Diabetic Eye Disease

Saman Senanayake

Academic unit of Ophthalmology

 DIABETES AND THE EYE
• Vision Hyperglycaemia
Cataract
DR Background Ischaemic
Maculopathy Exudative
Cystoid
Pre-proliferative
Proliferative
Glaucoma ( primary & neovascular )
Cranial nerve palsies ( diplopia )
Retinovascular disease Retinal vein and artery occlusion
Ischaemic optic neuropathy
What is diabetic retinopathy?

Diabetic retinopathy is diabetic

microangiopathy affecting the retinal blood
vessels resulting predominantly from poor
metabolic control and leading to progressive
retinal damage which may end in complete
visual loss.
Which patients are affected?
• It affects both type 1 and type 2 diabetics.
• The incidence and prevalence is highest among young onset insulin
treated patients
• It is less common in individuals with secondary diabetes i.e.
following pancreatitis.
• It is the commonest cause of blindness among the working
population.
 Risk factors
 Poor metabolic control
 Associated hypertension especially if poorly
controlled
 Longer duration of diabetes
 Type 1 versus Type 11 Diabetes
 LDL Cholesterol
 Pregnancy
 Anaemia ? Smoking
Pathogenesis
Microangiopathy
Capillary Occlusion
Microvascular occlusion Microvascular leakage

Retinal ischaemia Breakdown of the blood-

retinal barrier
VEGF, Angiotensins
IGF-1, GH, FGF
VEGF
Cotton wool spots
Capillary closure Retinal haemorrhage

Arteriovenous shunts Retinal exudates/ oedema

 Neovascularisation
 MICROANEURYSMS

resolve rupture occlude leak

50%
disappear
within 3 years
haemorrhage Infarction hard exudates
(cotton wool
spots)
 NEW VESSELS
Rubeosis iridis

rupture
organise

preretinal & fibrosis

vitreous
haemorrhage
traction retinal neovascular glaucoma
detachment
Background retinopathy
Results from the early changes
associated with DR
Not sight threatening
( not in macula )
Few scattered microaneurysms,
haemorrhages, hard exudates and
cotton wool spots

ETDRS std2Al
 Microaneurysms

These are earliest clinically detectable abnormality

in diabetic retinopathy
They appear as small red dots sometimes
indistinguishable from haemorrhages
They range in size from 20 - 200µm
 Haemorrhages

‘dot’ and ‘blot’ – originate from the venous end of

the capillaries and therefore situated in the compact
middle layers
‘flame –shaped’ - originate from superficial
precapillary arterioles and therefore follow the
course of the nerve fibre layers
 Exudates

These are located between the inner plexiform and

inner nuclear layers
They have a yellow waxy appearance
They result from the leakage of lipoproteins from
the capillaries
Maculopathy
Results from the leakage of fluid
from retinal capillaries around the
fovea
Sight threatening complication
Microaneurysms, haemorrhages,
hard exudates at the macula

ETDRS std3l
Maculopathy

Focal Diffuse Ischaemic

Due to focal Diffuse leakage Due to

leakage from from capillaries hypoperfusion of
microaneurysms throughout the the macula
and capillaries posterior pole
 ‘Cotton-wool spots’

These are retinal microinfarcts as a consequence

of retinal ischaemia
Pre-proliferative retinopathy
Result from retinal ischaemia
Cotton Wool Spots > 5
Sight threatening
complication
Venous irregularities
(beading, duplication and
loops), multiple
haemorrhages, multiple
cotton wool spots and
intra-retinal microvascular
abnormalities
 Intraretinal
Venous beading
microvascular
abnormalities
(IRMA)

Definite indication Represents AV-

of the presence of shunts in the retinal
retinal ischaemia layers
Proliferative retinopathy
Results form retinal hypoperfusion
Sight threatening complication
Characterised by
neovascularisation, pre-retinal
haemorrhage and fibrous tissue

ETDRS std5l
Proliferative retinopathy

ETDRS std10Ar ETDRS std10Cr

NVD – new vessels on the disc

Proliferative retinopathy

ETDRS std7l

NVE – new vessels elsewhere

Proliferative retinopathy

Pre-retinal or subhyaloid
haemorrhage
Advanced diabetic eye disease
End result of all complications
Sight is invariably compromised
Vitreous haemorrhage, fibrous
tissue, recent retinal detachment,
rubeosis iridis (neovascular
glaucoma)

ETDRS std12r
 Classification of DR
Background retinopathy

Pre-proliferative retinopathy

Maculopathy may accompany or develop

later
Proliferative retinopathy
TYPE 11 TYPE 1

80% BLINDNESS Advanced Diabetic Eye

Disease
Diagnosis
• Direct ophthalmoscopy

• Slit-lamp biomicroscopy
- to detect the
presence of retinal
oedema
Diagnosis
• Retinal photography

• Fluorescein angiography
(to detect leakage)
IRMA from
Neovascularisation
Macular oedema
Management
• Screening
• DR is usually asymptomatic
• Early proliferative changes can only be detected by
screening
• Ophthalmoscopy +/- photography
• Detect sight threatening retinopathy and refer
to ophthalmologists
• Maculopathy
• Proliferative retinopathy
• Severe preproliferative retinopathy
Management
Medical
Delaying onset and preventing progression

 Good metabolic control

 Tight blood pressure control
 Correction of underlying anaemia
 Drug treatment:
• ?ACE-I, Angiotensin II antagonists
• Statins
• Aspirin
Management
Ophthalmological
Preventing progression (laser photocoagulation)
 Maculopathy
 FOCAL – focal laser
 DIFFUSE – grid laser
 ISCHAEMIC – poor outcome from laser
 Proliferative retinopathy
 Panretinal photocoagulation
Management of center involved macular
odema

• Anti VEGF intra vitreal injections

• Intravitreal steroids
Dexamathezone
Triamcinalone
Treatment of DR
Laser : Problems
• 60 - 70 % effective

• Delivery
Discomfort with PRP, Multiple treatment sessions

• Complications
Focal - accidental foveal burn
Deterioration of ischaemic maculopathy

• PRP - limitation of DVLA driving visual fields,

Scotoma,
Decreased night vision,
Choroidal detachment,
Pre-retinal haemorrhage,
Deterioration if pre-existing macula oedema
(in type II diabetic subjects)
DR – The Future
• Screening - National Programme
• Assessment Methods -
Scanning Laser Ophthalmoscope ( SLO ),
Ocular Computerised Tomography ( OCT ),
Stereo Digital Photography
• Treating retinopathy risk factors to target levels
• New Laser Technologies eg Microdiode laser
• New Medical Therapies -
Protein Kinase -C inhibition, Octreotide,
Intra-Vitreal Steroids, Newer Anti VEGF Options
THANK YOU