CASE DATA

Demography: 51 year-old male

Chief Complaint: Deterioration of distance and near vision over a period of three months

Illness: Spots or dark strings floating in vision (floaters),Blurred vision, impaired color vision

Ocular History: Last eye test: A year ago

Medical History: Poorly controlled insulin dependent Diabetes Mellitus for the last 10 years

Fundus Examination: Blot and dot hemorrhages Few hard exudates in the macular area, Retinal edema

Fluorescein Angiography: Extensive leakage supero-temporal to the optic disc

DIABETIC RETINOPATHY

Diabetic Retinopathy refers to the retinal changes seen in patients with Diabetes mellitus

6 MILLIONDiabetics

•STDR•As on April 2015

10 MILLIONDiabetics

•Projected STDR•By 2035

PATHOGENESIS

• Micro vascular occlusion• Micro vascular leakage

LOCATION DISORDERCapillary Occlusion  Dilatation  Micro aneurysms  Abnormal  PermeabilityArteriole Narrowing  of origin  of Terminal  arteriesVein Dilatation  Beading  Reduplication  Looping, Kinking  Branch vein occlusion  Central veins occlusion

RETINAL VASCULAR PATHOLOGY IN DIABETIC RETINOPATHY

MICROVASCULAR LEAKAGE

Degeneration and loss of pericytes

Plasma leakage

Intraretinal hemorrhageHard exudate(Circinate pattern)

Capillary wall weakening

micro aneurysm

Retinal edema

MICROVASCULAR OCCLUSION

Neovascularizationand fibrovascular proliferation

VEGF

Increased plasma viscosityDeformation of RBCIncreased platelets stickiness

Decreased capillary blood flow

and perfusion

Endothelial cell damage and proliferation

Capillary basement membrane thickening

Retinal hypoxia

A-V shuntIRMA*

*intraretinal microvascular abnormalities

Proliferative retinopathy

Rubeosis iridis

ETIOLOGY

Duration of Diabetes

• Sex

Poor metabolic control

• Pregnancy

Hypertension

• Hyperlipidemia

Others-obesity, OCP’s, Anaemia, Smoking

TYPESDiabetic retinopathy

Non-Proliferative

Proliferative

Maculopathy

Advanced diabetic eye disease

NPDR

MildModerat

esevere

Very severe

ETDRS CLASSIFICATION(Modified Airlie House Classification)

FEATURES OF NPDR

Splinter

haemorrhage

Dot & Blot haemorrhage

s

Cotton wool spots

Hard exudates

Hard exudates

Cotton wool spots

↑↑

Dilatation & beading of veins

Intraretinal microvascular abnormalities

Microaneurys

ms

Neova

scul

arizat

ion

of d

isc

↑

New vessels of the disc (advanced)

New vessels elsewhere

• Macular ischemia• Retinal capillary non-perfusion• Progressive NPDR

• Macular edema• Increased retinal vascular

permeability• Seen in both NPDR and PDR• Focal or diffuse or mixed• Cause of visual loss in DR

DIABETIC MACULOPATHY

FOCAL MACULAR OEDEMA

DIFFUSE MACULAR OEDEMA

MACULAR ISCHEMIA

CLINICALLY SIGNIFICANT MACULAR OEDEMA (CSME)

Retinal oedema within 500 microns

of centre fovea

Hard exudates within 500 microns of fovea

if as with adjacent retinal thickening

Retinal oedema > 1 disc diameter, any part

is within 1 disc diameter of centre of

fovea

OCT CLASSIFICATION OF DIABETIC MACULAR OEDEMA

• Sponge like thickening of retinal layers due to accumulation of fluid.

• Large cystoid space involving variable depth of retina with intervening septa.

• Serous detachment of retina.• Tractional detachment of fovea.• Taut posterior hyaloid membrane.

VISION IN DR

ADVANCED DIABETIC EYE DISEASE

End result of uncontrolled proliferative Diabetic retinopathy.COMPLICATIONS:

Vitreous haemorrhage

Tractional retinal detachment

Neovascular glaucoma

Rubeosis iridis

INVESTIGATIONS

Blood sugar

OCT

Haemogram

24hr urine

retentionRFT

urine

Lipid profile

HbA1C

FFA

MANAGEMENT

SCREENING

MEDICAL THERAPY

PHOTOCOAGULATION

Prevention Treat underlying conditions

Control blood sugar – HbA1c < 7Control blood pressure – SBP < 130 mmHgControl lipid profile – TG, LDLCorrect anemiaControl diabetic nephropathy

Pregnancy makes DR worsen

MEDICAL THERAPY

Focal or Grid • CSME in both NPDR

and PDRPanretinal

• PDR

PHOTOCOAGULATION

FOCAL PHOTOCOAGULATION

GRID PHOTOCOAGULATION

PANRETINAL PHOTOCOAGULATION (PRP)

• Indications for pars plana vitrectomy (PPV) in DR• Severe persistent vitreous hemorrhage• Progressive tractional RD (threatening or

involving macula)• Combined tractional and rhegmatogenous

RD• Premacular subhyaloid hemorrhage• Recurrent vitreous hemorrhage after laser

PRP

SURGICAL MANAGEMENT

• Pars plana vitrectomy (PPV)• Membrane peeling (MP)• Endolaser (EL)• Fluid gas exchange (FGX)

• SF6

• C3F8

VITREORETINAL SURGERIES

CHANCES OF GOING BLIND

AGE(yrs)

FUNDUS LESION

% OF BLIND PATIENTS

<29 Retinal microaneurysms

Intraretinal hemorrhages+ Hard

exudates

0

4

30-59 Retinal microaneurysms

Intraretinal hemorrhages+ Hard

exudates

12

24

(within 5yrs of onset of disease)

Hypertensive retinopathyRadiation retinopathyCentral retinal vein

occlusion (CRVO)Branch retinal vein

occlusion (BRVO)Ocular ischemic syndromeHIV-related retinopathy

DIFFERENTIAL DIAGNOSIS

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