DIABETIC

RETINOPATHY
DATIN DR SAKINAH BT ZAKARIAH

PRESENTED BY:
- NUR ALIS NAJWA (1129200919450)
- MUHAMMAD ANAS (1129200919449)
- MALIHA SULTANA (1129200919499)
Introduction

• Diabetic Retinopathy (DR) is a condition with progressive

retinal damage that occurs due to microvascular complication
of diabetes mellitus.

• All diabetics are at risk of developing DR

• Within 20 years of diagnosis of DM, nearly ALL with T1DM and

2/3 of T2DM will have some degree of DR

• DR is the commonest cause of visual loss among working

adults in Malaysia
Cause of blindness (National Eye
Survey II 2014)
Prevalence of DM

• Prevalence is higher in Kedah

(25.4%), followed by Perlis
(20.6%) and Johor (19.8%).
Lowest in Sabah & Sarawak

• Highest among Indians, followed

by Malay and Chinese

• WHO estimates that in year 2030,

Malaysia would have 2.48 million
people with DM
 Prevalence & Incidence of DR

• D R is a le adin g c o mplic atio n o f DM with pre vale n c e wo rldwide ran ge s f ro m

6.8 t o 44.4%

• I n Ma lays ia, th e pre vale n c e o f D R f ro m 2007 diabe tic e ye re gis tr y was 36.8%

• P ro po r t io n o f patie n ts with s igh t th re ate n ing DR was 15.6% an d pro po r tio n o f

pat ie n t with blin dn e s s was 9.0%

• No re t rie vable data o n th e pre vale n c e o f DR in c h ildre n an d ado le sc e n ts in

Ma lays ia

S t u dy in Au stralia s h o ws pre vale n c e o f e arly D R in

c h ildre n < 11 ye ars was 8% c o mpare d to 25% > 11y / o

Quality of Life

• Reduce vision-related function

• Reduces independence and productivity

• Limits social interactions
• Restricts ability to perform daily functions

• Patient’s ability to manage their diabetes is also aff ected

• Difficulty reading nutritional information on food
• Difficulty taking insulin / medications
• Difficulty exercising
Why DR Is Common??
 Risk factors

 Duration of diabetes

• It is the most impor tant risk factor.

• In patients diagnosed with diabetes before the age of 30 years, the incidence of DR
af ter 10 years is 50% and af ter 30 years 90% .

 Poor control of diabetes

 Pregnancy

• The risk of progression is related to the severity of DR in the fi rst trimester

 Hypertension

 Sex: incidence is more in females than males

 Others: smoking, obesity and hyperlipidemia

 Pathophysiology

 Diabetic retinopathy is a
microangiopathy aff ecting retinal
precapillary arterioles, capillaries and
venules

 Retinopathy has features of:

• Microvascular leakage (mild-mod NDPR)

• Microvascular occlusion (severe NDPR-

PDR)
Microvascular Occlusion
Microvascular Leakage
 Clinical Presentation

 Patients might be asymptomatic in the early stages

 As the disease progresses, the symptoms include:

• Blurred vision

• Floaters and fl ashes

• Distor ted vision

• Dark areas in the vision

• Poor night vision

• Impaired color vision

• Par tial or total loss of vision

Signs seen in diabetic retinopathy on fundus
examination:

 Microaneur ysm : macular area (the earliest

detectable lesion)

 Retinal hemorrhage : both deep (dot and blot

hemorrhages) and super fi cial hemorrhages
(fl ame-shaped)

 Hard exudates : yellowish-white waxy-looking

patches are arranged in clumps or in circinate
pattern. These are commonly seen in the macular
area

 Cotton wool spot : accumulations of neuronal

debris within the ner ve fi ber layer

 Macular oedema

 Venous and ar terial changes

 Intraretinal microvascular abnormalities

(IRMA)
Diabetic Retinopathy
Grading
NUR HAFIZAH BINTI NASIRUDIN
1129200919446
1.Retinal thickening at or within
500 μm of the center of the fovea
2.Hard exudates at or within 500
μm of the center of the fovea if
adjacent to an area of retinal
thickening
3.Retinal thickening of at least 1
disc area any portion of which is
within 1500 μm (approximately 1
disc diameter) from the center of
the fovea
1 2

3 4
Screening of
Diabetic Retinopathy
MALIHA SULTANA
 Screening tools

Binocular
indirect
ophthalmoscope
Direct ophthalmoscope
(BIO)
PAN-ophthalmoscope
 Mydriatic/non-mydriatic fundus camera

Slit lamp biomicroscope

Sensitivity and Specifi city of the screening tools
• NICE recommends that
DR screening modalities
should have a sensitivity of at
least 80%, a specificity of
at least 95% and a technical
failure rate of no greater than
5%.

