EPIDEMIOLOGY AND NATURAL HISTORY OF DIABETIC RETINOPATHY Powerpoint Presentation

EPIDEMIOLOGY AND NATURAL HISTORY OF DIABETIC RETINOPATHY

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Slide 1 :

EPIDEMIOLOGY AND NATURAL HISTORY OF DIABETIC RETINOPATHY Tatiana Segato University of Padova

Slide 2 :

EPIDEMIOLOGIC DATA ABOUT DIABETIC RETINOPATHY ARE USEFUL IN DEVELOPING STRATEGIES TO PREVENT OR REDUCE ITS OCCURRENCE OR PROGRESSION

Slide 3 :

A large number of epidemiologic studies about prevalence and incidence of diabetic retinopathy have been performed during last years In the next two slides are summarized some limitations of the studies and the major risk factors.

Slide 4 :

Epidemiologic studies limitations sample size duration type of patients methods to quantify retinopathy definition of hypertension data analysis

Slide 5 :

Risk Factors duration of diabetes metabolic control blood pressure elevated lipids type of treatment (BISED)

Slide 6 :

Metabolic Control and Diabetic Retinopathy

Slide 7 :

DCCT: metabolic control and Diabetic retinopathy in type 1 diabetes (1441 patients; follow up 6,5 years) PATIENTS WITH NO DR reduction by 76% of the adjusted mean risk for the development of DR 2. PATIENTS WITH DR reduction by 54% of the progression of DR reduction by 47% of the development of severe NPDR or PDR reduction by 56% of laser treatment need DCCT: N Engl J Med 1993

Slide 8 :

DCCT / EDIC 4 years follow-up Conventional therapy HbA1 8.2% Intensive therapy HbA1 7.9% EDIC: Epidemiology of Diabetes Interventions and Complications study New Eng J Med 2000

Slide 9 :

Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with tipe 2 diabetes (UKPDS 33) The Lancet, 1998

Slide 10 :

Metabolic control and retinopathy progression >= 2 levels in type 2 diabetes UKPDS, 33 The Lancet, 1998

Slide 11 :

The intensive treatment group had a substantial 25% reduction in the risk Of microvascular endpoints UKPDS, 33 The Lancet, 1998

Slide 12 :

Hypertension Control and Diabetic Retinopathy

Slide 13 :

EFFECT OF LISINOPRIL ON PROGRESSION OF RETINOPATHY IN NORMOTENSIVE PEOPLE WITH TYPE 1 DIABETES. Two year randomised double-blind placebo-controlled trial with lisinopril in normotensive ( <155/90 mmHg ) type 1 diabetic patients. Lancet, 1998 EUCLID

Slide 14 :

Lisinopril halves the progression of retinopathy in IDDM over 2 yrs period (p<0.02) Progression to proliferative retinopathy is significantly reduced (p<0.03) Incidence of new retinopathy is reduced by 30% (n.s.) The effect of Lisinopril on retinopathy in people with IDDM (EUCLID)

Slide 15 :

Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes UKPDS Br Med J 1998

Slide 16 :

Blood Pressure : Tight vs Less Tight Control cohort, median values Less tight control 154/87 Tight control 144/82 UKPDS Br Med J 1998

Slide 17 :

Proportion of two step progressionof DR at various intervals in UKPDS vs hypertension controls (Risk reduction 34%) Cumulative event rate (%) UKPDS Br Med J 1998

Slide 18 :

UKPDS Br Med J 1998

Slide 19 :

Similar proportion of patiens in the two groups showed deterioration in retinopathy by two grades after nine years. CAPTOPRIL 31% ATENOLOL 37% UKPDS 39 Br Med J 1998

Slide 20 :

EFFECTS OF AGGRESSIVE BLOOD PRESSURE CONTROL IN NORMOTENSIVE TYPE 2 DIABETIC PATIENTS ON ALBUMINURIA, RETINOPATHY AND STROKES. ABCD: The Appropriate Blood Pressure Control in Diabetes Kidney International 2002 Robert W. Schrier et al.

