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( Diabitc Retinopathy )

Chronic Hyperglycemia

5 Pathway :

1- Advanced Glycation Of End Profduct :

Glucose ‫ ﻳﺼﻴﺮ ﻓﻴﻬﺎ‬Lipid ‫ واﻟـ‬Protin ‫اﻟـ‬

2- Protein Kinase C Activation :

Nuro ‫ ﻃﺒﻴﻌﻲ ﻓﻲ اﻟﺠﺴﻢ ﺑﺲ ﻣﺨﺼﺺ ﻟﻠـ‬Enzyme ‫ﻫﻮ‬

‫ ﻣﻊ اﻟﺴﻜﺮي ﻳﺼﻴﺮ ﻟﻪ‬، ‫ ﻳﺴﺎﻋﺪ ﻓﻲ ﻧﻘﻞ اﻹﺷﺎرات‬System
‫ وﻳﺄﺛﺮ‬NuroSystem ‫ أﻛﺜﺮ ﻣﻦ اﻻزم ﻓﻴﺨﺮج ﻣﻦ اﻟـ‬Actevation
. ‫ﻋﲆ وﻇﺎﺋﻒ اﻟﺠﺴﻢ اﻟﺜﺎﻧﻴﺔ‬
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3- Inflammation :

Chronic Low Grade ‫اﻛﺘﺸﻔﻮا ﻣﻊ اﻟﺴﻜﺮي ﻳﺤﺼﻞ‬

‫ وﺗﺴﺪ‬Inflammatory Cells ‫ وﺗﻮدي ﻟﻮﺟﻮد‬Inflamation
VEGF ‫ ﻓﺘﺒﺪأ اﻟـ‬Tissue Hypoxia ‫اﻷوﻋﻴﺔ اﻟﺪﻣﻮﻳﺔ وﺗﻌﻤﻞ‬

$ Pathogenesis :

A- Retinal Neurodegenration ( First )Nwely

Discovered :
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Inner Retina ‫ ﻓﻲ اﻟـ‬Thining ‫ ﻻﺣﻀﻮ وﺟﻮد‬OCT ‫ﻓﻲ اﻟـ‬

Nuroprotective ‫ ﻋﺸﺎن ﻛﺬا ﻳﻌﻤﻠﻮن أﺑﺤﺎث ﻋﲆ‬Layers
. Ca Chanel Blockers ‫ زي اﻟـ‬Drugs

B- Retinal Capillary Leakage :

- Microvascular Leakage And Occlusion :

‫ ﺑﺲ ﻟﻮ زاد ﻳﺪﺧﻞ ﻋﲆ اﻟـ‬Cappilary ‫ﻳﺤﺪث ﻋﲆ ﻣﺴﺘﻮى اﻟـ‬

. Musculer Layer ‫ ﻻن ﺣﻮﻟﻬﺎ‬Arteriols ً‫ و ﻧﺎدر ﺟﺪا‬Venule

‫ و‬Basment Membrane ‫ ﻳﺘﻜﻮن‬Cappilary Structuer ‫اﻟـ‬

Basment ‫ ﺗﺤﻤﻲ اﻟـ‬Pericyte ‫ﻣﺤﺎط ﺑـ‬Endothlioum
Membrane
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‫ ﻟﺬاﻟﻚ ﻣﻦ أﺳﺒﺎب اﻟـ‬، Pericyte ‫ ﺗﺤﺎﻓﻆ ﻋﲆ اﻟـ‬Muler Cell ‫اﻟـ‬

‫ اﻟﻠﻲ‬Retinal Neurodegenration ‫ ﻫﻮ اﻟـ‬Leakeage
. ‫ﻳﺤﺪث أول ﺷﻲء‬

Plasma Leak ‫ وﺗﻌﻤﻞ‬Capillary Wall Weakening ‫ﻳﺼﻴﺮ‬

Hard Exudate ‫ وﺑﻌﺪﻳﻦ‬Retinal Edema ‫وﺑﻌﺪﻳﻦ‬

Arteriols ‫ ﻳﻜﻮن ﻓﻲ اﻟـ‬Hypertinsive Retinopathy ‫اﻟـ‬

Basment ‫ ﻳﺨﻠﻲ اﻟـ‬inflammation ‫ ﺑﺴﺒﺐ اﻟـ‬Oclusions ‫اﻟـ‬

Lumen ‫ وﺑﺎﻟﺘﺎﻟﻲ ﻳﻘﻠﻞ ﺣﺠﻢ اﻟـ‬Thick ‫ ﻳﺼﻴﺮ‬membrane
، Endothelium ‫ أﻳﻀﺎً ﻳﻐﻴﺮ ﺷﻜﻞ اﻟـ‬، ‫وﺑﺎﻟﺘﺎﻟﻲ ﻳﺴﺒﺐ إﻧﺴﺪاد‬
. ‫ ﻳﻜﺒﺮ ﺣﺠﻤﻬﺎ‬Platelets ‫ واﻟـ‬RBC ‫وأﻳﻀﺎً ﻳﺤﺼﻞ ﺗﻐﻴﺮات ﻓﻲ اﻟـ‬
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‫ وﻧﺎدرا ﻳﺤﺼﻞ‬Venule ‫ و اﻟـ‬Capilerays ‫ﻟﻴﻪ ﻳﺤﺪث ﻓﻲ ﻓﻲ اﻟـ‬

