DIABETIC

RETINOPATHY
Dr Paavan Kalra
Department of Ophthalmology,
S P Medical College,
Bikaner
• Diabetic retinopathy is a disorder of the retinal
vessels that eventually develops to some
degree in nearly all patients with long-
standing diabetes mellitus.
• Contributes 4.8% of the 37 million cases of
blindness throughout the world
• Most Common cause of bilateral severe visual
loss in working age group in US
• A recent study in urban population in south
India estimates prevalence of DM in adult
population as high as 28% & the prevalence
of DR in diabetics to 18%
RISK FACTORS
• Age at diagnosis of diabetes
• Duration
• Poor control of diabetes
• Pregnancy
• Hypertension
• Nephropathy
• Hyperlipidemia
• Obesity
• Anemia
• Smoking
• Cataract surgery
 PATHOGENESIS
Hyperglycemia

Intracellular sorbitol accumulation

Free radicals
Glycated end products
Disruption of ion channel function
Protein kinase C activation

Microangiopathy Hematological &

Direct effect
(damage to Rheological changes
on retinal cells
capillary wall)

Intra retinal Edema Microvascular Occlusion

hemorrhages Exudates Ischemia
IRMA
Neovascularization hemorrhage
Fibrosis Traction
• Angiogenic stimulators
Vascular Endothelial Growth Factor – A
Platelet Derived Growth Factor
Hepatocyte Growth Factor

• Angiogenesis inhibtors
Endostatin
Angiostatin
Pigment Epithelium Derived Factor
 CLASSIFICATION
Acc to Kanski 7th ed ( 2011)
Background Diabetic Retinopathy
Diabetic Maculopathy
Preproliferative Diabetic Retinopathy
Proliferative Diabetic Retinopathy
Advanced Diabetic Eye Disease

Most detailed classification was given by ETDRS study

NORMAL CAPILLARIES PERICYTE LOSS

MICRO ANEURYSM THROMBOSED

MICRO ANEURYSM
MICRO ANEURYSMS
 INTRARETINAL
HEMORRHAGES
EXUDATES
(HARD)
NORMAL ISCHEMIA
COTTON WOOL SPOTS
(“SOFT EXUDATES”)
INTRA RETINAL MICROVASCULAR
ABNORMALITIES
Venous Loop Venous Beading

Venous Segmentation Retinal arteriole obliteration

 PROLIFERATIVE DR

NEO
VASCULARIZATION
: DISC
 PROLIFERATIVE DR

NEO
VASCULARIZATION
: ELSEWHERE
 ADVANCED DIABETIC EYE DISEASE

• Pre retinal
hemorrhage
• Vitreous
hemorrhage
• Traction RD
• Rubeosis
Iridis
• Neovascular
Glaucoma
DIABETIC MACULOPATHY

FOCAL
DIFFUSE
ISCHEMIC

DIFFUSE FOCAL
ISCHEMIC MACULOPATHY
HIGH RISK PDR CONCEPTS FROM
DRS & ETDRS

NVD > 1/4 - 1/3 disc area

NVD < 1/4-1/3 disc area

with pre retinal or vitreous hemorrhage

NVE >1/2 disc area

with pre retinal or vitreous hemorrhage
CLINICALLY SIGNIFICANT CONCEPTS FROM
MACULAR EDEMA DRS & ETDRS
Work Up - History
Duration of diabetes
Past glycemic control (hemoglobin A1c)
Medications
Systemic history (e.g., obesity, renal
disease, systemic hypertension, serum
lipid levels, pregnancy)
Ocular history
Workup : Examination

Visual acuity
Measurement of IOP
Gonioscopy when indicated (for
neovascularization of the iris or increased
IOP)
Slit-lamp biomicroscopy
Dilated funduscopy including stereoscopic
examination of the posterior pole
Examination of the peripheral retina and
vitreous, best performed with indirect
ophthalmoscopy or with slit-lamp
biomicroscopy, combined with a contact
lens
Work up : Ophthalmic Investigations
• Fundus Photography
• Fluorescein Angiography
to guide treatment of CSME
to identify Ischemic maculopathy
IRMA vs NV
evaluation in hazy media
not a screening modality
not a routine investigation
• Optical Coherence Tomography
Retinal thickening
assessment & Monitoring of edema
vitreo macular traction
• USG – B scan
INTERNATIONAL CLINICAL DIABETIC
RETINOPATHY
DISEASE SEVERITY SCALE
 INTERNATIONAL CLINICAL
DIABETIC MACULAR EDEMA
DISEASE SEVERITY SCALE
 Treatment Modalities

• LASER Photocoagulation (ARGON)

CSME – Focal & Grid
PDR with HRC – Pan Retinal Photocoagulation
• Other LASERS for CSME – Frequency doubled Nd YAG
Micro pulse Diode
• INTRA VITREAL anti VEGF – Bevacizumab, Ranibizumab
• INTRA VITREAL steroids – Triamcinolone acetonide
• PARS PLANA VITRECTOMY

Strict Glycemic Control delays the

onset and progression
 Deferral of focal photocoagulation

• 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.
• Adjunctive treatment may be considered-
intravitreal corticosteroids or antivascular
endothelial growth factor agents (off-label
use).
 Panretinal photocoagulation
• may be considered as patients approach
high-risk PDR.
• 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.
• Screening of all cases above the age of 40
years irrespective of status of diabetes
THANK YOU