Gos 31 Presentation 1by Dr. Anand Sudhalkar, Baroda

Diabetic Retinopathy Diabetic Retinopathy Presentation and Presentation and

ClassificationClassificationDr Anand SudhalkarDr Anand Sudhalkar

05/13/10 2Eye Hospital & Retinal Laser Centre, Baroda

PROLONGED Hyperglycemia PROLONGED Hyperglycemia complications :complications :

END STAGE RENAL DISEASEEND STAGE RENAL DISEASE RETINOPATHYRETINOPATHY NON-TRAUMATIC LOWER LIMB NON-TRAUMATIC LOWER LIMB

AMPUTATIONSAMPUTATIONS

END STAGE RENAL DISEASE END STAGE RENAL DISEASE AND RETINOPATHY: AND RETINOPATHY:

DENMARK STUDY DENMARK STUDY TI: Incidence of retinopathy in type I (insulin-TI: Incidence of retinopathy in type I (insulin-

dependent) diabetes: association with clinical dependent) diabetes: association with clinical nephropathy.nephropathy.

AU: Kofoed-Enevoldsen-A; Jensen-T; Borch-Johnsen-AU: Kofoed-Enevoldsen-A; Jensen-T; Borch-Johnsen-K; Deckert-TK; Deckert-T

SO: J-Diabet-Complications. 1987 Jul-Sep; 1(3): 96-9SO: J-Diabet-Complications. 1987 Jul-Sep; 1(3): 96-9 110 IDDM 5 YEARS FOLLOWUP110 IDDM 5 YEARS FOLLOWUP PDR IN 74% WITH PROTEINUREA, AGAINST PDR IN 74% WITH PROTEINUREA, AGAINST

14% IN WITHOUT.14% IN WITHOUT. BDR IN 93% WITH AND 37% WITHOUT BDR IN 93% WITH AND 37% WITHOUT

PROTEINUREA.PROTEINUREA.

PREVALENCE OF PREVALENCE OF RETINOPATHYRETINOPATHY

10% AMONGST ALL DM10% AMONGST ALL DM 40% Of these have CSME40% Of these have CSME Out of all BDR 3% have CSMEOut of all BDR 3% have CSME Out of all PPDR 38% have CSMEOut of all PPDR 38% have CSME out of all PDR 71% have CSMEout of all PDR 71% have CSME 5% of maturity-onset, IDDM at diag.5% of maturity-onset, IDDM at diag. Prevalence Prevalence ↑↑ Duration of Hyperglycemia Duration of Hyperglycemia After 20 yr. 99% of IDDM and 60% of NIDDM After 20 yr. 99% of IDDM and 60% of NIDDM

have retinopathyhave retinopathy

37.931.5

20.0030.00

80.0090.00

100.00

SELF (100) PHY (58) OPHTH (92)

NDR BDR PDR/VH

CHI-SQURE : 57.26132 DF : 4 SIGNIFICANCE : .00000

REVIEW OF 250 DIABETIC PATIENTS

65.5 63.1

10.0020.00

30.0040.00

50.0060.00

70.0080.00

90.00100.00

TOTAL IDDM NIDDM

NDR DR

30.834.5

0.0010.00

20.0030.00

40.0050.00

60.0070.0080.00

90.00100.00

TOTAL IDDM NIDDM

NDR BDR PDR/VH

36.431.6

100.00

I (<5 YR) I (5-10YR) I (>10YR) N (<5 YR) N (5-10YR) N (>10YR)

NDR BDR PDR/VH

(11) (19) (25) (68) (81) (46)

RETINOPATHY (Theoretical) RETINOPATHY (Theoretical) CLASSIFICATION:CLASSIFICATION:

BDR : Mild, Mod., BDR : Mild, Mod., Sev.Sev.

PPDR (Florid)PPDR (Florid) PDRPDR GLIOSIS AND TRDGLIOSIS AND TRD END STAGE : NVI, END STAGE : NVI,

NVGNVG

Clinically significant Macular oedema can exist at any stage

BDR : MILDBDR : MILD

MICROANEURYSMSMICROANEURYSMS DOT HAEMORRHAGESDOT HAEMORRHAGES HARD EXUDATESHARD EXUDATES SOFT EXUDATESSOFT EXUDATES

OCCASIONAL

MICROANEURYSMSMICROANEURYSMS

BDR : MODERATEBDR : MODERATE

HARD EXUDATESSOFT EXUDATESRETINAL THICKENING

SEVERE BDR & PPDR: SEVERE BDR & PPDR: Blot Haem Blot Haem 44 Quadr. Quadr. Venous Beading Venous Beading 22 Quadrants, Quadrants, IRMA IRMA 11 quadrant. quadrant.

