Prevention of blindness in Diabetic Retinopathy

1. Prevention of blindness in diabetes mellitus
Dr Md Afzal Mahfuzullah
MCPS,FCPS
Felow Vitreo Retina
Assistant Professor (Vitreo Retina)
Department Of Ophthalmology
Bangabandhu Sheikh Mujib Medical University

2. Diabetes mellitus
 Diabetes is one of the most prevalent and serious non- communicable
diseases all over the world.
 Among the adults (age 20-79 years) with diabetes in the top five South
East Asian countries, Bangladesh is in the second position.

3. Diabetes mellitus, Cont
 The number of people with diabetes in Bangladesh was 5.10
million in 2013, which is expected to increase to 8.20 million
by 2035.
 Reason for blindness in diabetes is due to diabetic retinopathy

4. Diabetic Retinopathy
 Diabetic retinopathy is the major ocular complication associated with
diabetes.
 It represents the leading cause of legal blindness in the working-age
population of developing countries.
 Classically diagnosis is based on abnormalities of the retinal
microvasculature,

5. Diabetic Retinopathy, Cont
 Diabetic retinopathy is now widely recognized as a neurovascular
disease.
 All patients with diabetes are at increased risk for eye disease
including diabetic retinopathy, proactive measures, and timely
intervention can prevent or delay subsequent vision loss.

6. Diabetic Retinopathy, Cont
 Systemic management of diabetes by combined control of
glycaemia, blood pressure, and serum lipid levels remains the
most important method of preventing diabetic retinopathy onset
and progression.
 Once detected, surgical and medical interventions including
photocoagulation, intravitral drug injection and , surgical
vitrectomy can help to preserve vision.

7. 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
 Associated 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

8. Risk factors,Cont
 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
 Others
 Obesity, increased BMI, high waist-to-hip ratio
 Hyperlipidemia
 Anemia

9. Pathogenesis
 Microvascular leakage
 Microvascular occlusion

10. Microvascular leakage
Degeneration and loss of pericytes
Plasma leakage
Intraretinal hemorrhageHard exudate
(Circinate pattern)
Capillary wall weakening
microaneurysm
Retinal edema

11. Microvascular occlusion
Neovascularization
and fibrovascular proliferation
VEGF
Increased plasma viscosity
Deformation of RBC
Increased platelets stickiness
Decreased capillary blood flow
and perfusion
Endothelial cell damage and proliferation
Capillary basement membrane thickening
Retinal hypoxia
A-V shunt
IRMA*
*intraretinal microvascular abnormalities
Proliferative
retinopathy
Rubeosis
iridis

13.  Classification
 Non-proliferative diabetic retinopathy (NPDR)
 Proliferative diabetic retinopathy (PDR)
 Advanced diabetic eye disease(ADED)

14. Non-proliferative diabetic retinopathy
 Mild NPDR
 Moderate NPDR
 Severe NPDR
 Very Severe NPDR

15. Signs Of NPDR
 Microaneurysm
 Retinal hemorrhage
“Dot or Blot”
“Flame or Splinter shape” hemorrhage
 Hard exudate
 Cotton wool Spot
 Venous beading
 Intra-retinal microvascular abnormalities (IRMA)

16. Mild NPDR
 Microaneurysm

17. Microaneurysm

18. Moderate NPDR
 More microaneurysms
 Scattered hard exudates
 Cotton-wool spots

19. Hemorrhage

20. 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

21.  Microaneurysms may leak
plasma constituents into
the retina
 Scattered hyperfluorescent

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

23. Retinal Hemorrhage,Cont
 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

24. Dot Spot VS Flame Shape

25. Dot Spot VS Flame Shape

26. 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. 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"

30. Hard Exudate VS Cotton Wool Spot

33. 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

35. Focal macular edema
Diffuse macular edema

36. Macular ischemia

37. Clinical Significant Macular Edema (CSME)
1 of 3
Retinal edema within
500 microns of centre
fovea
Hard exudates within 500
microns of fovea if ass with
adjacent retinal thickening
Retinal edema > 1 disc
diameter, any part is within 1
disc diameter of centre of
fovea

38. Proliferative diabetic retinopathy
 5% of DM pt.
 Finding
 Neovascularization : NVD, NVE
 Vitreous changes
 Advanced diabetic eye disease
 Final stage of Uncontrolled PDR
 Blindness from persistent vitreous hemorrhage,
tractional RD, opaque membrane formation,

40. Neovascularization of disc

41.  Fluorescein dye leakage is
seen in neovascularized
area
 Neovascularization of
elsewhere

43. Rubeosis iridis
(neovascularisation of the iris)
Neovascular glaucoma

45. Vitreous changes

46. Tractional retinal detachmentVitreous hemorrhage

47. New vessels of the disc (advanced)

48. Subhyaloid hemorrhage

49. Subhyaloid hemorrhage

50. 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
 ocular pain

52. Management
Diabetic retinopathy

53. Medical therapy
 Treat underlying conditions
 Control blood sugar – HbA1c < 7
 Control blood pressure – SBP < 130 mmHg
 Control lipid profile – TG, LDL
 Correct anemia
 Control diabetic nephropathy

54. Management, Cont
 Laser Photocoagulation(PRP)
 Intravitreal injection Anti VEGF
 Intravitreal triamcinolone acetonide (Steroid)
 Vitreoretinal surgery

55. Photocoagulation
 Focal or Grid Laser
 (CSME in both NPDR and PDR)
 Panretinal Photocoagulation (PRP)
 (PDR)

56. Laser
 Panretinal photocoagulation (PRP)
 PDR
New vessels
Vitreous or preretinal hemorrhage
New vessels on optic disc or within
1,500 microns from optic disc rim
Large new vessels
 Iris or angle neovascularization
 CSME

57. 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

58. Focal photocoagulation

59. Grid photocoagulation

60. Panretinal photocoagulation (PRP)

61. Advanved Diabetic Eye Disease(ADED)

62. 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

63. Vitreous hemorrhage Tractional retinal detachment

64. Vitreoretinal Surgery
 Pars plana vitrectomy (PPV)
 Membrane peeling (MP)
 Endolaser (EL)
 Fluid gas exchange (FGX)
 Silicon oil injection
 SF6
 C3F8

65. Patient Profile
Mrs Nargis Akhter
Age:45 years
Diabetic for 10 years (On Insulin)
Visual acuity : Right eye: Hand movement
Left eye: 3/60

67. After 1 month of vitrectomy Surgery (PPV)
Visual acuity
Right eye: 6/18
Left eye:6/36
Before surgery After surgery

68. Take home message
 Diabetic retinopathy is a complex neurovascular disorder that may
threaten vision in all patients with diabetes.
 A proactive, multidisciplinary approach can help significantly
reduce the risk for vision loss from diabetes and associated eye
disease such as diabetic retinopathy.
 The intricate mechanisms contributing to disease pathogenesis
continue to be elucidated.
 Future research should be integrative in nature, addressing both
systemic and ocular factors as they contribute to vision impairment
in diabetes.

69. Thank