DIABETIC

RETINOPATHY
DR SRAVYA M V
SECOND YEAR
MS SALAKYATANTRA
GAVC TPRA
• Retinal changes seen in patients with diabetes mellitus
Etiopathogenesis

Risk factors

• Duration of diabetes
• After 10 years 20% type 1 & 25% type 2

• After 20 years 90% type 1 & 60% type 2

• After 30 years 95% of both

• Type of DM
• Type 1 > type 2

• PDR type 1
• DME type 2
• Age of onset – after puberty not a risk factor

• Sex F : M 4:3

• Poor metabolic control – hyperglycemia for long duration triggers the onset

• Heredity

• Pregnancy

• Hypertension

• Others – smoking, obesity, anemia, hyperlipidemia

Pathogenesis
• Hyperglycemia – in uncontrolled DM – starting point of onset of DR

• Microangiopathy - affecting retinal pre-capillary arterioles, capillaries & venules

• Mechanisms

i. Cellular damage

• Hyperglycemia produces
• Damage to the cells of retina, endothelial cells

• Loss of pericytes

• Thickening of basement membrane of capillaries

ii. Haematological & biochemical changes
• Platelet adhesiveness increases

• Blood viscosity increases

• Red blood cells deformation & Rouleaux formation

• Serum lipids get altered abnormally

• Leukostasis increases

• Fibrinolysis increases
Effects of microangiopathy producing DR

• Breakdown of blood-retinal barrier

Retinal oedema

Haemorrhages

Leakage of lipids (hard exudates)

• Weakened capillary wall

Microaneurysms

Haemorrhages

• Microvascular occlusions
Ischaemia & its effects

Cotton-wool spots (due to infarct of nerve fibre layer)

Arteriovenous shunts, i.e. intraretinal microvascular abnormalities (IRMAs)

MICROVASCULAR LEAKAGE
MICROVASCULAR OCCLUSION
Classification of DR

1. Non-proliferative diabetic retinopathy (NPDR)

• Mild NPDR

• Moderate NPDR

• Severe NPDR

• Very severe NPDR

2. Proliferative diabetic retinopathy (PDR)

3. Diabetic maculopathy

4. Advanced diabetic eye disease (ADED)

I. Non-proliferative diabetic retinopathy (NPDR)

Ophthalmoscopic features

• Microaneurysms
In the macular area & elsewhere

Due to focal dilation of capillary wall following loss of pericytes.

Appear as red dots

Leak fluid, proteins & lipids

• Retinal haemorrhages
Deep (dot & blot haemorrhages )

Superficial haemorrhages (flame-shaped)

• Hard exudates
Yellowish-white waxy-looking patches

Arranged in clumps / in circinate pattern

Common in the macular area

Due to chronic localised oedema

Composed of leaked lipoproteins & lipid filled macrophages

• Cotton-wool spots

Small whitish fluffy superficial lesions

• Venous abnormalities
Beading, looping & dilatation

Adjacent to area of capillary non-perfusion

• Intraretinal microvascular abnormalities (IRMA)

Fine irregular red lines connecting arterioles with venules
ETDRS study classification

• On the basis of severity

1. Mild NPDR

• At least one microaneurysm must be present

2. Moderate NPDR

• Microaneurysms/intraretinal hemorrhage in 2 or 3 quadrants

• Early mild IRMA

• Hard exudates & cotton-wool spots may / may not be present

Mild NPDR
Moderate NPDR
3. Severe NPDR Any one of the following (4-2-1 Rule)

• 4 quadrants of microaneurysms & extensive intraretinal hemorrhages

• 2 quadrants of venous beading

• 1 quadrant of IRMA changes

4. Very severe NPDR Any two of the following

•4 quadrants of microaneurysms & extensive intraretinal hemorrhages

• 2 quadrants of venous beading

• 1 quadrant of IRMA changes

Severe NPDR
II. Proliferative diabetic retinopathy (PDR)

• Neovascularization over the changes of very severe NPDR - hallmark of PDR

• Neovascularization at the optic disc (NVD) and/or elsewhere (NVE) in the

fundus - along the course of the major temporal retinal vessels

• These new vessels may proliferate in the plane of retina / spread into the
vitreous
PDR
• Later on results in formation of
• Fibrovascular epiretinal membrane formed due to condensation of connective tissue
around the new vessels
• Vitreous detachment & vitreous hemorrhage

NVE NVD VH
• Types
1. PDR without HRCs (Early PDR) - early NVD / NVE

2. PDR with HRCs

High-risk characteristics (HRC)

• NVD <l / 4 disc area with vitreous hemorrhage (VH) / Preretinal hemorrhage (PRH)