( 45% go to PDR in one yr.)( 45% go to PDR in one yr.)

PDR PDR VENOUS DILATATIONS AND VENOUS DILATATIONS AND BEADING, LARGE AREAS OF IRMA, BEADING, LARGE AREAS OF IRMA,

NON-PERFUSION, NVENON-PERFUSION, NVE

PDR PDR VENOUS DILATATIONS AND VENOUS DILATATIONS AND BEADING, LARGE AREAS OF IRMA, BEADING, LARGE AREAS OF IRMA,

NON-PERFUSION, NVENON-PERFUSION, NVE

PDR : NVDPDR : NVDSUBHYALOID AND VITREOUS SUBHYALOID AND VITREOUS

HEMORRHAGESHEMORRHAGES

High Risk : NVD > 2/3 rd, NVE 2 places, V.H

STAGE OF FIBROUS STAGE OF FIBROUS PROLIFERATIONPROLIFERATION

GLIOSISGLIOSIS TRDTRD

STAGE OF RUBIOSIS IRIDISSTAGE OF RUBIOSIS IRIDIS

NVINVI NVGNVG

TREATMENT ORIENTED TREATMENT ORIENTED OUTLOOKOUTLOOK

WHEN & HOW SHOULD WE TREAT ?WHEN & HOW SHOULD WE TREAT ? IDENTIFY :IDENTIFY :

1 CSME & differentiate from1 CSME & differentiate from

MACULAR ISCHEMIA AND MACULAR ISCHEMIA AND

HAEMORRHAGE HAEMORRHAGE

2 PRE-PROLIFERATIVE STAGE2 PRE-PROLIFERATIVE STAGE

HIGHRISK FACTORSHIGHRISK FACTORS

International Clinical Classification of Diabetic Retinopathy, Severity of Diabetic Macular Edema,

Detailed Table

Mild Diabetic Macular Edema : Some retinal thickening or hard exudates in posterior pole but distant from the macula Moderate Diabetic Macular Edema : Retinal thickening or

hard exudates approaching the center of the macula but not

involving the centerSevere Diabetic Macular Edema : Retinal thickening or

hard exudates involving the center o the macula

CSME : FOCAL CSME : FOCAL

CSMECSME DIFFUSE DIFFUSE

Differenciate from :Differenciate from :MACULAR ISCHEMIA, MACULAR ISCHEMIA,

Differenciate from : Differenciate from : MACULAR HEMORRHAGEMACULAR HEMORRHAGE

CLASSSIFY ACCORDING TO CLASSSIFY ACCORDING TO TREATMENT PROTOCOLS : TREATMENT PROTOCOLS :

BDR + CSME BDR + CSME ( Focal laser )( Focal laser ) PDR + CSME PDR + CSME ( FOCAL + PRP)( FOCAL + PRP) PDR+V.H. NONABSORBINGPDR+V.H. NONABSORBING

( PPVIT)( PPVIT) PDR+MACULAR TRACTION PDR+MACULAR TRACTION

( PPVIT)( PPVIT) TRD TRD ( PPVIT + ENDOLASER)( PPVIT + ENDOLASER)

FACTORS MODIFYING FACTORS MODIFYING CLINICAL PRESENTATIONCLINICAL PRESENTATION

RVORVO CAROTID ARTERY CAROTID ARTERY

DISEASEDISEASE HYPERTENSIONHYPERTENSION

36.431.6

100.00

I (<5 YR) I (5-10YR) I (>10YR) N (<5 YR) N (5-10YR) N (>10YR)

NDR BDR PDR/VH

CHI-SQURE :32.97361 DF : 10 SIGNIFICANCE : .00028

(11) (19) (25) (68) (81) (46)

COMPARISION OF 250 WITH I & N DIABETIC PATIENTS

Today’s SituationToday’s Situation

Summary of the current situationSummary of the current situation Use brief bullets, discuss details verballyUse brief bullets, discuss details verbally Original assumptions that are no longer validOriginal assumptions that are no longer valid

Available OptionsAvailable Options

State the alternative strategiesState the alternative strategies List advantages & disadvantages of eachList advantages & disadvantages of each State cost of each optionState cost of each option

RecommendationRecommendation

Recommend one or more of the strategiesRecommend one or more of the strategies Summarize the results if things go as proposedSummarize the results if things go as proposed What to do nextWhat to do next Identify action itemsIdentify action items

Gos 31 Presentation 1by Dr. Anand Sudhalkar, Baroda

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