YOUSAF ALIYOUSAF ALI

LECTURER(DOCTOR OF LECTURER(DOCTOR OF OPTOMETRY)OPTOMETRY)

Objectives of Objectives of presentationpresentation

Diabetes is one of the global health Diabetes is one of the global health challenges, affecting about 3 % challenges, affecting about 3 % population of the world.population of the world.

Diabetic ophthalmopathy – a Diabetic ophthalmopathy – a common, sight-threatening common, sight-threatening complication of diabetes. complication of diabetes.

DIABETES MELLITUS:

TYPE 1 (IDDM) ------- Insulin dependent diabetes mellitusTYPE 2 (NIDDM) ---- Non Insulin dependent diabetes mellitus

SYSTEMIC EFFECTS OF DIABETES

STROKE

CORONARY ARTERY DISEASENEPHROPATHY

PERIPHERAL VASCULAR DISEASEPERIPHERAL NEUROPATHY

DIABETIC DIABETIC OPHTHALMOPATHYOPHTHALMOPATHY

EXTRA RETINAL EFFECTS OF

DIABETES ON EYE

LidsStyesChalazionXanthelasmas

Lens

Cataract

EXTRA RETINAL EFFECTS OF DIABETES ON EYE

CorneaKeratitisRecurrent corneal erosionPersistent epithelial defects

EXTRA RETINAL EFFECTS OF DIABETES ON EYE

Refractive ErrorOsmotic swelling of lens causes myopic shift.

EXTRA RETINAL EFFECTS OF DIABETES ON EYE

Glaucoma

Angle closure glaucoma

Neovascular glaucoma

Blood associated glaucoma

EXTRA RETINAL EFFECTS OF DIABETES ON EYE

Vitreous humor

Asteroid hyalosis

EXTRA RETINAL EFFECTS OF DIABETES ON EYE

Occlusive retinal vascular diseases

CRAOCRVOBRAOBRVO

EXTRA RETINAL EFFECTS OF DIABETES ON EYE

CRVO

BRVO

BRAO

CRAO

OPTIC NERVE

Acute disc oedema Mild acute AION Optic nerve hypoplasia Optic atrophy

EXTRA RETINAL EFFECTS OF DIABETES ON EYE

Cranial nerve palsies

Focal small vessel occlusion & ischaemic demyelination---- cause

Occulomotor Trochlear

& Abducent nerves palsies.

EXTRA RETINAL EFFECTS OF DIABETES ON EYE

3RD NERVE PALSY

Infectious diseases

ENDOPHTHALMITIS MUCORMYCOSIS cause internal and external ophthalmoplegia, Proptosis, ptosis. HERPES ZOSTER INFECTION may affect the trigeminal nerve. Cause Uveities and keratits.

EXTRA RETINAL EFFECTS OF DIABETES ON EYE

Diabetic Diabetic RetinopatRetinopathyhy

TYPES OF DIABETES MELLITUS AND

OCULAR INVOLVEMENT

Diabetic RetinopathyType 1 Diabetics 40%Type 2 Diabetics 20%

Diabetic Retinopathy

EPIDEMIOLOGY

Prevalence increases with duration of diabetes & age. After 20 years of diabetes, 99% pts with IDDM & 60% with NIDDM—have some degree of retinopathy. 70-80 million people affected worldwide. 5-8% population of Pakistan is affected. 5-10% of all diabetics have sight-threatening retinopathy.

CLINICAL CLASSIFICATION OF DRDisease Severity Scale

• No Retinopathy • NPDR

MildModerate Severe

• PDR• ADED• EDED

AMERICAN ACADEMY OF OPHTHALMOLOGY

RISK FACTORS

Onset / Duration of Diabetes:

DM before 30yrs of age —----

incidence 50%

DM after 10yrs ----- incidence

90% Type of Diabetes ( IDDM --- 40%,

NIDDM-----20%) Age -----higher risk of PDR in younger

diabetics. Sex ------Men with IDDM have ↑ risk of

developing PDR.

Diabetic Control Nephropathy Hypertension Hyperlipidemias Cigarette smoking Pregnancy

RISK FACTORSCONT’D

DIABETIC MICROANGIOPATHY

High Blood Sugar

COMPLICATIONS:• Ocular / Retinal• Renal• Neuropathic• Peripheral Vascular

Capillary Leakage Capillary Closure

Structural damage &Functional failure

Pathogenesis of diabetic retinopathy

Consequences of retinal ischaemia

Consequences of chronic leakage

BGDR CLINICAL FEATURES

Micro-aneurysm Intra retinal haemorrhages Hard exudates Retinal oedema

Micro-aneurysm

Intra retinal haemorrhages

Hard exudates Retinal oedema

MANAGEMENT (BGDR)

Proper diabetic control Proper management of hypertension, anaemia and renal disease. Observations for

Maculopathy Ischaemia New vessels

DIABETIC MACULOPATHY

“Involvement of fovea by oedema & hard exudates

or Ischaemia.”

MACULOPATHY

Focal Diffuse Ischaemic Mixed

Focal diabetic maculopathy

Diffuse diabetic maculopathy

Ischemic diabetic maculopathy

Mixed Maculopathy

PRE-PROFLIFERATIVE DR

CLINICAL FEATURES Large blot haemorrhages Venous changes--- dilatation, beading, looping IRMA Capillary non-perfusion

MANAGEMENT Close observation Laser on progression

Preproliferative diabetic retinopathy

PROLIFERATIVE DR

NVDNVEVitreous/Pre-retinal

hemorrhage

Proliferative diabetic retinopathy

Neovascularization of disc = NVD

• Affects 5-10% of diabetics

• IDDM at increased risk (60% after 20 years)

Neovascularization elsewhere = NVE

NVD NVD + NVE

LASER TREATMENT FOR PDR

Neo-vascularization in DR

Principle of PRP

PRP

ADVANCED DIABETIC EYE DISEASE

Persistent new vessels Tractional retinal detachment Neovascular glaucoma

Persistent new vessels

Tractional RD

Neo-vascular Glaucoma

END STAGE DIABETIC EYE DISEASE

Phthisical eye

INDICATIONS FOR VITREO-RETINAL SURGERY

Retinal detachment involving macula

Severe persistent vitreous haemorrhage

Dense, persistent premacular haemorrhage

Progressive proliferation despite laser therapy

PPV for DR

FOR YOUR TIME & ATTENTION