• NVD I /4 to 1 /3 of disc area with / without VH /PRH

• NVE > l / 2 disc area with VH / PRH

Ill. Diabetic maculopathy

• Changes in macular region

• Diabetic macular oedema (DME) occurs due to increased permeability of the

retinal capillaries
Clinico-angiographic classification of diabetic maculopathy

l. Focal exudative maculopathy

• Microaneurysms

• Hemorrhages

• Well-circumscribed macular oedema

• Hard exudates - circinate pattern

2. Diffuse exudative maculopathy

• Diffuse retinal oedema

• Thickening throughout the posterior pole

• Relatively few hard exudates

3 . Ischaemic maculopathy
• Due to microvascular blockage

• Marked visual loss

• Microaneurysms

• Hemorrhages

• Mild/no macular oedema

• A few hard exudates

4. Mixed maculopathy
• Combined features of ischemic & exudative maculopathy
• OCT-based classification of diabetic macular edema

I. Non-tractional DME
a. Spongy thickening of macula (>290 µ)

b. Cystoid macular oedema (CME)

c. Neurosensory detachment with / without (a) / (b) above

2. Tractional DME
d. Vitreo-foveal traction (VFT)

e. Taut/thickened posterior hyaloid membrane

 NEUROSENSORY RETINAL DETACHMENT
CME

VITREO FOVEAL TRACTION

IV. Advanced diabetic eye disease

• End result of uncontrolled PDR

Complications
• Persistent vitreous hemorrhage

• Tractional retinal detachment

• Neovascular glaucoma
MANAGEMENT

Includes its screening, investigations & treatment

A. Screening –
- To prevent visual loss

- For a timely intervention

• First examination, 3 years after diagnosis of type l DM & at the time of diagnosis in type 2 DM

• Every year, till there is no DR or there is mild NPDR

• Every 6 months, in moderate NPDR

• Every 3 months, in severe NPDR

• Every 2 months, in PDR with no high-risk characteristics

B. Investigations

• Urine examination

• Blood sugar estimation

• Renal function tests: serum creatinine, blood urea,24 hour urinary protein

• Lipid profile

• Hemogram

• Glycosylated haemoglobin (HbA1C)

• FFA should be carried out to elucidate areas of neovascularization, leakage & capillary
nonperfusion

• OCT to study detailed structural changes in diabetic maculopathy

C. Metabolic control of diabetes mellitus & associated risk factors

• Control of glycaemia

Target blood glucose level: fasting 50 mg%, & LDL 10mg%

• Control of associated hypertension

Target blood pressure levels:130/80 mm Hg

• Lifestyle changes

Prohibit smoking & alcohol consumption, take regular exercises

D. Treatment of diabetic retinopathy

I . Intravitreal anti-VEGF drugs

Bevacizumab ( 1.25 mg) & Ranibizumab (0.5 mg)

Preferred over laser therapy particularly

• Focal CME involving centre of fovea

• Diffuse DME

• DME with neurosensory detachment

•Before pan retinal photocoagulation (PRP) in patients with PDR & diffuse DME
II. Intravitreal steroids

Risk of glaucoma, steroid induced cataract & increased vulnerability to

endophthalmitis restrict its use
Ill. Laser therapy

• Focal laser for focal DME & grid laser for diffuse DME

• Laser helps possibly by stimulating the RPE pump mechanism & by inhibiting
VEGF release

• Laser therapy is performed using double frequency YAG laser 532 run / argon
green laser / diode laser
i. Macular photocoagulation

• Focal photocoagulation

- Focal DME not involving the center of fovea

• Grid photocoagulation

- Diffuse DME

- In cases not responding to anti-VEGFs & intravitreal steroids

ii. Pan retinal photocoagulation (PRP) / scatter laser

• Consists of 1200-1600 spots, each 500 µm in size & 0.1 sec duration

• Laser burns are applied outside the temporal arcades & on nasal side one
disc diameter from the disc up to the equator

• The burns should be one burn width apart

• PRP produces destruction of hypoxic retina

Indications

• PDR with HRCs

• Neovascularization of iris ( NI)

• Severe NPDR associated with

• Poor compliance for follow-up

• Before cataract surgery/YAG capsulotomy

• Renal failure

• One eyed patient

• Pregnancy
IV. Surgical treatment

• Tractional DME with NPDR

Pars plana vitrectomy (PPV) + removal of posterior hyaloid

• Advanced PDR with dense vitreous haemorrhage

PPV + removal of opaque vitreous gel + endo photocoagulation

• Advanced PDR with extensive fibrovascular epiretinal membrane

PPV + removal of fibrovascular epiretinal membrane + endo photocoagulation

• Advanced PDR with tractional retinal detachment

PPV + endo photocoagulation + reattachment of detached retina

THANK YOU