Diabetic retinopathyDiabetic retinopathy(diagnostics, therapy, classification)(diagnostics, therapy, classification)

Diabetic retinopathyDiabetic retinopathy(diagnostics, therapy, classification)(diagnostics, therapy, classification)

Diabetes mellitus- definitionDiabetes mellitus- definitionDiabetes mellitus- definitionDiabetes mellitus- definition

• Diabetes mellitusDiabetes mellitus is disease with high is disease with high glucose level (hyperglycaemia) due to glucose level (hyperglycaemia) due to absolute or relative lack of insulin produced absolute or relative lack of insulin produced in beta cells of Langerhans pancreatic isletsin beta cells of Langerhans pancreatic islets

• Diabetes mellitusDiabetes mellitus is disease with high is disease with high glucose level (hyperglycaemia) due to glucose level (hyperglycaemia) due to absolute or relative lack of insulin produced absolute or relative lack of insulin produced in beta cells of Langerhans pancreatic isletsin beta cells of Langerhans pancreatic islets

Diabetes mellitus- classificationDiabetes mellitus- classificationDiabetes mellitus- classificationDiabetes mellitus- classification

Diabetes type 1Diabetes type 1Diabetes type 2Diabetes type 2Gestational diabetesGestational diabetes

Diabetes type 1Diabetes type 1Diabetes type 2Diabetes type 2Gestational diabetesGestational diabetes

Epidemiology of diabetes Epidemiology of diabetes (CZ in (CZ in 2009)2009)Epidemiology of diabetes Epidemiology of diabetes (CZ in (CZ in 2009)2009)

• 800 000 800 000

• 8% of population8% of population

- DM type 1DM type 1 8%8%

- DM type 2DM type 2 92%92%

• 800 000 800 000

• 8% of population8% of population

- DM type 1DM type 1 8%8%

- DM type 2DM type 2 92%92%

Pathogenesis of diabetes type 1Pathogenesis of diabetes type 1Pathogenesis of diabetes type 1Pathogenesis of diabetes type 1

• The destruction of insulin-producing beta-The destruction of insulin-producing beta-cells of pancreatic islets of Langerhanscells of pancreatic islets of Langerhans

(autoimmune process, a genetic predisposition, external (autoimmune process, a genetic predisposition, external environmental factor, in the second of identical twins environmental factor, in the second of identical twins diabetes arises only in 50% of cases)diabetes arises only in 50% of cases)

• The destruction of insulin-producing beta-The destruction of insulin-producing beta-cells of pancreatic islets of Langerhanscells of pancreatic islets of Langerhans

(autoimmune process, a genetic predisposition, external (autoimmune process, a genetic predisposition, external environmental factor, in the second of identical twins environmental factor, in the second of identical twins diabetes arises only in 50% of cases)diabetes arises only in 50% of cases)

Pathogenesis of diabetes type 2Pathogenesis of diabetes type 2Pathogenesis of diabetes type 2Pathogenesis of diabetes type 2

• Failure of insulin secretion in pancreatic Failure of insulin secretion in pancreatic beta-cellsbeta-cellsReduction of insulin action in target tissues Reduction of insulin action in target tissues (insulin resistance)(insulin resistance)

• Failure of insulin secretion in pancreatic Failure of insulin secretion in pancreatic beta-cellsbeta-cellsReduction of insulin action in target tissues Reduction of insulin action in target tissues (insulin resistance)(insulin resistance)

InsulinInsulinInsulinInsulin

discovered 1921 discovered 1921 (Banting, Best, (Banting, Best, Macleod, Collip)Macleod, Collip)

hyperglycaemic ketoacidotic coma hyperglycaemic ketoacidotic coma hyperglycaemic hyperosmolar comahyperglycaemic hyperosmolar comalactacidotic comalactacidotic comahypoglycaemic comahypoglycaemic coma

hyperglycaemic ketoacidotic coma hyperglycaemic ketoacidotic coma hyperglycaemic hyperosmolar comahyperglycaemic hyperosmolar comalactacidotic comalactacidotic comahypoglycaemic comahypoglycaemic coma

