DIABETIC

RETINOPATHY

Dr Hina Amber
WMO Ophthalmology
Eye unit 2
What is diabetic eye disease?
Diabetic Retinopathy
It is the disease of retina
caused by microangiopathy due to
long term effect of hyperglycemia
leading to progressive damage to
retina.
DR is common in which type of diabetes?
In type 1 DM
• Duration of DM (common in type 1 due to prolong duration)
• Poor Metabolic control (increase HbA1C associated with increased
risk)
Does diabetic retinopathy progresses in
pregnancy ?
 Yes
• Increased hormones level in pregnancy cause the vascular changes by
increasing vascular permeability and increase release of VEGF by placenta
cause significant progression of DR
What is the relation between diabetic
retinopathy and diabetic nephropathy?
Level of renal impairment in DN is proportional
to the damage of retina in DR
Diabetic nephropathy always precedes the diabetic retinopathy.
Renin-angiotensin levels raised in DN which cause microvascular
complications in eye including vasoconstriction, inflammation, oxidative
stress, cell hypertrophy & proliferation, angiogenesis & fibrosis
Name the drug used in treatment of DN helps
to reduce progression of DR?
ACE inhibitors
• They reduces the microvascular abnormalities by improving glucose
metabolism
What should be the desired blood pressure level in
pt with both hypertension & DM to delay the
progression of DR?
BP should strictly control below 140/80mmHg

• Systemic hypertension is common in pt with type 2 DM. In hypertension

vasoconstriction & high blood flow cause damage to retinal endothelial cells.
Which results in increase permeability, edema formation, hemorrhages and
relase of VEGF which worsen the DR
Can anemia worsen DR?
 Yes
Anemia cause retinal hypoxia which leads to infarction of nerve fiber
layer and clinically menifest as cotton wool spots. Retinal hypoxia also
leads to vascular dilatation and microtraumas to vessels wall results in
hemorrhages and edema
Can vit D worsen Diabetic retinopathy?
No
Vit D exerts an anti inflammatory effect by decreasing the
proliferation of lymphocytes, natural killer cells and severe pro-
inflammatory cytokines. So it slows the progression of disease.
Does smoking has any effect on DR?
Smoking worsen the disease
Smoking reduced retinal blood flow and also reduce the ability of
retinal blood vessels to autoregulate to hypoxia due to vasoconstrictive
effect of nicotine
In pt with hyperlipidemias which sign of DR
is numerous?
Hard exudates
Which eye conditions protect against
progression of DR?
High myopia, choroidal degeneration & extensive old chorio
retinopathy PROTECT against DR
these conditions believed to act in the same manner as Pan retinal
photocoagulation by reducing the metabolic needs of retina..
 What is the pathophysiology of
Neovascularization in diabetic retinopathy?
Pathophysiology
Pathophysiology
What are the symptoms of DR?
Symptoms
DR is asymptomatic in early stages. As disease progress symptoms
may include
• Blurred vision
• Floaters
• Dark spots in vision
• Distorted vision
• Poor night vision
• Impaired color vision
• Partial or complete loss of vision
Dark spots in DR
Which is the earliest sign of DR?
Microaneurysms

Localized saccular outpouching

of capillary wall. Usually seen in
the area of capillary non perfusion
appears as red dot.
it is the earliest sign of DR
 What is the difference between dot blot & flame
shaped hemorrhages?
 Retinal Hemorrhages
• Dot & Blot Hemorrhages
Deep hemorrhages present in inner
nuclear or outer plexiform layer. Usually
round or oval in shape

• Flame shaped or splinter

hemorrhages
More superficial, present in nerve fiber
layer
Dot blot & flame shaped hemorrhages
What is the difference between hard exudates
and cotton wool spots?
Hard exudates

