Diabetic Retinopathy

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2 : Common systemic diseases affecting the eye Infectious Toxoplasmosis Toxocariasis TB Syphilis Leprosy HIV CMV Non-infectious Endocrine – diabetes, thyroid Connective tissue disease – RA/ SLE/ Wegeners/ PAN/ Systemic sclerosis Vasculitides (GCA) Sarcoidosis Behcet’s Disease Vogt Koyanagi Harada syndrome Phakomatoses
3 : Diabetes mellitus Thyroid eye disease Hypertension
4 : DIABETES MELLITUS -A METABOLIC DISORDER -ENDOGENOUS INSULIN DEFICIENCY/RESISTANCE -SUSTAINED HYPERGLYCEMIA Types: -type 1 -autoimmune destruction of insulin- producing beta cells of the pancreas. -type 2 - insulin resistance and relative insulin deficiency.
5 : Clinical features Asymptomatic Symptomatic : polydipsia, polyuria, weight loss, recurrent infection Complications -macrovascular : IHD, stroke, peripheral vascular disease -microvascular : nephropathy, neuropathy, retinopathy
6 : What is diabetic eye disease? Diabetic eye disease refers to a group of eye problems that people with diabetes may face as a complication of diabetes. All can cause severe vision loss or even blindness. Diabetic eye disease may include: Diabetic retinopathy—damage to the blood vessels in the retina. Cataract glaucoma
7 : Diabetes affects more than 230 million people worldwide. If the current trend continues, 370 million people worldwide are expected to have diabetes by the year 2030. WHO People with diabetes are estimated to be 25 times more likely to develop blindness than people without diabetes. WHO 33% of the total diabetic population will suffer from some form of diabetic retinopathy, and a third of these will have sight-threatening complications. WHO The prevalence of diabetic retinopathy increases with longer durations of diabetes. NEI After 20 years of diabetes, nearly all patients with Type I diabetes and >60% of patients with Type II diabetes have some degree of retinopathy. ADA Prevalence of diabetic retinopathy among NIDDM aged 40 years and above with duration of more than 5 years is 14.6%. Second National Health and Morbidity Survey - Diabetes DIABETES MELLITUS statistic
8 :
9 : CLINICAL PRESENTATION Asymptomatic - detect by screening Advance stage: Visual acuity loss Floaters Blurred vision-macula edema
10 : Pathogenesis HYPERGLYCAEMIA Shunts excess glucose into the aldose reductase pathway Sugars into alcohol (eg, glucose into sorbitol, galactose to galactitol). Injury to Intramural pericytes of retinal capillaries Loss of autoregulation Weakness of capillary walls Microaneurysm Dot and Blot hemorrhage (d) Flame-shaped hemorrhages (s) Increased permeability Leakage of fluid and proteinaceous material Retinal edema & hard exudates +/-Macula Accumulation ruptured
11 : Retinal findings in background diabetic retinopathy, including blot hemorrhages (long arrow), microaneurysms (short arrow), and hard exudates (arrowhead).
12 : Pathogenesis Closure of retinal capillaries occurs, leading to hypoxia Focal ischaemia Cotton-wool spots Vasoproliferative factors Extensive ischaemia Neovascularization Hemorrhage into the vitreous cavity or the preretinal space. Tractional retinal detachments Rubeosis iridis 2° Glaucoma Nerve fiber infarction As the disease progresses vitreous traction Regress,avascular fibrous tissue VEGF
13 : Neovascularization
14 : Neovascular Glaucoma
15 : Neovascular glaucoma
16 : Cotton wool spot
17 : High intracellular osmolarity (in tissues that do not need GLUT-4: (vessels, lens, nerves) HYPERGLYCAEMIA Cataracts III*, IV, VI Neuropathy PLR preserved early stage Pathogenesis
18 : Grade of Retinopathy (by early traetment diabetic retinopathy study,ETDRS) Non-proliferative diabetic retinopathy(NPDR): mild, moderate, severe Proliferative diabetic retinopathy(PDR) Diabetic maculopathy
19 : Microaneurysms-outpouching capillary due to pericyte loss Dot and blot hemorrhages: as microaneurysms rupture in the deeper layers of the retina Flame-shaped hemorrhages are splinter hemorrhages that occur in the more superficial nerve fiber layer. Retinal edema and hard exudates are caused by the breakdown of the blood-retina barrier, allowing leakage of serum proteins, lipids, and protein from the vessels. Cotton-wool spots are nerve fiber layer infarctions from occlusion of precapillary arterioles. Venous loops and venous beading frequently occur adjacent to areas of nonperfusion and reflect increasing retinal ischemia IRMA are remodeled capillary beds without proliferative changes. These collateral vessels do not leak on fluorescein angiography and can usually be found on the borders of the nonperfused retina.
