3. Diabetes mellitus
Group of common metabolic disorders
Caused by a complex interaction of genetics and environmental factors
Lack of insulin hyperglycemia
Diagnostic criteria : Fasting plasma glucose > 126 mg/dl
Type 1 DM – Insulin-dependent diabetes (IDDM)
Results from pancreatic beta-cell destruction, usually leading to absolute or near total
insulin deficiency
Type 2 DM - Non-insulin-dependent diabetes (NIDDM)
Variable degrees of insulin resistance and impaired insulin secretion, resulting in
hyperglycemia and other metabolic derangements due to insufficient insulin action.
4. Diabetes mellitus
Long-standing hyperglycemia leads to multiple organ damage
Macrovascular complications
Stroke
Heart disease and hypertension
Peripheral vascular disease
Foot problems
Microvascular complications
Diabetic eye disease : retinopathy and cataracts
Renal disease
Neuropathy
Foot problems
5. Diabetic retinopathy
The most severe of ocular complications of diabetes
Caused by damage to blood vessels of the retina, leads to
retinal damage
Microvascular complication of longstanding diabetes mellitus [1]
Most prevalence cause of legal blindness between the ages of
20 and 65 years
Common in DM type 1 > type 2
6. Risk factors
Duration of diabetes
Most important
Pt diagnosed before age 30 yr
50% DR after 10 yrs
90% DR after 30 yrs
Poor metabolic control
Less important, but relevant to development and progression of DR
HbA1c ass. with risk
Pregnancy
Ass with rapid progression of DR
Predicating factors : poor pre-pregnancy control of DM, too rapid control
during the early stages of pregnancy, pre-eclampsia and fluid imbalance
7. Risk factors
Hypertension
Very common in patients with DM type 2
Should strictly control (<140/80 mmHg)
Nephropathy
Ass with worsening of DR
Renal transplantation may be ass with improvement of DR and
better response to photocoagulation
Other
Obesity, increased BMI, high waist-to-hip ratio
Hyperlipidemia
Anemia
9. Microvascular leakage
Degeneration and loss of pericytes Capillary wall weakening
Plasma leakage microaneurysm
Retinal edema
Hard exudate Intraretinal hemorrhage
(Circinate pattern)
10. Non-proliferative diabetic retinopathy
Right eye: Micro aneurysm, few flame-shaped and dot-blot hemorrhages and hard
exudate [with hard exudate in macula area] , neovascularization
moderate non proliferative diabetic retinopathy
Left eye: Micro aneurysm, numerous flame-shaped and dot-blot hemorrhage [more than
20 dots in 4 quadrant], hard exudate [with hard exudate in macula area]
neovascularization severe non proliferative diabetic retinopathy
18. Severe NPDR
4-2-1 rule
4 quadrants of severe retinal hemorrhages
2 quadrants of venous beading
1 quadrant of IRMA
Very severe NPDR more than 1 of above
19. Microaneurysm
Localized saccular outpouchings of capillary wall red dots
Focal dilatation of capillary wall where pericytes are absent
Fusion of 2 arms of capillary loop
Usually seen in relation to areas of capillary non-perfusion
at the posterior pole esp temporal to fovea
The earliest signs of DR
22. Retinal Hemorrhage
Capillary or microaneurysm is weakened rupture
intraretinal hemorrhages
Dot & blot hemorrhages
Deep hemorrhage - inner nuclear layer or outer plexiform layer
Usually round or oval
Dot hemorrhages - bright red dots (same size as large microaneurysms)
Blot hemorrhages - larger lesions
Flame-shape or splinter hemorrhages
More superficial - in nerve fiber layer
Absorbed slowly after several weeks
Indistinguishable from hemorrhage in hypertensive retinopathy
May have co-existence of systemic hypertension BP must be checked
27. Hard exudate
Intra-retinal lipid exudates
Yellow deposits of lipid and protein within the retina
Accumulations of lipids leak from surrounding capillaries and
microaneuryisms
May form a circinate pattern
Hyperlipidemia may correlate with the development of hard
exudates
28.
29. Cotton Wool Spot
White fluffy lesions in nerve fiber layer
Result from occlusion of retinal pre-capillary arterioles
supplying the nerve fibre layer with concomitant swelling of
local nerve fibre axons
Also called "soft exudates" or "nerve fiber layer infarctions"
Fluorescein angiography shows no capillary perfusion in the
area of the soft exudate
Very common in DR, esp if pt with HT
34. Venous beading
Dilatation and beading of retinal vein
Appearance resembling sausage-shaped dilatation of
the retinal veins
Sign of severe NPDR
35.