Intra retinal yellowish

deposits of lipids and
lipoproteins leaks from
surrounding capillaries and
microaneurysms. Located
mainly within outer plexiform
layer.
Hypofluorescent on FA
Cotton wool spots
Also called soft exudates or
nerve fiber layer infarcts.
White fluffy lesions in nerve
fiber layer results from
occlusion of retinal pre
capillary arterioles.
Hypofluorescent on FA
Hard exudates & soft exudates
What venous changes occur in DR?
 Venous Beading
Sign of severe PDR. Sausage shaped dilatation of retinal veins.
Veous looping and segmentation also occur
What are IRMAs?
 Intraretinal microvascular abnormalities
Abnormal dilated retinal
capillaries (arterio-vanular
shunt) or may represent
intraretinal neovascularization
which has not breached the
internal limiting membrane
and act to supply the area of
non perfusion.
What is the diagnostic sign of PDR?
Neovascularization
Diagnostic sign of proliferative
diabetic retinopathy. Newly
formed blood vessels or fibrous
tissue or both arising from retina
or optic disc & extending along
the inner surface of retina or
optic disc or vitreous cavity
Rhobiosis iridis (iris neovasscularization)
What is diabetic maculopathy?
 Diabetic Maculopathy
It is the most common cause of
visual impairment in diabetic
patients particularly type ll
Diabetic macular edema is due to
capillary leakage & fluid is initially
located between the outer
plexiform and inner nerve fiber
layer. With further accumulation of
fluid the fovea assumes a cystoid
appearance known as cystoid
macular edema
What are different types of diabetic macular
edema?
Types of diabetic maculopathy
4 types
1: Focal diabetic maculopathy
2: Diffuse diabetic maculopathy
3: Ischemic diabetic maculopathy
4: Mixed
Focal Diabetic Maculopathy
• Well circumscribed retinal
thickening and focal edema
• Circinate hard exudates
• Focal hyperfluorescence on FA
Diffuse Diabetic Maculopathy
• Diffuse retinal thickening
• Frequent cystoid macular
edema
• Generalized hyperflourescence
on FA
Ischemic Diabetic Maculopathy
• Occurs as a result of non perfusion
of parafoveal capillaries with or
without intraretinal fluid
accumulation
• Macula appears relatively normal
• Poor visual acuity
• Capillary non perfusion on FA
Mixed Diabetic Maculopathy
Diabetic maculopathy rarely exist
isolated and most commonly have
two or more of the component
Define CSME?
Classification of DR according to severity
Proliferative DR
Classification of DME
What systemic and ocular investigations
should be done in pt with DR?
Investigations
Systemic Investigation
• Serum blood sugar level & HbA1c
• Fasting lipid profile
• RFTs
• Monitor BP

Ocular investigation
• complete ocular examination (VA, IOP, slit lamp examination, light reflex)
• Dilated fundus examination
• Optical coherence tomography
• Ultrasonography (B scan)
• Fundus photography (for documentation purpose)
• Fundus fluorescein angiography
OCT and FFA
B-scan
How will you manage pt with DR?
Management
• Observation & follow up
• Medical treatment
• Topical NSAIDs
• Laser therapy
• Anti VEGF agents
• Vitrectomy
When a diabetic pt should go for eye
examination ?
Depends upon type of diabetes
• For type 1 diabetes: after 5 years of diagnosis
• for type 2 diabetes: at the time of diagnosis
What Medical treatment should be consider
in pt with DR?
Medical treatment
To control systemic factors
• Anti diabetics (to control blood sugar levels. HbA1c must be in 6-7%
range)
• Anti hypertensive (should maintain below 140/80 mmHg)
• Lipid lowering drugs
• Renal function markers should be within normal limits
Which topical agent is used in treatment of
DME?
Topical NSAIDs
• Topical nepafenac eye drops used to treat DME. It reduces vascular
permeability by inhibiting the inflammatory cascade
What laser options are available for DR?
 Laser therapy
• Panretinal photocoagulation
• Procedure involves creating thermal burns in peripheral retina leading to
tissue coagulation to improve retinal oxygenation
• Spot size 200-500 um
• Duration 0.1- 0.3 sec
• Power 100-600 mwatt
• PRP is done in 3 sessions . In 1st session inferior quadrant PRP is done
followed by superior quadrant in 2nd session then nasal & temporal
quadrant in 3rd session
Indications of PRP