20 : Non-proliferative diabetic retinopathy(NPDR) mild : at least 1 microaneurysm Moderate: presence of hemorrhages, microaneurysms, and hard exudates. With this condition, venous beading, and intraretinal microvascular abnormalities (IRMA) occur less frequently than with severe NPDR. Severe: (4-2-1) is characterized by hemorrhages and microaneurysms in 4 quadrants, with venous beading in at least 2 quadrants and IRMA in at least 1 quadrant. NPDR may occur with diabetic maculopathy.
21 : mild moderate severe
22 : Proliferative diabetic retinopathy Neovascularization-hallmark. It most often occurs near the optic disc (neovascularization of the disc [NVD]) within 3 disc diameters of the major retinal vessels (neovascularization elsewhere [NVE])
23 : Proliferative DR Neovascularization of disc = NVD Neovascularization elsewhere = NVE
24 : Boat-shaped preretinal hemorrhage associated with neovascularization elsewhere.
25 : Fibrovascular proliferations within the vitreous cavity
26 : Clinically significant macular edema is defined as any of the following: Retinal thickening located 500 µm or less from the center of the foveal avascular zone (FAZ) Hard exudates with retinal thickening 500 µm or less from the center of the FAZ Retinal thickening 1 disc area or larger in size located within 1 disc diameter of the FAZ Diabetic maculopathy
27 : Diabetic maculopathy Exudative maculopathy
28 : Blood glucose control: *lifestyle and behavior modification diet control smoking exercise weight reduction *medication Other medical factors should be addressed: *hypertension Regular follow-up Photocoagulation Vitrectomy Intravitreal Anti-VEGF Management
29 : PHOTOCOAGULATIOn Argon laser Diabetic maculopathy focal photocoagulation: edema is due to leakage of specific microaneurysms, the leaking vessels are treated directly grid photocoagulation: foci of leakage are nonspecific Proliferative diabetic retinopathy Panretinal laser photocoagulation: the entire retina is treated with laser, except the macular area. Complications :  loss of peripheral vision, worsening visual acuity, reduced night vision, and hemorrhaging in the eye.
30 : Panretinal Grid pattern
31 : How Does Photocoagulation Work?! destroying the hypoxic retina decreases the production of vasoproliferative factors, such as VEGF, thus reducing the rate of neovascularization.
32 : severe persistent vitreous hemorrhage, tractional retinal advisable for eyes with vitreous hemorrhage that fails to resolve spontaneously within 6 months. Purpose: remove the blood to permit evaluation and possible treatment of the posterior pole, to release tractional forces that pull on the retina, to repair a retinal detachment, and to remove the scaffolding into which the neovascular complexes may grow. complications : cataract, recurrent vitreous hemorrhage, further retinal detachment. Vitrectomy
33 : Intravitreal Anti-VEGF Bevacizumab (Avastin) has been used to treat vitreous hemorrhage. In addition, this agent has been used to treat optic nerve or retinal neovascularization as well as rubeosis license to treat colon cancer, off label use to treat PDR, cheaper than Vitrase. Around rm180 per injection ovine hyaluronidase (Vitrase): In large phase III clinical trials, intravitreal injections of it have been shown to be safe and to have modest efficacy for the clearance of severe vitreous hemorrhage. More than 70% of subjects in these studies had diabetes, and the most frequent etiology of the vitreous hemorrhage was proliferative diabetic retinopathy. Expensive due to specific use to the eye and have been license for that. around rm3000 per injection
34 : reference http://emedicine.medscape.com/article/1225122-overview


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