The document provides information about diabetic retinopathy including: - It is a microvascular complication of long-standing diabetes mellitus that can cause blindness, and is the most common cause of blindness among working age adults. - Risk factors include long duration of diabetes, poor blood glucose control, hypertension, and nephropathy. - It is classified as non-proliferative diabetic retinopathy or proliferative diabetic retinopathy. Signs include microaneurysms, hemorrhages, cotton wool spots, hard exudates, and abnormal blood vessel growth in severe cases. - Treatment involves tight blood glucose and blood pressure control, as well as laser photocoagulation surgery

1. WELCOME TO ALL
Presented by:
Dr.Muhammad Saiful Islam
Resident,Phase A
MD Neurology(NINSH)

2. Diabetic Retinopathy
26/9/2016

3. Diabetic retinopathy
 The most severe ocular complications of diabetes.
 Caused by damage to blood vessels of the retina, leads to
retinal damage.
 Microvascular complication of longstanding diabetes mellitus.
 Most prevalence cause of blindness between the ages of 30
and 65 years.
 Common in DM type 1 > type 2

4.  Duration of diabetes
 Long duration ass with increased risk of DR
 Pt diagnosed before age 30 yr
 50% DR after 10 yrs
 90% DR after 30 yrs
 Poor metabolic control
  HbA1c ass. with  risk
 Pregnancy
 Ass with rapid progression of DR
Risk factors

5.  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
 Anaemia
 Smoking
Risk factors

6. I. Microvascular occlusion
II. Microvascular leakage
Pathogenesis

7. Microvascular Leakage
Degeneration and loss of pericytes
Plasma leakage
Intraretinal hemorrhageHard exudate
Capillary wall weakening
microaneurysm
Retinal edema

8. 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

9. Tractional retinal detachmentVitreous hemorrhage

10. Classification
 Non-proliferative diabetic retinopathy (NPDR)
 Proliferative diabetic retinopathy (PDR)
 Maculopathy

11. Non-proliferative diabetic retinopathy
 Mild NPDR
 Moderate NPDR
 Severe NPDR

12.  Microaneurysm
 Retinal hemorrhage
 “Dot or Blot” Spot
 “Flame or Splinter shape” hemorrhage
 Hard exudate
 Cotton wool Spot
 Venous beading,looping,dilation,tortousity
 Intra-retinal microvascular abnormalities (IRMA)
Sign NPDR

13. Mild NPDR
Microaneurysm sometime dots and
blots haemmorhage and hard
exudate

14. Moderate NPDR
 More microaneurysm
 Scattered hard exudates
 Cotton-wool exudates

15. 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
Severe NPDR

16.  Localized outpouching of capillary wall small red dots often
in punctate pattern due to focal dilatation of capillary wall
where pericytes are absent.
 The earliest signs of DR
Microaneurysm

17. Microaneurysm

18.  Capillary or microaneurysm is weakened  rupture 
intraretinal hemorrhages
 Dot & blot hemorrhages
 Deep hemorrhage - inner nuclear layer or outer plexiform layer
 Usually round or oval shape
 Dot hemorrhages - bright red dots (same size as large microaneurysms)
 Blot hemorrhages - larger lesions
 Flame-shape or splinter hemorrhages
 More superficial - in nerve fibre layer
 Indistinguishable from hemorrhage in hypertensive retinopathy
Retinal Hemorrhage

19. Dot & Blot vs Splinter
haemorrhage

22. Hemorrhage

23.  Yellowish patches of lipid and protein within the
retina.
 Accumulations of lipid leaks from surrounding
capillaries and microaneurysms or exudates.
 May form a circinate pattern.
Hard exudate

24. Hard
exudate

25.  White spots or patches composed of axoplasm and
organelles of nerve fibre.
 Also called "soft exudates"
 Fluorescein angiography shows no capillary perfusion in
the area of the soft exudate
 More common in pt with hepertensive retinopathy
Cotton Wool Spot

27. Hard Exudate VS Cotton Wool Spot

30.  Dilatation ,beading,looping of retinal vein.
 Appearance resembling sausage-shaped
dilatation of the retinal veins.
 Sign of severe NPDR.
Venous beading

31.  Intraretinal neovascularization arising from
either major arteries or veins .
 Indicate severe NPDR  rapidly progress to
PDR.
Intra-retinal Microvascular
Abnormalities (IRMA)

32. IRMA

33.  Macular ischemia or exudates
 Macular haemorrhage
 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
Diabetic Maculopathy
Means lesions in and around the macula

35. Microaneurysm

36. Microaneurysm and
blot dot hemorrhage

37. Blot Dot hemorrhage

38. IRMAs

39. Hard Exudate

40. Cotton Wool spots

41. Venous Beading

42. 5% of DM pnt develop PDR
Finding:
 Neovascularization : NVD, NVE
 Vitreous haemorrhage
 Tractional haemorrhage
Proliferative diabetic retinopathy

44. Neovascularization of disc

45. Fluorescein dye leakage is seen
in neuvascularized area
Neovascularization of elsewhere

46. NVD

49. Vitreous changes

50. Tractional retinal detachmentVitreous hemorrhage

51. NVE
Venous
beading
IRMA

52. New vessels elsewhere

53. New vessels elsewhere

54. New vessels of the disc

55. New vessels of the disc (advanced)

56. Subhyaloid haemorrhage

57. Subhyaloid hemorrhage

58.  Blurred or distorted vision or difficulty in reading
 Partial or total loss of vision
 Eye pain
Signs & symptoms of DR