Diabetes mellitus Diabetes mellitus (acute complications)(acute complications)Diabetes mellitus Diabetes mellitus (acute complications)(acute complications)

Diabetes mellitus Diabetes mellitus (late complications)(late complications)Diabetes mellitus Diabetes mellitus (late complications)(late complications)

1.1. retinopathyretinopathy

2.2. nephropathynephropathy

3.3. diabetic footdiabetic foot

4.4. neuropathyneuropathy

1.1. retinopathyretinopathy

2.2. nephropathynephropathy

3.3. diabetic footdiabetic foot

4.4. neuropathyneuropathy

Diabetes mellitus Diabetes mellitus (therapy)(therapy)Diabetes mellitus Diabetes mellitus (therapy)(therapy)

• EducationEducation

• DietDiet

• Oral antidiabeticsOral antidiabetics

• InsulinInsulin

• EducationEducation

• DietDiet

• Oral antidiabeticsOral antidiabetics

• InsulinInsulin

Diabetic retinopathy Diabetic retinopathy (definition)(definition)Diabetic retinopathy Diabetic retinopathy (definition)(definition)

• Diabetic retinopathyDiabetic retinopathy is is microangiopathymicroangiopathy, , ie. retinal vascular impairment in diabetic ie. retinal vascular impairment in diabetic patientspatients

• Diabetic retinopathyDiabetic retinopathy is is microangiopathymicroangiopathy, , ie. retinal vascular impairment in diabetic ie. retinal vascular impairment in diabetic patientspatients

Diabetic retinopathy Diabetic retinopathy (history)(history)Diabetic retinopathy Diabetic retinopathy (history)(history)

• DM first description– DM first description– Ebers papyrus (1550 before Ch.), Ebers papyrus (1550 before Ch.), Aretaios from Kappadokia (2th century) Aretaios from Kappadokia (2th century)

• DR was first described after Helmholtz DR was first described after Helmholtz ophthalmoscope discovery (1851)ophthalmoscope discovery (1851)

• First description of DRFirst description of DR – – Jäger (1851), Desmarres Jäger (1851), Desmarres (1855), von Gräfe (1858)(1855), von Gräfe (1858)

• First classification of DRFirst classification of DR – – Ballantyn a Löwensteine Ballantyn a Löwensteine (1943), (1943), nonproliferative and proliferative DRnonproliferative and proliferative DR

• DM first description– DM first description– Ebers papyrus (1550 before Ch.), Ebers papyrus (1550 before Ch.), Aretaios from Kappadokia (2th century) Aretaios from Kappadokia (2th century)

• DR was first described after Helmholtz DR was first described after Helmholtz ophthalmoscope discovery (1851)ophthalmoscope discovery (1851)

• First description of DRFirst description of DR – – Jäger (1851), Desmarres Jäger (1851), Desmarres (1855), von Gräfe (1858)(1855), von Gräfe (1858)

• First classification of DRFirst classification of DR – – Ballantyn a Löwensteine Ballantyn a Löwensteine (1943), (1943), nonproliferative and proliferative DRnonproliferative and proliferative DR

• First First retinal fotocoagulationretinal fotocoagulation– – Meyer-Schwickerath Meyer-Schwickerath (1945), solar photocoagulator (heliostat)(1945), solar photocoagulator (heliostat)

• Regression of proliferative DR after postpartual Regression of proliferative DR after postpartual hypophysal necrosis (1953) – hypophysal necrosis (1953) – Simmonds- Sheehan Simmonds- Sheehan syndromesyndrome

• Discovery of Discovery of fluorescence angiographyfluorescence angiography – – Novotny, Novotny, Alvis (1959)Alvis (1959)

• First First retinal fotocoagulationretinal fotocoagulation– – Meyer-Schwickerath Meyer-Schwickerath (1945), solar photocoagulator (heliostat)(1945), solar photocoagulator (heliostat)

• Regression of proliferative DR after postpartual Regression of proliferative DR after postpartual hypophysal necrosis (1953) – hypophysal necrosis (1953) – Simmonds- Sheehan Simmonds- Sheehan syndromesyndrome

