Diabetic Retinopathy amp Hypertensive RetinopathyBy

ChVineela

Diabetic Retinopathy

bull Diabetic retinopathy is retinopathy (damage to the retina) caused by complications of diabetes mellitus which can eventually lead to blindness

bull It is an ocular manifestation of systematic disease which affects up to 80 of all diabetic patients

DR - Pathogenesisbull Damage to capillaries ndash

ndash formation of microaneurysm (MA) and ndash leakage leading to

bull dot amp blot haemorrhage bull exudates and bull oedema

bull Changes in blood constituents leading ndash to decreased blood flow

bull Micro-vascular or small blood vessel occlusion leading to ndash capillary non-perfusion

bull Consequences of ischaemia are ndash formation of new blood vessels (neo-vascularisation) as retina

responds by secreting vascular endothelial growth factor VeGF

Micro-vascular

Changes

Diabetic Retinopathy (DR) ndash Risk factors

bull Duration of diabetes

bull Poor control of Diabetes

bull Pregnancy

bull Hypertension

bull Nephropathy

bull Obesity and hyperlipidemia

bull Smoking

Classification

1 ) Non ndashproliferative -Mild - Moderate - Severe - Very Severe

2) Proliferative

3)Diabetic Maculopathy-- focal exudative -diffuse exudative - ischemic - mixed

Non-proliferative changes- clinical

bull Microaneurysms (MA) ndash appear as tiny red dotsbull Oedema ndash clinically causes thickness

raquoLocalised due to leakage from MAsrsquoraquoDiffuse due to capillary leakageraquo Initially located between the OPL and INLraquoLater involves the INL and NFLraquoeventually the entire thickness of the

retina becomes oedematousraquoAt the fovea it is cystic in nature

Non-proliferative changes ndash Clinical Features contd

Exudatesformed at the

junction of normal and oedematous retina

composed of lipoprotein and lipid-filled macrophages

located mainly within the outer plexiform layer

Non-proliferative Clinical Features contd

Haemorrhage bull lsquoDot and blotrsquo ndash in

the compact middle layers from venous end of capillariesbull lsquoflame shapedrsquo as

they are placed superiorly in nerve fibre layer (RNFL)

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Diabetic Retinopathy

bull Diabetic retinopathy is retinopathy (damage to the retina) caused by complications of diabetes mellitus which can eventually lead to blindness

bull It is an ocular manifestation of systematic disease which affects up to 80 of all diabetic patients

DR - Pathogenesisbull Damage to capillaries ndash

ndash formation of microaneurysm (MA) and ndash leakage leading to

bull dot amp blot haemorrhage bull exudates and bull oedema

bull Changes in blood constituents leading ndash to decreased blood flow

bull Micro-vascular or small blood vessel occlusion leading to ndash capillary non-perfusion

bull Consequences of ischaemia are ndash formation of new blood vessels (neo-vascularisation) as retina

responds by secreting vascular endothelial growth factor VeGF

Micro-vascular

Changes

Diabetic Retinopathy (DR) ndash Risk factors

bull Duration of diabetes

bull Poor control of Diabetes

bull Pregnancy

bull Hypertension

bull Nephropathy

bull Obesity and hyperlipidemia

bull Smoking

Classification

1 ) Non ndashproliferative -Mild - Moderate - Severe - Very Severe

2) Proliferative

3)Diabetic Maculopathy-- focal exudative -diffuse exudative - ischemic - mixed

Non-proliferative changes- clinical

bull Microaneurysms (MA) ndash appear as tiny red dotsbull Oedema ndash clinically causes thickness

raquoLocalised due to leakage from MAsrsquoraquoDiffuse due to capillary leakageraquo Initially located between the OPL and INLraquoLater involves the INL and NFLraquoeventually the entire thickness of the

retina becomes oedematousraquoAt the fovea it is cystic in nature

Non-proliferative changes ndash Clinical Features contd

Exudatesformed at the

junction of normal and oedematous retina

composed of lipoprotein and lipid-filled macrophages

located mainly within the outer plexiform layer

Non-proliferative Clinical Features contd

Haemorrhage bull lsquoDot and blotrsquo ndash in

the compact middle layers from venous end of capillariesbull lsquoflame shapedrsquo as

they are placed superiorly in nerve fibre layer (RNFL)

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

DR - Pathogenesisbull Damage to capillaries ndash

ndash formation of microaneurysm (MA) and ndash leakage leading to

bull dot amp blot haemorrhage bull exudates and bull oedema

bull Changes in blood constituents leading ndash to decreased blood flow

bull Micro-vascular or small blood vessel occlusion leading to ndash capillary non-perfusion

bull Consequences of ischaemia are ndash formation of new blood vessels (neo-vascularisation) as retina

responds by secreting vascular endothelial growth factor VeGF

Micro-vascular

Changes

Diabetic Retinopathy (DR) ndash Risk factors

bull Duration of diabetes

bull Poor control of Diabetes

bull Pregnancy

bull Hypertension

bull Nephropathy

bull Obesity and hyperlipidemia

bull Smoking

Classification

1 ) Non ndashproliferative -Mild - Moderate - Severe - Very Severe

2) Proliferative

3)Diabetic Maculopathy-- focal exudative -diffuse exudative - ischemic - mixed

Non-proliferative changes- clinical

bull Microaneurysms (MA) ndash appear as tiny red dotsbull Oedema ndash clinically causes thickness

raquoLocalised due to leakage from MAsrsquoraquoDiffuse due to capillary leakageraquo Initially located between the OPL and INLraquoLater involves the INL and NFLraquoeventually the entire thickness of the

retina becomes oedematousraquoAt the fovea it is cystic in nature

Non-proliferative changes ndash Clinical Features contd

Exudatesformed at the

junction of normal and oedematous retina

composed of lipoprotein and lipid-filled macrophages

located mainly within the outer plexiform layer

Non-proliferative Clinical Features contd

Haemorrhage bull lsquoDot and blotrsquo ndash in

the compact middle layers from venous end of capillariesbull lsquoflame shapedrsquo as

they are placed superiorly in nerve fibre layer (RNFL)