36. Intra-retinal microvascular
abnormalities (IRMA)
Abnormal dilated retinal capillaries or may represent
intraretinal neovacularization which has not breached
the internal limiting membrane of the retina
Indicate severe NPDR rapidly progress to PDR
37.
38. Area of capillary non-perfusion
FA shows extensive areas of hypofluorescence due to
capillary non-perfusion and venous beading
39. Diabetic maculopathy
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
Ass with planning for treatment
43. Clinical Significant Macular Edema
(CSME)
1 of 3
Retinal edema Hard exudates within Retinal edema > 1 disc
within 500 microns 500 microns of fovea diameter, any part is
of centre fovea if ass with adjacent within 1 disc diameter
retinal thickening of centre of fovea
68. Signs & symptoms of DR
Blurred or distorted vision or difficulty reading
Floaters
Partial or total loss of vision
a shadow or veil across patient’s visual field
Eye pain
85. Medical therapy
Prevention
Treat underlying conditions
Control blood sugar – HbA1c < 7
Control blood pressure – SBP < 130 mmHg
Control lipid profile – TG, LDL
Correct anemia
Control diabetic nephropathy
Pregnancy makes DR worsen
86. Laser
Panretinal photocoagulation (PRP)
High-risk PDR (3/4)
Vitreous or preretinal hemorrhage
New vessels
New vessels on optic disc or within 1,500 microns from optic
disc rim
Large new vessels
Iris or angle neovascularization
CSME
88. Laser panretinal photocoagulation (PRP)
Inducing involution of new vessels
Preventing vitreous hemorrhage and preventing visual loss
Limitations :
Patient must have clear lens and vitreous
If cataract treat before laser PRP
If vitreous hemorrhage vitrectomy + laser photocoagulation
92. Surgery
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
94. Screening for DR
Juvenile onset DM > 5 years then every year
Adult onset DM at diagnosis (> 30) then every year
DM with pregnancy in first trimester then every trimester
95. Follow up
Retinal abnormality Follow up
Normal or rare microaneurysms Once a year
Mild NPDR q 9 months
Mod NPDR q 6 months
Severe NPDR q 4 months or laser
CSME q 2-4 months ** or laser
PDR q 2-3 months ** or laser
100. Past history
Underlying diseases : DM poor controlled ,
HT poor controlled
Current medication
metformin 500 mg 2*1 o pc
Nifedipine 20 mg 1*2 o pc
Amlopine 10 mg 1*1 o pc
101. Physical examination
GA : a middle aged woman with normal
consciousness, good co-operation
V/S : T 36.9 BP 157/83 mmHg P 94/min
RR 16/min
HENT : no discharge per ears, nose, no
bleeding per gum, cervical LN cant’ be
palpable
Heart : normal S1S2, no murmurs
Lungs : clear & equal breath sounds both
lungs
102. Ocular examination
OD OS
VA c C 6/9 -2 Pj
VA c PH 6/9 -
Lids & Lashes & Normal Normal
Conjunctiva
Cornea Clear Clear
Iris
Lens Clear Clear
Anterior chamber Normal depth, clear Normal depth, clear
Pupil 3 mmRTLBE RAPD -
EOM Full Full
IOP 20 20
103. Fundus examination
OD OS
Red reflex Normal Normal
Vessels Normal 2:3 Normal 2:3
Background & Macula Dot & blot hemorrhage dot blot hemorrhage ,
NVE NVE , old hemorrhage
Fibrous and retinal break
involve macula
Disc No NVD , C:D 0.3 No NVD , C:D 0.3
105. Problem list
Unilateral chronic painless visual loss
Flashing and Floaters
Poor controlled DM, poor controlled HT
Dot & blot hemorrhages with NVE BE
Fibrous & Retinal break involve macula LE
108. Management in this case
DR
LE
PPV
Pars plana vitrectomy
membrane peeling Indications for PPV in DR
Severe persistent VH
Endolaser Progressive tractional RD
Combined TRD & RRD
silicone oil injection Premacular subhyaloid hemorrhage
Recurrent VH after laser PRP
