucoma

Treatment : complicated vitrectomy Poor prognosis

Advanced diabetic eye disease

Case scenario

Identification data : ผปวยหญงไทยค อาย 49 ป อาชพ คาขาย ภมลำาเนา อ.สงเมน จ. แพร

Chief complaint : ตาซายมว 6 เดอน กอนมารพ.

Case

6 เดอน กอนมารพ. ผปวยมอาการตาซายมว อาการคอยๆ เปน และเปนมากขนเรอยๆ ตาขวามองเหนปกตด ไมมปวดตา ปวดศรษะ ไมมตาแดง นำาตา-ขตาปรมาณเทาเดม อาการตาซายมว มองใกลมวพอๆ กบ มองไกล กลางวนมวพอๆ กบกลางคน ไมมแสงรอบดวงไฟ

1 สปดาหกอนมารพ. ตาซายมวมาก ประกอบกบ

เหนภาพซอน มวตถลอยไปมา ปดตาแลวมไฟกระพรบเปนบางครง ไมมปวดตา ปวดศรษะ จงมารพ.แพร ไดรบการรกษา แตอาการไมดขน จงสงตวมารกษาตอทรพ. มหาราช

Present illness

Underlying diseases : DM (poor controlled), HT (poor controlled)

Current medicationmetformin 500 mg 2*1 o pcNifedipine 20 mg 1*2 o pcAmlopine 10 mg 1*1 o pc

ไมเคยตรวจตามากอน ปฏเสธประวตการผาตดทตามากอน และอบตเหตท

ตาFamily history : แมเปน DM, ปฏเสธโรคตาใน

ครอบครว

Past history

GA : a middle aged woman with normal consciousness, good co-operation

V/S : T 36.9 BP 157/83 mmHg P 94/min RR 16/min

HENT : no discharge per ears, nose, no bleeding per gum, cervical LN cant’ be palpable

Heart : normal S1S2, no murmurs Lungs : clear & equal breath sounds

both lungsAbdomen : soft, not tenderExt : no pitting edema

Physical examination

OD OSVA c C 6/9 -2 PjVA c PH 6/9 -Lids & Lashes & Conjunctiva

Normal Normal

Cornea Clear ClearIrisLens Clear ClearAnterior chamber Normal depth, clear Normal depth, clearPupil 3 mmRTLBE RAPD -EOM Full FullIOP 20 20

Ocular examination

OD OSRed reflex Normal Normal Vessels Normal 2:3 Normal 2:3Background & Macula

Dot & blot hemorrhageNVE

dot blot hemorrhage ,

NVE , old hemorrhage

Fibrous and retinal break involve macula

Disc No NVD , C:D 0.3 No NVD , C:D 0.3

Fundus examination

Problem lists

Unilateral chronic painless visual loss Flashing and Floaters Poor controlled DM, poor controlled HT Dot & blot hemorrhages with NVE BE Fibrous & Retinal break involve macula LE

Problem list

Right eye : PDR Left eye : PDR with TRD+RRD

Provisional diagnosis

Hypertensive retinopathy Central retinal vein occlusion (CRVO) Branch retinal vein occlusion (BRVO) Ocular ischemic syndrome

Differential diagnosis

LE Pars plana vitrectomy membrane peeling Endolaser silicone oil injection

Management in this case

Indications for PPV in DRSevere persistent VHProgressive tractional RDCombined TRD & RRDPremacular subhyaloid hemorrhageRecurrent VH after laser PRP

DR รายนจำาเปนตองผาตด PPV

หรอไม?

Closed observe (q 2-3 months) Laser PRP PPV + MP + EL + SOI

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