Proliferative diabetic retinopathy affects 5-10% of diabetics and is more common in those with juvenile-onset diabetes. It occurs when hypoxic retinal tissue develops abnormal blood vessels due to angiogenic factors like VEGF. This can lead to neovascularization of the retina or optic disc, vitreous hemorrhage, or tractional retinal detachment. Diabetic macular edema is a leading cause of vision loss and occurs when fluid leaks into the macula due to capillary damage. It is classified by its angiographic appearance and can be focal, diffuse, or ischemic in nature.

1. DIABETIC
RETINOPATHY
SOUMIK SEN
MB140039

2. PROLIFERATIVE DIABETIC
RETINOPATHY
 Proliferative diabetic retinopathy affects 5-10% of the
diabetic population.
 Type 1 diabetics are particularly at risk with an
incidence of about 60% after 30 years of onset of
diabetes.
 Therefore it is more common in patients with juvenile
onset diabetes.

3. PATHOGENESIS
 Occurrence of neovascularization is the hallmark of PDR.
It occurs over the changes of NPDR.
 Caused by angiogenic growth factors elaborated by
hypoxic retinal tissue in an attempt to revascularize
hypoxic retina.
 These substances promote neovascularization on the
retina and the optic head and occasionally on the iris.
 VEGF, placental growth factor and pigment epithelium
derived factor appears to be of particular importance.
 It usually occurs along the course of major temporal
retinal vessels.

4. DIAGNOSIS
 NEOVASCULARIZATION AT DISC: Describes neovascularization on or
within one disc diameter of the optic nerve head.
 NEOVASCULARIZATION ELSEWHERE: Describes neovascularization
along the course of the major vessels.
 FLUORESCENT ANGIOGRAPHY: Highlights the neovascularization
during the early phases and shows hyper fluorescence due to
leakage of dye from neovascular tissue.

5. NEOVASCULARISATION AT THE
DISC (NVD)

6. NVD

7. NEOVASULARISATION
ELSEWHERE (NVE)

8. NEOVASCULARISATION AT THE
IRIS (NVI)
NEOVASCULARISATION AT THE IRIS
NEOVASCULAR GLAUCOMA

9. VITREOUS CHANGES
VITREOUS HAEMORRHAGE TRACTIONAL RETINAL DETACHMENT

10. FURTHER CLASSIFICATION
OF PDR
 On the basis of high risk characteristics(HRCs) described by
the diabetic retinopathy study(DRS) group, PDR can be
further classified into:
1. EARLY NVD OR NVE PDR without HRCs (EARLY PDR).
2. PDR with HRCs.

11. HIGH RISK
CHARACTERISTICS
 NVD 1/4TH TO 1/3RD of disc area with or without vitreous
hemorrhage or pre-retinal hemorrhage.
 NVD <1/4TH disc area with vitreous hemorrhage or pre-
retinal hemorrhage.
 NVE >1/2 disc area with vitreous hemorrhage or pre-retinal
hemorrhage.

12. DIABETIC MACULOPATHY
 Most common cause of visual impairment in diabetic patients,
particularly type 2.
 Diffuse retinal edema is caused by extensive capillary leakage and
localized edema is caused by focal leakage from microaneurysms
and dilated capillary segments.
 The fluid is initially located between outer plexiform and inner
nuclear layers; later it may also involve the inner plexiform and the
nerve fibre layers, until eventually the entire thickness of the retina
becomes edematous.

13. WHY IS DIABETIC MACULAR
EDEMA SO IMPORTANT?
 The macula is responsible for central vision.
 Diabetic macular edema may be
asymptomatic at first. As the edema moves
in to the fovea (the center of the macula) the
patient will notice blurry central vision. The
ability to read and recognize faces will be
compromised.

14. CLINICO-ANGIOGRAPHIC
CLASSIFICATION OF DIABETIC
MACULOPATHY1. FOCAL EXUDATIVE MACULOPATHY
2. DIFFUSE EXUDATIVE MACULOPATHY
3. ISCHAEMIC MACULOPATHY
4. MIXED MACULOPATHY

15. FOCAL EXUDATIVE
MACULOPATHY SIGNS: Micro aneurysm, hemorrhages and well circumscribed macular
edema and hard exudates arranged in a circinate pattern.
 FA: Focal area or hyperfluorescence due to leakage and good macular
perfusion.

16. DIFFUSE EXUDATIVE
MACULOPATHY SIGNS: Diffuse retinal edema and thickening throughout the posterior pole
with relatively few hard exudates.
 FA: Extensive hyper fluorescence at the posterior pole due to leakage.

17. ISCHAEMIC MACULOPATHY
 It occurs due to microvascular blockage.
 SIGNS: micro aneurysms, dot and blot hemorrhage, mild or no macular
edema and few hard exudates.
 FA: capillary non perfusion at the fovea and frequently other areas of
capillary non-perfusion at the posterior pole and periphery.

18. CLINICALLY SIGNIFICANT
MACULAR EDEMA
 It is diagnosed if one of the following three criteria are present
on slit lamp examination with 90D lens.
1. Thickening of the retina at or within 500 µm of the center of
the fovea.
2.Hard exudates at or within 500 µm of the center of the fovea, if
associated with thickening of the adjacent retina.
3.Area of retinal thickening 1 disc diameter or larger in size,
within 1 disc diameter of the center of the fovea.

19. CSME
Retinal oedema
within 500 microns of
centre fovea
Hard exudates within
500 microns of fovea if
ass with adjacent retinal
thickening
Retinal oedema > 1 disc
diameter, any part is
within 1 disc diameter of
centre of fovea

20. ADVANCED DIABETIC EYE
DISEASE Serious vision-threatening complications of DR.
 Occurs in pts who have not had laser therapy or in whom laser
photocoagulation has been unsuccessful.
 Complication:
1. Persistent vitreous hemorrhage
2. Tractional retinal detachment
3. Opaque membrane formation
4. Neovascular glaucoma
 Treatment: Pars plana vitrectomy.
 Poor prognosis

21. MICROANEURYSMS

22. DOT AND BLOT
HEMORRHAGE

23. HARD EXUDATES

24. COTTON WOOL SPOTS

25. VENOUS BEADING

26. IRMA