59. I. Medical treatment
II. Surgical Intervention:
1. Panretinal photocoagulation(PRP)
2.Vitreoretinal Haemorrhage
Treatment

60.  Prevention by
 Control blood sugar – HbA1c < 7
 Control blood pressure – SBP < 130 mmHg
 Control lipid profile – TG, LDL
 Correct anemia
 Control diabetic nephropathy
 Stop smoking
 Aldose reductase inhibitor can be use
Medical therapy

61. Panretinal photocoagulation (PRP):
 High-risk PDR
 Vitreous or preretinal hemorrhage
 Iris or angle neovascularization
Reduce the rate of progression to blindness by about 50%
Laser

62. I. Focal or Grid :
NPDR and PDR
II. Panretinal
photocoagulation(PRP):PDR
Photocoagulation

63. Grid photocoagulation

64. Panretinal photocoagulation (PRP)

65.  Pars plana vitrectomy (PPV)
 Membrane peeling (MP)
 Endolaser (EL)
 Fluid gas exchange (FGX)
Vitreoretinal Surgery

66.  Juvenile onset DM - 5 years after diagnosis or earlier
then annually.
 Adult onset DM -at diagnosis then annually.
 DM with pregnancy in first trimester then every
trimester.
Screening for DR

67.  Serious vision-threatening complications of
DR
Vitreous hemorrhage
Tractional retinal detachment
Opaque membrane formation
Neovascular glaucoma
 Treatment : Vitrectomy
Advanced diabetic eye disease

69. Definition:
Hypertensive retinopathy is retinal vascular damage
caused by hypertension.

70. Introduction:
 Bilateral
 Symmetrical
 Small blood vessel disease
 Caused by systemic hypertension
 Acute or chronic
 Systolic or diastolic
 End organ disease manifestation

71. Prevalence:
 The second most common retinal vascular disease
 Malignant hypertension (240/140mmhg) 0.5-0.75%
 Hypertensive retinopathy 4-10%

72. Risk factor:
 Afro-Caribbeans = relative risk factor 2x
 Age
 Family history
 Obesity
 Smoking
 Alcohol consumption
 Stress
 Lack of exercise

73. Pathophysiology:
Systermic
chronic
hypertension
Arteriosclerosi
s and
atherosclerosis
Narrowing of
retinal
arterioles
Retinal
Ischaemia
Hypoxia
Increased
capillary
permeability
Retinal Oedema, retinal
haemorrhage,cotton wool spots,
hard exudates

75. Clinical Manifestation:
 Most patients are asymptomatic.
 Some present with headaches and blurred vision.
 On ophthalmoscopy :
 Generalized arteriolar narrowing
 Changes of the arterovenous crossings
 Flame haemorrhage
 Microaneurysms
 Cotton-wool exudate
 Optic disc swelling

79. Generalised narrowing of the retinal arterioles:

80. Focal narrowing of the retinal arterioles –
Copper and Silver Wiring

83. Grade 4 Retinopathy:

84. Classification
Keith-Wagener-Barker classification
Grade Description
Grade 1 Mild generalised narrowing, sclerosis, and tourtuosity of the retinal
arterioles(Silver wiring) mild asymptomatic hypertension.
Grade 2
G 1+Definite focal narrowing ,constriction, sclerosis at the site of AV
crossing (AV nipping); blood pressure is higher and sustained.
Grade 3 G 2+Retinopathy (cotton-wool spots, flame shape haemorrhages); blood
pressure is higher and more sustained; headaches, vertigo, and
nervousness; mild impairment of cardiac, cerebral, and renal function
Grade 4 G 3+Neuroretinal oedema, including pappilloedema, blood pressure
persistently elevated; severe impairment of cardiac, cerebral, and renal
function

85. Diagnosis:
 Diagnosis is made by thorough history of the
patient, ophthalmoscopy (direct or indirect)
and also physical examination.
 History
 May reveal decrease of patient vision, occipital
headache and high blood pressure.
 Physical examination
 May detect elevation of blood pressure
 Ophthalmoscopy

86. Management:
 A major aim of treatment is to prevent, limit, or
reverse such target organ damage by lowering the
patient's high blood pressure.
 Lifestyle changes  Promote Healthy lifestyle;
exercise, healthy foods
 Advice patient to reduce the Blood Pressure
 Taking the medication accordingly
 Referral to medical team

87. Differentiation of retinopathy:
Hypertensive Retinopathy Diabetic Retinopathy
 Dry retina
 Rare oedema
 Few haemorrhages
 Multiple cotton wool spots
 Flame-shaped haemorrhages
 AV nipping present
 Copper and silver wiring
 Venous beading absent
 IRMA usually absent
 Macular star present
 Wet retina
 Extensive oedema
 Multiple dot blot haemorrhages
 Few cotton wool spots
 Rare flame-shaped
haemorrhages
 AV nipping absent
 Wiring absent
 Venous beading present
 IRMA may present
 Macular star absent

88. Thank you