Slide 21 :

ABCD TRIAL: PROGRESSION OF DR (? 2 STEPS) follow up INTENSIVE MODERATE 2 yrs 13% 21% p<0,05 5 yrs 34% 46% p<0,02 Enalapril 38% Nisoldipine 30% p=n.s. BP 128/75 BP 137/81 INCIDENCE 39% 42%

Slide 22 :

SERUM LIPIDS AND DIABETIC RETINOPATHY

Slide 23 :

Cusik et al Ophth 2003: “The regression of hard exudates is most likely due to agressive lipid lowering” Klein et al Ophth 2002: “Plasma lipids are associated with the presence of hard exudate” Klein et al Brit J Oph 2002: “Association of elevated plasma LDL cholesterol with diabetic retinopathy” Kaushik et al Diab Res 2001: “Simvastatin retards progression of retinopathy in diabetic patients with hypercholesterolemia”

Slide 24 :

THE RESULTS OF THESE STUDIES HIGHLIGHT BENEFITS OF LIPID-LOWERING THERAPY IN DIABETIC RETINOPATHY BUT THEY NEED FURTHER DATA BY INCORPORATING LARGER NUMBER OF PATIENTS AND BY INCREASING THE DURATION OF EACH TRIAL

Slide 25 :

Fundus examination Direct ophthalmoscopy Indirect ophthalmoscopy Biomicroscopy Fundus photography Fluorescein Angiography

Slide 26 :

…Fluorescein angiography is not needed to diagnose CSME or PDR, both of which are diagnosed by means of the clinical exam. However, it is an extremely valuable test for selected patients with DR, and is commonly used in the following ways: American Academy of Ophthalmology, preferred practice patterns, 1993

Slide 27 :

FLUORESCEIN ANGIOGRAPHY (FA) IS GENERALLY USED FOR TREATMENT PLANNING. THE MAJOR ADVANTAGE OF FA OVER FUNDUS PHOTOGRAPHY IS ITS ABILITY TO DETECT MACULAR ISCHEMIA DENOTED BY NONPERFUSION OF THE RETINAL CAPILLARIES AND TO DETECT SUBTLE DME AS EVIDENCED BY FLUORESCEIN LEAKAGE FROM THE CAPILLARIES.

Slide 28 :

DIABETIC RETINOPATHY LESIONS Microaneurysm Hemorrhages Hard exudates cotton wool spot IRMA Venous abnormalities New vessels: papillary and/or elsewhere Vitreous/Preretinal hemorrhages

Slide 29 :

The ETDRS severity scale has been widely applied in research settings, publications, and in meetings of retina subspecialty groups, and it has shown satisfactory reproducibility and validity.Although it is recognized as the “gold standard” for grading the severity of diabetic retinopathy in clinical trials, its use in everyday clinical practice has not proven to be easy or practical.

Slide 30 :

INTERNATIONAL CLINICAL DIABETIC RETINOPATHY DISEASE SEVERITY SCALE Ophthalmology 2003

Slide 31 :

Slide 32 :

INTERNATIONAL CLINICAL DIABETIC MACULAR EDEMA DISEASE SEVERITY SCALE Ophthalmology 2003

Slide 33 :

Slide 34 :

If diabetic macular edema is present, it can be categorized as follows

Slide 35 :

Advanced Diabetic Eye Disease Tractional retinal detachment Rubeosis iridis Neovascular glaucoma

Slide 36 :

THE NEED TO SCREEN FOR DIABETIC RETINOPATHY IS UNCONTROVERSIAL. Detection of sight threatening retinopathy and treatment by laser therapy has been shown to be effective in preventing the onset of visual impairment. Data from epidemiologic studies strongly support the implementation of intensive therapy to normalize blood glucose, blood pressure and lipid levels resulting in an even greater reduction in the risk of diabetic retinopathy and laser treatment.

abdelsamee on Dec 30, 2009 Says :

good but incomplete

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