Diabetic Retinopathy Source: Kanski's clinical ophtolmology

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DIABETIC
RETINOPATHY
YUZBASHEVA NIHAL 221B

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PREVALENCE
 Prevalence of diabetic retinopathy (DR) in diabetics is
approximately 40%
 More common in type 1 diabetes than in type 2
 Sight-threatening disease is present in up to 10%
 Proliferative diabetic retinopathy (PDR) affects 5-10% of the
diabetic population
 Type 1 diabetics are at particular risk, with an incidence of up to
90% after 30 years

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RISK FACTORS
DURATION OF DIABETES
POOR CONTROL OF DIABETES
PREGNANCY
HYPERTENSION
NEUROPATHY
OTHER RISK FACTORS

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PATHOGENESIS

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Classification
BACKGROUND DIABETIC RETINOPATHY(BDR)
DIABETIC MACULOPATHY
PROLIFERATIVE DIABETIC RETINOPATHY(PPDR)
PDR
ADVANCED DIABETIC EYE DISEASE

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MICROANEURYSMS
HISTOPATHOLOGY
Two arms of a capillary loop that may fuse to become a
microaneurysm
An area of capillary non-perfusion and adjacent
microaneurysms

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MICROANEURYSMS
HISTOPATHOLOGY
microaneurysm with endothelial cell proliferation (cellular
microaneurysm)
eosinophilic (dark pink) degenerate pericytes

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MICROANEURYSMS
Microaneurysms and dot/blot haemorrhages at the posterior
pole
FA shows scattered hyperfluorescent spots in the posterior
fundus

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RETINAL HAEMORRHAGES
Histology shows blood lying diffusely in the retinal nerve fibre
and ganglion cell layers and as globules in the outer layers
retinal nerve fibre layer (flame) haemorrhages

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RETINAL HAEMORRHAGES
dot and blot haemorrhages deep dark haemorrhages

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Exudates
Histology shows irregular eosinophilic deposits mainly in
the outer plexiform layer
small exudates and microaneurysms

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EXUDATES
more extensive exudates, some associated with
microaneurysms;
exudates involving the fovea, including central crystalline
cholesterol deposition – focal laser has recently been
applied superotemporal to the fovea

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EXUDATES
FA of exudates. Clinical appearance exudates not shown on FA

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DIABETIC MACULAR OEDEMA
(DBO)
OCT shows retinal thickening and cystoid FA shows leaking microaneurysms and central diffuse
hyperfluorescence with a flower-petal configuration

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DIABETIC MACULAR OEDEMA
(DMO)
Focal diabetic maculopathy. A ring of hard exudates
temporal to the macula
FA late phase shows focal area of hyperfluorescence
due to leakage to the centre of the exudate ring

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DIABETIC MACULAR OEDEMA
(DMO)
Diffuse diabetic maculopathy. Dot and blot haemorrhages
– diffuse retinal thickening is present
late-phase FA shows extensive hyperfluorescence
at the posterior pole due to leakage

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ISCHAEMIC MACULOPATHY
Ischaemic diabetic maculopathy. FA venous
phase shows hypofluorescence due to
capillary non-perfusion at the central
macula and elsewhere

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COTTON WOOL SPOTS
Histology shows cytoid bodies in the retinal
nerve fibre layer

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COTTON WOOL SPOTS
Clinical appearance red-free photography showing differing appearance of
cotton wool spots and haemorrhages

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VENOUS CHANGES
Looping Beading Severe Segmentation

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INTRARETINAL MICROVASCULAR
ABNORMALITIES
Histology shows arteriolar-venular shunt and a few
microaneurysms within a poorly perfused capillary;
phase contrast microscopy
Clinical appearance

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PROLIFERATIVE RETINOPATHY
Disc new vessels - Mild severe FA shows leaking disc vessels, with extensive
peripheral capillary dropout and a small focus of
leaking vessels elsewhere

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PROLIFERATIVE RETIONOPATHY
New vessels elsewhere. Mild Severe Associated with fibrosis

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PROLIFERATIVE RETINOPATHY
New vessels on the iris (rubeosis iridis)

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TREATMENT
PATIENT EDUCATION
DIABETIC CONTROL
OTHER RISK FACTORS (CONTROLLED)
FENOFIBRATE
SMOKING(DISCONTINUED)
OTHER MODIFIABLE FACTORS (CONTROLLED)

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TREATMENT OF DIABETIC MACULAR
OEDEMA
Laser photocoagulation
Subthreshold micropulse diode laser
Intravitreal anti-VEGF agents (ranibizumab and bevacizumab)
Intravitreal triamcinolone
Pars plana vitrectomy
Specific recommendations

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LASER PHOTOCOAGULATION

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LASER PHOTOCOAGULATION
Prior to focal laser treatment Immediately following focal laser

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LASER PHOTOCOAGULATION
prior to modified macular grid laser treatment immediately post-grid laser

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LASER PHOTOCOAGULATION
appearance 2 months following a limited laser grid

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PARS PLANA VITRECTOMY
Preoperative appearance
Appearance several weeks postoperatively

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PARS PLANA VITRECTOMY
pre- and postoperative macular OCT scans

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LASER TREATMENT FOR
PROLIFERATIVE RETINOPATHY
Limited panretinal photocoagulation, with fresh
retrohyaloid haemorrhage
more extensive treatment

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LASER TREATMENT FOR
PROLIFERATIVE RETINOPATHY
retinal appearance several weeks after laser composite image of ‘pattern scan’ multispot array
treatment

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LASER TREATMENT FOR
PROLIFERATIVE RETINOPATHY
Informed consent
Co-existent DMO
Lens
Anaesthesia
Laser parameters
Review
Indicators of regression

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LENS PARAMETERS
SPOT SIZE
DURATION
POWER
SPACING
EXTENT OF TREATED AREA
PATTERN OF TREATMENT

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Targeted retinal photocoagulation
(TRP)
Wide-field FA showing widespread areas of capillary non-perfusion – the arrow indicates a well-
defined example

38. z THANK YOU FOR ATTENTION!