‫ ؟‬Arteroles ‫ﻓﻲ اﻟـ‬

Basment ‫ ﺣﻮل اﻟـ‬muscular Layer ‫ﻷﻧﻬﺎ ﺗﺘﻤﻴﺰ ﺑﻮﺟﻮد‬

. Muller ‫ ﻟﻠـ‬damage ‫ ﻣﻬﻤﺎ ﺣﺪث‬، membrane

: Microvascular Leakage ‫ﺷﺮح اﻟـ‬

‫ أو ﺑﺴﺒﺐ اﻟـ‬Direct ‫ ﺳﻮاء ﺑﺸﻜﻞ‬Percyte Loss ‫ﺑﺴﺒﺐ اﻟـ‬

. Muller ‫ ﻓﻲ اﻟـ‬neurodegenerative

‫ وﺑﺴﺒﺐ ﻗﻮة اﻟﻀﻐﻂ ﻳﻌﻤﻞ‬، ‫ ﺿﻌﻴﻒ‬Wall ‫ﻳﺨﻠﻲ اﻟـ‬

‫ وﺗﺘﺠﻤﻊ‬Plasma Leakage ‫ ﻳﻌﻤﻞ‬، Microanuresum
Hard ‫ ﻳﻌﻤﻞ‬Lipofucin ‫ وﺗﺘﺠﻤﻊ اﻟـ‬Retinal Edema ‫وﺗﺘﻜﻮن‬
Exudate
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Thrombosis ‫ ﻳﺼﻴﺮ ﻟﻬﺎ‬Microaneurysm ‫ﻓﻲ اﻟﻐﺎﻟﺐ اﻟـ‬

. ‫وﺗﻨﻘﻔﻞ‬

: Microvascular Occlusion ‫ﺷﺮح اﻟـ‬

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Atrerules ‫ ﺗﻘﻮم اﻟـ‬، ‫ ﺑﺴﺒﺐ اﻹﻧﺴﺪاد‬Hypoxia ‫ﺑﻌﺪ ﻣﺎ ﻳﺼﻴﺮ‬

IRMA ‫ وﺗﻜﻮن اﻟـ‬Venules ‫ ﺗﺮوح ﻟﻠـ‬Coolaterals ‫ﺗﻄﻠﻊ‬
Cotton ‫ وﻳﻈﻬﺮ ﻓﻲ ﻫﺬا اﻟﻤﻜﺎن اﻟـ‬، AV Shunt ‫ﻧﺴﻤﻴﻬﺎ اﻟـ‬
. Wool Spot

Note : Cotton Wall Spot

Nerve ‫ ﻓﻲ اﻟـ‬Ischemia ‫ وﻫﻲ ﻋﺒﺎرة ﻋﻦ‬ill defind ‫ﺷﻜﻠﻬﺎ‬

‫ ﺑﺴﺒﺐ اﻟـ‬Axon ‫ ﻓﻲ اﻟـ‬Edema ‫ ﻓﻴﺤﺼﻞ‬Fiber Layer
Nerve Fiber ‫ واﻟﻤﻔﺮوض اﻟـ‬، Pale ‫ ﻓﻴﺼﻴﺮ ﻟﻮﻧﻬﺎ‬Ischemia
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‫ﺷﻔﺎﻓﺔ‬

‫ ﺳﻤﻴﻜﺔ‬Nerve Fiber Layer ‫ ﺗﺤﺼﻞ اﻟـ‬OCT ‫ﻓﻲ اﻟـ‬

Localized Thikning in Nerve Fiber Layer

، VEGF ‫ ؟ ﺗﻔﺮز اﻟﺸﺒﻜﻴﺔ اﻟـ‬complete occlusion ‫ﻟﻮ ﻛﺎن‬

‫ وﻣﻊ اﻟﺰﻣﻦ ﻳﺘﻜﻮن‬، Neovascularization ‫وﺗﺤﻔﺰ إﻧﺸﺎء‬
. Traction ‫ وﺗﻌﻤﻞ‬Fibrovascular Proliferation

Leak ‫ وﺟﺪارﻫﺎ ﻗﻮي وﻣﺎ ﺗﻌﻤﻞ‬Retina ‫ ﺻﺪﻳﻘﺔ ﻟﻠـ‬IRMA ‫اﻟـ‬

. Neovascularization ‫ﺑﻌﻜﺲ اﻟـ‬
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- Venous Changes :
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‫اذا ﺗﺪﻣﺮت أﻏﻠﺐ اﻟـ ‪ capillaries‬ﻳﻮﺻﻞ اﻟﻀﺮر ﻟﻠـ ‪Venuoles‬‬

‫) ﻳﻌﻨﻲ ‪ Ischemia‬ﻛﺒﻴﺮة ( وﺗﻜﻮﻳﻨﻬﺎ ﻳﺸﺒﻪ اﻟـ ‪، capillaries‬‬
‫وﻫﺬه أﻛﺜﺮ ﻋﻼﻣﺔ ﻋﲆ ﺣﺪوث اﻟـ ‪. PDR‬‬

‫ﻓﻴﺤﺼﻞ ‪ Looping‬و ‪ ) Beading‬ﻣﺜﻞ اﻟـ ‪( Microanuresm‬‬

‫اذا زادت اﻟـ ‪ Beading‬ﻳﺤﺼﻞ اﻟـ ‪ ) Segmentation‬أﺟﺰاء‬

‫ﻛﺒﻴﺮة ﻣﻦ اﻟـ ‪ Venules‬ﺗﻜﻮن ‪ Dilated‬و أﺟﺰاء ﺻﻐﻴﺮة ﺗﻜﻮن‬
‫‪( Normal‬‬
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Note : Duration is Most Important Risk factor .

Note : Hyperlipedemia increase Haed Exudate .

Note : Anemia Nwelly Discoverd .

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