• Discovery of Discovery of fluorescence angiographyfluorescence angiography – – Novotny, Novotny, Alvis (1959)Alvis (1959)

Diabetic retinopathy Diabetic retinopathy (history)(history)Diabetic retinopathy Diabetic retinopathy (history)(history)

• First use of laserFirst use of laser– – Meyer-Schwickerath (1955-1958), Meyer-Schwickerath (1955-1958), xenon lampxenon lamp

• Rubine laser (1960)Rubine laser (1960)• Argon laser (1968)Argon laser (1968)• Pars plana vitrectomyPars plana vitrectomy – – Machemer, Parel (1970)Machemer, Parel (1970)

• Fluorophotometry Fluorophotometry – – Cunha-Vaz (1975), preretinopathyCunha-Vaz (1975), preretinopathy

• First use of laserFirst use of laser– – Meyer-Schwickerath (1955-1958), Meyer-Schwickerath (1955-1958), xenon lampxenon lamp

• Rubine laser (1960)Rubine laser (1960)• Argon laser (1968)Argon laser (1968)• Pars plana vitrectomyPars plana vitrectomy – – Machemer, Parel (1970)Machemer, Parel (1970)

• Fluorophotometry Fluorophotometry – – Cunha-Vaz (1975), preretinopathyCunha-Vaz (1975), preretinopathy

Diabetic retinopathy Diabetic retinopathy (history)(history)Diabetic retinopathy Diabetic retinopathy (history)(history)

• 1976- 1976- Diabetic Retinopathy StudyDiabetic Retinopathy Study (DRS)- laser (DRS)- laser reduces risk of blidness in proliferative DRreduces risk of blidness in proliferative DR

• 1985- 1985- Early Treatment Diabetic Retinopathy Early Treatment Diabetic Retinopathy StudyStudy (ETDRS)- focal laser photocoagulation (ETDRS)- focal laser photocoagulation reduces risc of visual acuity lost in diabetic reduces risc of visual acuity lost in diabetic macular edemamacular edema

• 1976- 1976- Diabetic Retinopathy StudyDiabetic Retinopathy Study (DRS)- laser (DRS)- laser reduces risk of blidness in proliferative DRreduces risk of blidness in proliferative DR

• 1985- 1985- Early Treatment Diabetic Retinopathy Early Treatment Diabetic Retinopathy StudyStudy (ETDRS)- focal laser photocoagulation (ETDRS)- focal laser photocoagulation reduces risc of visual acuity lost in diabetic reduces risc of visual acuity lost in diabetic macular edemamacular edema

Diabetická retinopatie Diabetická retinopatie (historie)(historie)Diabetická retinopatie Diabetická retinopatie (historie)(historie)

• Diabetes mellitus- 8% populationDiabetes mellitus- 8% population• 25% diabetics - DR25% diabetics - DR• 5% diabetics - proliferative DR5% diabetics - proliferative DR• DR rare until first 3-5 years of duration of DMDR rare until first 3-5 years of duration of DM• DR in 60- 90% after 15- 20 years of duration of DR in 60- 90% after 15- 20 years of duration of

DMDM• DR in 97% after 30 years of duration of DMDR in 97% after 30 years of duration of DM

• Diabetes mellitus- 8% populationDiabetes mellitus- 8% population• 25% diabetics - DR25% diabetics - DR• 5% diabetics - proliferative DR5% diabetics - proliferative DR• DR rare until first 3-5 years of duration of DMDR rare until first 3-5 years of duration of DM• DR in 60- 90% after 15- 20 years of duration of DR in 60- 90% after 15- 20 years of duration of

DMDM• DR in 97% after 30 years of duration of DMDR in 97% after 30 years of duration of DM

Diabetic retinopathy Diabetic retinopathy (epidemiology)(epidemiology)Diabetic retinopathy Diabetic retinopathy (epidemiology)(epidemiology)

Patophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathy

• MicroangiopathyMicroangiopathy

• Lost of endothelial cells and pericitesLost of endothelial cells and pericites

• Thickening of basal membrane of retinal Thickening of basal membrane of retinal capillariescapillaries (glycoproteins) (glycoproteins)