• Non-mydriatic fundus camera

has high sensitivity and
specificity. It eliminates
the need for pupillary
dilatation, promoting
compliance, efficiency and
safety.
 Pupillary Dilatation

• Non-mydriati c fundus photography generally doesn't require pupil dilatati on

if performed in an adequately darkened room .
• However, in cases of small pupil and ungradable photos, pupillary dilatati on can
increase the sensiti vity of screening by over 50%.
• Be aware of possible side eff ects of pupillary dilator (tropicamide 1%). It
may induce acute angle closure glaucoma in high risk individuals (history
of glaucoma and shallow anterior chamber). But, the use of tropicamide 1% alone
has not been reported to cause this complicati on.
Examination and Grading of Diabetic Retinopathy by
Healthcare Professionals
EXAMINATION SCHEDULE
• Early detection of sight threatening
retinopathy by regular examination is
the key to reduce visual loss and
blindness from DR.
Treatment and Management
of Diabetic Retinopathy
General

1. Patient education to comply with review and treatment schedules

to optimize the visual outcomes

2. Diabetic control should be optimized

3. Other risk factors (systemic hypertension and hyperlipidemia)

should be controlled

4. Smoking should be discontinued and diet modifi cation and

exercised should be practiced.

5. The key of prevention of diabetic retinopathy is patient education

and long term control of blood sugar.
1. DIABETIC MACULAR EDEMA (DME)

 Intraocular steroids

 Intraocular anti-vascular endothelial growth factor (anti-

VEGF)

 Laser focal /grid ( laser photocoagulation)

 1. DIABETIC MACULAR EDEMA (DME)
(INTRAVITREAL STEROIDS/ANTI-VEGF INJECTION)

DRUGS FOR INTRAVITREAL DRUGS FOR INTRAVITREAL

STEROIDS ANTI-VEGF
1. Triamcinolone acetate 1. Ranibizumab
2. Dexamethasone 2. Bevacizumab
3. Fluocinolone 3. Pegaptanib sodium
4. Aflibircept
 1. DIABETIC MACULAR EDEMA (DME)
(INTRAVITREAL STEROIDS/ANTI-VEGF INJECTION)

INTRAVITREAL STEROIDS INTRAVITREAL ANTI-VEGF

Intravitreal steroids are used for their Intravitreal anti-VEGF are used to
anti-inflammatory, angiostatic and decrease the abnormal and harmful
anti-permeability effects. new blood vessels formation.

Decrease growth
Block the VEGF molecules
factors

Stabilises endothelial Decrease the abnormal and harmful

cell tight junctions new blood vessels formation

Reduces permeability Decrease leakage and swelling of

to water and soluites the retina
1. DIABETIC MACULAR EDEMA (DME)
(LASER FOCAL/GRID)

Focal laser treatment is used Grid laser treatment is used to

to treat macular edema due to treat macular edema due to
focal leakage diffuse leakage

Aim
1. To stimulate fluid absorption and to ablate microaneurysm
2. Reduce risk of moderate visual loss
- The treatment uses a fi nite
amount /power/distribution of
laser spots which can seal leaky
aneurysms /vessels by creating a
microscopic scar

- Once leakage stops or reduces, the

remaining fl uid will be reabsorbed
into the eye leading to stabilization
or improvement of visual acuity.
2. NON-PROLIFERATIVE DIABETIC
RETINOPATHY (NPDR)

MILD AND MODERATE NPDR:

- Strict metabolic control of diabetes

- Control of obesity and malnutrition

- Control of hypertension

- Aspirin has been advised to reduce platelet stickiness

- Regular check up for blood sugar, blood pressure and fundus

monitoring at least every 3 months

SEVERE NPDR

- LASER SCATTERED PAN RETINAL PHOTOCOAGULATION

 SEVERE NPDR
LASER SCATTERED PAN RETINAL PHOTOCOAGULATION

• It is 360 degree pan retinal photocoagulation (PRP) given with

2 burns width occurring as distance between 2 separate burns

• Total of 500 to 1000 burns are required for complete scatter

PRP.
 3. PROLIFERATIVE DIABETIC
RETINOPATHY (PDR)
(PAN RETINAL PHOTOCOAGULATION)

 PRP place laser spots in the peripheral retina for 360 degrees
sparing the central 30 degrees of the retina

 Initial treatment consisted of 1200 to 1600 burns of moderate

intensity, 500 micro-meter size.
 3. PROLIFERATIVE DIABETIC
RETINOPATHY (PDR)
(PAN RETINAL PHOTOCOAGULATION)

MECHANISM OF ACTION
Photocoagulation of
 PRP may improve oxygenation of ischemic inner layer retina
retinal layers by destroying some of the metabolically
highly active photoreceptor cells

 Relieving hypoxia Reduce metabolic

and oxygen demand
 Removing stimulus for vascular endothelial growth
factors.

Regression of new
vessel
4. ADVANCED DIABETIC EYE DISEASE
(ADED)

 Intraocular steroids

 Intraocular anti-VEGF

 Pars plana vitrectomy with endolaser

 4. ADVANCED DIABETIC EYE DISEASE
(ADED)
(PARS PLANA VITRECTOMY AND ENDOLASER)

INDICATION: macular
edema is associated with
tangential traction from
thickened and taut posterior
hyaloid (vitreomacular
traction)
SUMMARY OF TREATMENT FOR
DIABETIC RETINOPATHY
THANK YOU