• High risk PDR (3/4)

• Vitreous or preretinal hemorrhage
• New vessels on optic disc or
within 1500 microns from disc rim
• Large new vessels
• NVA or NVI
• CSME
Argon focal laser
• Used to treat focal diabetic macular
edema in PDR as well as in NPDR.
Burns are applied to
microaneurysms & microvascular
lesions in the center of ring if
exudates located 500-3000 um
from center of macula
• Spot size 50-100um
• Duration 0.1 sec
• Power 100-150 mwatt
Grid laser
• Used to treat diffuse CSME.
Burns are applied at area of
diffuse retina thickness more
than 500um from center of
macula & 500 um from
temporal margin of optic disc
• Spot size 50 to 100 um
• Duration 0.1 sec
• Power 100-300 mwatt
What are the different anti VEGF available to
treat DME?
Intravitreal Anti VEGF
• BEVACIZUMAB (AVASTIN)
• Recombinant humanized monoclonal antibody that block
angiogenesis by inhibiting VEGF-A
• Typical dose is 1.25 mg in 0.05ml in adults and half that dose in
children administered at 4-6 weeks interval, this varies widely based
on disease & response
• Its half life is 20 days
• It has long duration of action & slow clearance
RANIBIZUMAB (Patizra/Lucentis)
• Antibody fragments inhibits the biological activity of VEGF-A
• Dose is 0.5mg/0.05ml
• Half life is 9 days
• 140 times higher affinity & 100 folds faster clearance than
bevacizumab
AFLIBERCEPT (Eylea)
• Recombinant fusion protein consisting of VEGF binding portion of
human VEGF receptor 1& 2
• Dose is 2mg/ 0.05ml every 4 weeks for the first 3 months followed by
2mg /0.05ml once after 8 weeks
What are the contraindications of intravitreal
anti VEGFs?
Contraindications of Anti VEGF
Major systemic events in past 3 months
• Stroke
• Cardiac arrest / MI
• Uncontrolled hypertension
At what BP reading anti VEGF
administration should be postpone ?
If bp is more than 150/80 mmHg delay
intravitreal administration of anti VEGF and
start antihypertensive therapy
Can we use intravitreal steroids for treatment
of DME?
Intravitreal steroids
Intravitreal triamcenolone ( 4mg/ 0.1ml) is indicated when DME ia
associated with traction from thickened posterior hyaloid.
What are the indications of PPV in DR?
Pars plana vitrectomy
• Indications
• Severe persistent vitreous
haemorrhage
• Progressive tractional RD involving
macula
• Combine tractional &
rhegnatogeneous RD
• Premacular subhyaloid hemorrhage
• recurrent vitreous hemorrhage
after PRP
What are the D/D of diabetic retinopathy and
their differentiating points?
Differential diagnosis of diabetic
retinopathy
• Hypertensive retinopathy
• radiation retinopathy
• Central retinal vein occlusion
• Ocular ischemic syndrome
• sickle cell retinopathy
• Anemic retinopathy
• Other microvasscular retinopathies
Hypertensive retinopathy
Compared to DR
Rare dot blot hemorrhages
• Flame shaped hemorrhage are
common
• Multiple cotton wool spots
• Macular edema rare
• AV nicking
• Disc edema
Radiation retinopathy
• NVD less common
• CNV and telangiectasis more
common
• Associated radiation
keratopathy, radiation cataract &
radiation optic neuropathy
Central retinal vein occlusion
• No dot blot hemorrhages
• No microaneurysms
• Flame shaped hemorrhage in all
quadrants
• Tortuous vessels
• rare hard exudates
• Optic disc edema common
Ocular ischemic syndrome
• Rare flame shaped hemorrhage,
common dot blot hemorrhages
• No hard exudates
• Rare macular edema
• Macular telangietasis
Anemic retinopathy
• Roth spots diagnostic
Sickle cell retinopathy
• Salmon patch hemorrhage
• Sea fan neovascularization
• Black sunburst (peripheral
chorioretinal scar)