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Diabetic Retinopathy (DR)

Diabetic Retinopathy (DR) . Ayesha S Abdullah 28.12.2012. Learning outcomes. By the end of the lecture the students would be able to; Describe the epidemiology of DR Correlate the pathogenesis of DR with the clinical presentation Identify signs of DR in a given fundus photograph

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Diabetic Retinopathy (DR)

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  1. Diabetic Retinopathy (DR) Ayesha S Abdullah 28.12.2012

  2. Learning outcomes By the end of the lecture the students would be able to; • Describe the epidemiology of DR • Correlate the pathogenesis of DR with the clinical presentation • Identify signs of DR in a given fundusphotograph • Identify the signs of proliferative DR and high risk Non-proliferative DR on a given fundus photograph • Outline the management for DR

  3. Diabetes Mellitus (DM) • Metabolic syndrome characterized by hyperglycaemia & insulin deficiency • Type 1 and type 2 & Gestational Diabetes Mellitus • Type 2 is more common than type 1 • A micro & macrovasculopathy

  4. Epidemiology of DM and DR • We are having a “global epidemic of DM”. • The prevalence of DM is estimated to rise from 2.8% (2000) to 4.4% (2030) • Most of this increase will occur as a result of a 150% rise in developing countries. • The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. • The prevalence is estimated to be 10% in Pakistan • With over 5.2 million people with DM , it is the 6th country with the largest population of people with DM. • With growing obesity, sedentary life style and increased aging population, the prevalence is estimated to rise further. Wild S, Roglic G, Green A, Sicree R, King H. Global Prevalence of Diabetes- Estimates for the year 2000 and projections for 2030. Diabetes Care 27:1047–1053, 2004

  5. Diabetic retinopathy • Is a microvascular complication of DM • The prevalence is highest among type 1 DM (40%) • Patients with DR are 25% more likely to go blind than non-diabetics • In UK 1000 individuals are registered blind each year due to diabetic eye disease • It is the leading cause of blindness in 20-64 year age group in USA

  6. Pathogenesis of Diabetic Retinopathy DR is a microangiopathy resulting in Microvascular occlusion Microvascular leakage

  7. Microvascular Occlusion Factors responsible for occlusion • Thickening of capillary basement membrane • Capillary endothelial cell damage and proliferation • Changes in R.B.Cs • Increased stickiness and aggregation of platelets

  8. Neovascularization Pathogenesis of Diabetic Retinopathy Microvascular occlusion Retinal capillary non-perfusion Retinal ischaemia & Hypoxia, ischaemia of the nerve fibres- soft exudates Arteriovenousshunts - IRMA(intra-retinal microvascualr abnormalities), venous changes, stagnation of blood and more hypoxia

  9. Microvascular Leakage Breakdown of inner blood-retinal barrier • Retinal haemorrhages • Retinal oedema • Diffuse edema • Hard exudates • Microaneurysims What is inner and outer blood-retinal barrier?

  10. Schematic of the retinal fundus illustrating the potential involvement of the components of the kallikrein–kinin system(KKS) found in the vitreous in diabetic retinopathy changes. Red lines indicate arteries and blue lines indicate veins. FXII, factor XII; FXIIa, factor XIIa; HK, high-molecular-weight kininogen; Kal, kallikrein; PK, prekallikrein; KKS, kallikrein–kinin system.

  11. Classification of diabetic retinopathy • Non-proliferative (NPDR) • Proliferative (PDR) • Diabetic Maculopathy

  12. Signs of DR • Microaneurysms (MA) • Hard exudates (HE) • Haemorrrhages (H) • Retinal oedema- macular oedema(CSME) • Cotton wool spots (CWS) • Intra-retinal microvasuclarabnormalities(IRMA) • Venous changes • Fibrovascualr proliferation –Neovascularization

  13. Microaneurysms & hard exudates

  14. Haemorrhages and cotton wool spots

  15. Neovasucalrization and fibrovasucalr proliferation

  16. Diabetic macular oedema

  17. Clinical presentation

  18. Stages of DR NPDR PDR

  19. Stages of DR

  20. Stages of DR 1. Mild NonproliferativeRetinopathy Signs: MA & HE 2. Moderate NonproliferativeRetinopathy Signs:Haemorrhages, microaneurysms, Soft exudates, IRMA 3. Severe Nonproliferative Retinopathy.. Signs: Along with microaneurysms, haemorrhages, IRMA and venous changes are also seen 4. Proliferative Retinopathy. Signs: NVE & NVD, vitreous haemorrhage, tractional RD

  21. Management of DR Indications • PDR • Clinically significant macular oedema Principles & modes • Metabolic control • Control of risk factors • Laser therapy- photocoagulation • Anti-VEGF agents • Vitreoretinalsurgery

  22. Recommended follow-up schedule

  23. Summary Home work List the risk factors for DR How does diabetic retinopathy cause vision loss? msqheartline@hotmail.com

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