DIABETIC RETINOPATHY

1. Adverse risk factors

2. Pathogenesis
5. Clinically significant macular oedema
6. Preproliferative diabetic retinopathy
3. Background diabetic retinopathy
4. Diabetic maculopathies
W Focal
W Diffuse
W Ischaemic
7. Proliferative diabetic retinopathy
Adverse Risk Factors
1. Long duration of diabetes
W Obesity
W Hyperlipidaemia
2. Poor metabolic control
3. Pregnancy
4. Hypertension
5. Renal disease
6. Other
W Smoking
W Anaemia
Pathogenesis of diabetic retinopathy
Consequences of retinal ischaemia
Consequences of chronic leakage
Location of lesions in background
diabetic retinopathy
Signs of background diabetic retinopathy
Microaneurysms usually
temporal to fovea
Intraretinal dot and
blot haemorrhages
Hard exudates frequently
arranged in clumps or rings
Retinal oedema seen as
thickening on biomicroscopy
Focal diabetic maculopathy
W Circumscribed retinal thickening
W Associated complete or incomplete
circinate hard exudates
W Focal leakage on FA
W Focal photocoagulation
W Good prognosis
Diffuse diabetic maculopathy
W Diffuse retinal thickening W Generalized leakage on FA
W Guarded prognosis
W Grid photocoagulation W Frequent cystoid macular oedema
W Variable impairment of visual acuity
Ischaemic diabetic maculopathy
W Macula appears relatively normal
W Capillary non-perfusion on FA
W Poor visual acuity W Treatment not appropriate
Clinically significant macular oedema
Hard exudates
within 500 3m
of centre of
fovea with adjacent
oedema which may
be outside 500 3m
limit
Retinal oedema one disc area or larger any
part of which is within one disc diameter
(1500 3m) of centre of fovea
Retinal oedema
within 500 3m
of centre of fovea
Treatment of clinically significant
macular oedema
W For microaneurysms in centre of hard
exudate rings located 500-3000 3m
from centre of fovea
Focal treatment
W Gentle whitening or darkening of
microaneurysm (100-200 3m, 0.10 sec)
W For diffuse retinal thickening located more
than 500 3m from centre of fovea and
500 3m from temporal margin of disc
Grid treatment
W Gentle burns (100-200 3m, 0.10 sec),
one burn width apart
Preproliferative diabetic retinopathy
Treatment - not required but watch for proliferative disease
W Cotton-wool spots
W Venous irregularities
W Dark blot haemorrhages
W Intraretinal microvascular
abnormalities (IRMA)
Signs
Proliferative diabetic retinopathy
W Flat or elevated
W Severity determined by comparing with area of disc
Neovascularization
Neovascularization of disc NVD
W Affects 5-10 of diabetics
W IDD at increased risk (60 after 30 years)
Neovascularization elsewhere NVE
Indications for treatment of proliferative
diabetic retinopathy
NVD > 1/3 disc in area Less extensive NVD
+ haemorrhage
NVE > 1/2 disc in area
+ haemorrhage
W Spot size (200-500 3m) depends
on contact lens magnification
W Gentle intensity burn (0.10-0.05 sec)
W Follow-up 4 to 8 weeks
W Area covered by complete PRP W Initial treatment is 2000-3000 burns
Laser panretinal photocoagulation
Assessment after photocoagulation
W Persistent neovascularization
W Haemorrhage
Poor involution
W Re-treatment required
W Regression of neovascularization
W Residual ghost` vessels or
fibrous tissue
Good involution
W Disc pallor
Indications for vitreoretinal surgery
Retinal detachment involving
macula
Severe persistent vitreous
haemorrhage
Dense, persistent premacular
haemorrhage
Progressive proliferation
despite laser therapy