• Failure of outer and inner blood retinal Failure of outer and inner blood retinal barrierbarrier

• MicroangiopathyMicroangiopathy

• Lost of endothelial cells and pericitesLost of endothelial cells and pericites

• Thickening of basal membrane of retinal Thickening of basal membrane of retinal capillariescapillaries (glycoproteins) (glycoproteins)

• Failure of outer and inner blood retinal Failure of outer and inner blood retinal barrierbarrier

Patophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathy

Patophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathy

Patophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathy

Patophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathyPatophysiology of diabetic retinopathy

1.1. Nonproliferative DRNonproliferative DR (NPDR) (NPDR)2.2. Proliferative DRProliferative DR (PDR) (PDR)3.3. Diabetic maculopathyDiabetic maculopathy (M) (M) (each level of diabetic retinopathy may or may not (each level of diabetic retinopathy may or may not

beaccompanied by diabetic maculopathy)beaccompanied by diabetic maculopathy)

1.1. Nonproliferative DRNonproliferative DR (NPDR) (NPDR)2.2. Proliferative DRProliferative DR (PDR) (PDR)3.3. Diabetic maculopathyDiabetic maculopathy (M) (M) (each level of diabetic retinopathy may or may not (each level of diabetic retinopathy may or may not

beaccompanied by diabetic maculopathy)beaccompanied by diabetic maculopathy)

Classification of diabetic retinopathyClassification of diabetic retinopathyClassification of diabetic retinopathyClassification of diabetic retinopathy

Nonproliferative DR Nonproliferative DR (NPDR)(NPDR)Nonproliferative DR Nonproliferative DR (NPDR)(NPDR)

• BeginningBeginning• Intermediate Intermediate • AdvancedAdvanced

• BeginningBeginning• Intermediate Intermediate • AdvancedAdvanced

Beginning NPDRBeginning NPDR

Intermediate NPDRIntermediate NPDR

Intermediate NPDRIntermediate NPDR

Advanced NPDRAdvanced NPDR

Proliferative DR Proliferative DR (PDR)(PDR)Proliferative DR Proliferative DR (PDR)(PDR)

• LightLight• IntermediateIntermediate • Fully advanced Fully advanced VH- vitreous hemorrhage, PRH- VH- vitreous hemorrhage, PRH-

preretinal hemorhage, TRD- retinal detachment at preretinal hemorhage, TRD- retinal detachment at center of maculacenter of macula

• LightLight• IntermediateIntermediate • Fully advanced Fully advanced VH- vitreous hemorrhage, PRH- VH- vitreous hemorrhage, PRH-

preretinal hemorhage, TRD- retinal detachment at preretinal hemorhage, TRD- retinal detachment at center of maculacenter of macula

Light PDRLight PDR

Intermediate PDRIntermediate PDR

Fully advanced PDRFully advanced PDR

Fully advanced PDRFully advanced PDR

Vitreous hemorrhage in Vitreous hemorrhage in fully advanced PDRfully advanced PDR

Diabetic maculopathy Diabetic maculopathy (M)(M)Diabetic maculopathy Diabetic maculopathy (M)(M)

• affects 33% of diabetic patients after 8-10 affects 33% of diabetic patients after 8-10 years of duration of diseaseyears of duration of disease

• the most common cause of vision loss in the most common cause of vision loss in diabetic retinopathydiabetic retinopathy

• affects 33% of diabetic patients after 8-10 affects 33% of diabetic patients after 8-10 years of duration of diseaseyears of duration of disease

• the most common cause of vision loss in the most common cause of vision loss in diabetic retinopathydiabetic retinopathy

Diabetic makulopathy Diabetic makulopathy (M)(M)Diabetic makulopathy Diabetic makulopathy (M)(M)

• Macular area is a predilection site for Macular area is a predilection site for edema formationedema formationMicroangiopathy leads to ischemia, fluid Microangiopathy leads to ischemia, fluid accumulation, formation of microcysts and accumulation, formation of microcysts and cystscystsHard exudates (lipid accumulation) occur Hard exudates (lipid accumulation) occur on the boundary of ischemic and normal on the boundary of ischemic and normal retinaretina

