Diabetes melitis & eye part 1 presentation at www.eyenirvaan.com

1. DIABETES MELLITUS
& EYE – PART 1
Pradnya Gogate B. Optom,
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2. Diabetes mellitus
 Endocrinological disorder
 Insulin is necessary for cells to properly
utilize glucose as a fuel
Absence of insulin
Reduction of insulin
Reduced receptor ability to use insulin
 Improper glucose production and use

3. Affected organs
 Eyes
 Kidney
 Nervous system
 Heart

4. Diabetes and eye
 Optics
 Lids
 Conjunctiva
 Cornea
 Iris
 Lens
 Accommodation
 Intra ocular pressure
 Vitreous
 Retina
 Retinal occlusive
diseases
 Optic disc
 Glaucoma
 Cranial nerves

5. Optics
 Myopic shift
 Increase in blood sugar
level
 Hyperglycemia
 Increase in osmotic
pressure of crystalline lens
 Increase in refractive
index of lens

6. Optics
 Hypermetropic shift
 Decrease in blood sugar level
 Hypoglycemia
 Decrease in osmotic
pressure of crystalline lens
 decrease in refractive index
of lens

7. Lids
 Prone to infections due
to high blood sugar
level
 Recurrent styes and
internal hardeolam
 Infection may spread
and cause orbital
cellulites

8. Conjunctiva
 Tortuous and more
constricted blood
vessels
 Conjunctival
microaneurysms

9. Cornea
 Superficial punctate
keratitis
 Delayed epithelial
healing
 Decreased corneal
sensation

10. Iris
 Rigid pupils – difficult
mydriasis
 Rubeosis iridis
 Neovascularisation of iris
 Retinal hypoxia
 Release of vasoproliferative
substance (angiogenic
factor)

11. Lens
 Pre-senile cataract
 True diabetic cataract
(snow-flake/snow-storm
cataract)

12. Accomodation
 Weakness of ciliary
body
 Decrease in
accommodation
 Precipitates presbyopia

13. Intra ocular pressure
 Risk factor for primary open angle glaucoma
(POAG)
 IOP increases in neovascular glaucoma

14. Vitreous
 Vitreous
haemorrhages
 Posterior vitreous
detachment

15. Retina
 Pathogenesis of Diabetic
retinopathy
 Microvascular occlusion
 Microvascular leakages

16. Microvascular occlusion
 Thickening of capillary basement membrane
 Capillary endothelium cell damage and
proliferation
 Changes in red blood cells leading to
defective oxygen transport
 Increased stickiness and aggregation of
platelets

17. Vascular changes in diabetic
retinopathy
 Microaneurysms
 Microvascular
occlusions
 New vessels

18. Consequences of Microvascular
occlusion
 Arteriovenous shunts(IRMA’s)
 Intra Retinal Microvascular abnormalities
 Due to areas of capillary drop outs
 Run straight course from venule to arteriole
 Never cross major retinal vessels
 Never leak extensively in FFA

19. Consequences of Microvascular
occlusion
 Neovascularisation
 Hypoxic retinal tissue
 Release of vasoformative substance
 NVD- Neovascularisation at disc and within one
disc diameter from disc
 NVE – Neovascularisation elsewhere
 Rubeosis iridis

20. Neovascularisation

21. Microvascular leakages
 Endothelial and pericytes tight cell
junction(1:1)
 Loss of pericytes
 Disruption of blood-retinal barrier
 Leakage of plasma constituents in retina
 Microaneurysms (out-pouching of blood
vessels)

22. Consequences of Microvascular
leakages
 Diffuse retinal oedema
 due to extensive capillary dilatation
 Localized retinal oedema
 Due to focal leakage from Microaneurysms
 Hard exudates
 At the junction of healthy and oedematous retina
 Composed of lipoprotein and lipid-laden
macrophages
 Form in a circinate pattern

23. Pathogenesis of Diabetic
retinopathy

24. Retinal changes in diabetic
retinopathy

25. Diabetic maculopathy
 Focal diabetic maculopathy
 Cystoid diabetic maculopathy(diffuse)
 Ischemic diabetic maculopathy
 Mixed diabetic maculopathy

26. Focal diabetic maculopathy
 Features of background diabetic
maculopathy in macular area
 Microaneurysms-
 Hard exudates-
 Flame shaped haemorrhages
 Dot-blot haemorrhages

27. Cystoid diabetic
maculopathy(diffuse)
 Few Microaneurysms, haemorrhages and hard
exudates
 Extensive macular oedema with accumulation of
extracellular fluid in Henel’s layer
 Formation of microcystic spaces
 FFA shows diffuse leakage at at posterior pole with
a ‘flower petal’ pattern with relatively perfused
macular area
 Persistent oedema may lead to formation of lamellar
hole at fovea

28. Cystoid diabetic
maculopathy(diffuse)

29. Ischemic diabetic maculopathy
 Few Microaneurysms, haemorrhages and
hard exudates
 Macular oedema varying from mild to Cystoid
 FFA reveals areas of capillary non-perfusion
in macular and paramacular regions

30. Mixed diabetic maculopathy
 Shows most of the features of before
mentioned types of diabetic maculopathies
 Significant exudates, oedema and ischemia

31. Clinically significant macular
oedema
 Retinal oedema within 500micron from fovea
 Hard exudates within 500micron of fovea with
adjacent retinal thickening may outside
500microns
 Retinal oedema of one disc diameter or
larger present within one disc diameter from
fovea

32. Clinically significant macular
oedema
 Irregular FAZ
 Microaneurysms
around FAZ leaking
in late stages of
angiogram
suggestive of CSMO

33. Management of diabetic
maculopathy
 Laser
photocoagulation
 Focal treatment – for
treatment of macular
oedema due to focal
leakage

34. Management of diabetic
maculopathy
 Grid treatment – for
macular oedema due to
diffuse leakage (CME
pattern)
 Laser is applied in a
series of circles around
fovea to reduce swollen
areas

35. Continued in Part II