• Macular area is a predilection site for Macular area is a predilection site for edema formationedema formationMicroangiopathy leads to ischemia, fluid Microangiopathy leads to ischemia, fluid accumulation, formation of microcysts and accumulation, formation of microcysts and cystscystsHard exudates (lipid accumulation) occur Hard exudates (lipid accumulation) occur on the boundary of ischemic and normal on the boundary of ischemic and normal retinaretina

Diabetic makulopathy Diabetic makulopathy (M)(M)Diabetic makulopathy Diabetic makulopathy (M)(M)

Diabetic makulopathy Diabetic makulopathy (M)(M)Diabetic makulopathy Diabetic makulopathy (M)(M)

Diabetic makulopathy Diabetic makulopathy (classification)(classification)Diabetic makulopathy Diabetic makulopathy (classification)(classification)

• Focal edemaFocal edema

• Difuse edemaDifuse edema

• Ischemic edemaIschemic edema (rare)- avascular zone in macula (rare)- avascular zone in macula

• Focal edemaFocal edema

• Difuse edemaDifuse edema

• Ischemic edemaIschemic edema (rare)- avascular zone in macula (rare)- avascular zone in macula

Focal edemaFocal edema

Difuse edemaDifuse edema

Ischemic edemaIschemic edema

Therapy of diabetic retinopathy Therapy of diabetic retinopathy and maculopathyand maculopathyTherapy of diabetic retinopathy Therapy of diabetic retinopathy and maculopathyand maculopathy

• Gold standard is laser photocoagulation of Gold standard is laser photocoagulation of ischemic retinal partsischemic retinal parts

• Laser can‘t be performed in central macular Laser can‘t be performed in central macular zonezone

• Gold standard is laser photocoagulation of Gold standard is laser photocoagulation of ischemic retinal partsischemic retinal parts

• Laser can‘t be performed in central macular Laser can‘t be performed in central macular zonezone

Laser therapy Laser therapy (technique)(technique)Laser therapy Laser therapy (technique)(technique)

• Laser therapy of DRLaser therapy of DR

1.1. focalfocal

2.2. panretinal (scatter)panretinal (scatter)

• Laser therapy of DRLaser therapy of DR

1.1. focalfocal

2.2. panretinal (scatter)panretinal (scatter)

Laser spots in retina suffered from NPDR

• Laser therapy of diabetic maculopathyLaser therapy of diabetic maculopathy

1.1. focalfocal

2.2. gridgrid

• Laser therapy of diabetic maculopathyLaser therapy of diabetic maculopathy

1.1. focalfocal

2.2. gridgrid

Laser therapy Laser therapy (technique)(technique)Laser therapy Laser therapy (technique)(technique)

Focal laserFocal laser

Grid laserGrid laser

Laser therapy Laser therapy (positives)(positives)Laser therapy Laser therapy (positives)(positives)

• Reducing of risc of visual lossReducing of risc of visual loss

• Reducing of risc of vitreous hemorrhage, Reducing of risc of vitreous hemorrhage, neovascular glaucoma and tractional retinal neovascular glaucoma and tractional retinal detachmentdetachment

• Reducing of risc of visual lossReducing of risc of visual loss

• Reducing of risc of vitreous hemorrhage, Reducing of risc of vitreous hemorrhage, neovascular glaucoma and tractional retinal neovascular glaucoma and tractional retinal detachmentdetachment

Laser therapy Laser therapy (negatives)(negatives)Laser therapy Laser therapy (negatives)(negatives)

• Paliative treatmentPaliative treatment

• Dark adaptation problemsDark adaptation problems• Paliative treatmentPaliative treatment

• Dark adaptation problemsDark adaptation problems

Surgical therapy of DRSurgical therapy of DRSurgical therapy of DRSurgical therapy of DR

• Pars plana vitrectomyPars plana vitrectomy- - (Machemer, Parel – (Machemer, Parel – 1970)1970)

• Pars plana vitrectomyPars plana vitrectomy- - (Machemer, Parel – (Machemer, Parel – 1970)1970)