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Micro-vascular

Changes

Diabetic Retinopathy (DR) ndash Risk factors

bull Duration of diabetes

bull Poor control of Diabetes

bull Pregnancy

bull Hypertension

bull Nephropathy

bull Obesity and hyperlipidemia

bull Smoking

Classification

1 ) Non ndashproliferative -Mild - Moderate - Severe - Very Severe

2) Proliferative

3)Diabetic Maculopathy-- focal exudative -diffuse exudative - ischemic - mixed

Non-proliferative changes- clinical

bull Microaneurysms (MA) ndash appear as tiny red dotsbull Oedema ndash clinically causes thickness

raquoLocalised due to leakage from MAsrsquoraquoDiffuse due to capillary leakageraquo Initially located between the OPL and INLraquoLater involves the INL and NFLraquoeventually the entire thickness of the

retina becomes oedematousraquoAt the fovea it is cystic in nature

Non-proliferative changes ndash Clinical Features contd

Exudatesformed at the

junction of normal and oedematous retina

composed of lipoprotein and lipid-filled macrophages

located mainly within the outer plexiform layer

Non-proliferative Clinical Features contd

Haemorrhage bull lsquoDot and blotrsquo ndash in

the compact middle layers from venous end of capillariesbull lsquoflame shapedrsquo as

they are placed superiorly in nerve fibre layer (RNFL)

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Diabetic Retinopathy (DR) ndash Risk factors

bull Duration of diabetes

bull Poor control of Diabetes

bull Pregnancy

bull Hypertension

bull Nephropathy

bull Obesity and hyperlipidemia

bull Smoking

Classification

1 ) Non ndashproliferative -Mild - Moderate - Severe - Very Severe

2) Proliferative

3)Diabetic Maculopathy-- focal exudative -diffuse exudative - ischemic - mixed

Non-proliferative changes- clinical

bull Microaneurysms (MA) ndash appear as tiny red dotsbull Oedema ndash clinically causes thickness

raquoLocalised due to leakage from MAsrsquoraquoDiffuse due to capillary leakageraquo Initially located between the OPL and INLraquoLater involves the INL and NFLraquoeventually the entire thickness of the

retina becomes oedematousraquoAt the fovea it is cystic in nature

Non-proliferative changes ndash Clinical Features contd

Exudatesformed at the

junction of normal and oedematous retina

composed of lipoprotein and lipid-filled macrophages

located mainly within the outer plexiform layer

Non-proliferative Clinical Features contd

Haemorrhage bull lsquoDot and blotrsquo ndash in

the compact middle layers from venous end of capillariesbull lsquoflame shapedrsquo as

they are placed superiorly in nerve fibre layer (RNFL)

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Classification

1 ) Non ndashproliferative -Mild - Moderate - Severe - Very Severe

2) Proliferative

3)Diabetic Maculopathy-- focal exudative -diffuse exudative - ischemic - mixed

Non-proliferative changes- clinical

bull Microaneurysms (MA) ndash appear as tiny red dotsbull Oedema ndash clinically causes thickness

raquoLocalised due to leakage from MAsrsquoraquoDiffuse due to capillary leakageraquo Initially located between the OPL and INLraquoLater involves the INL and NFLraquoeventually the entire thickness of the

retina becomes oedematousraquoAt the fovea it is cystic in nature

Non-proliferative changes ndash Clinical Features contd

Exudatesformed at the

junction of normal and oedematous retina

composed of lipoprotein and lipid-filled macrophages

located mainly within the outer plexiform layer

Non-proliferative Clinical Features contd

Haemorrhage bull lsquoDot and blotrsquo ndash in

the compact middle layers from venous end of capillariesbull lsquoflame shapedrsquo as

they are placed superiorly in nerve fibre layer (RNFL)

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Non-proliferative changes- clinical

bull Microaneurysms (MA) ndash appear as tiny red dotsbull Oedema ndash clinically causes thickness

raquoLocalised due to leakage from MAsrsquoraquoDiffuse due to capillary leakageraquo Initially located between the OPL and INLraquoLater involves the INL and NFLraquoeventually the entire thickness of the

retina becomes oedematousraquoAt the fovea it is cystic in nature

Non-proliferative changes ndash Clinical Features contd

Exudatesformed at the

junction of normal and oedematous retina

composed of lipoprotein and lipid-filled macrophages

located mainly within the outer plexiform layer

Non-proliferative Clinical Features contd

Haemorrhage bull lsquoDot and blotrsquo ndash in

the compact middle layers from venous end of capillariesbull lsquoflame shapedrsquo as

they are placed superiorly in nerve fibre layer (RNFL)

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Non-proliferative changes ndash Clinical Features contd

Exudatesformed at the

junction of normal and oedematous retina

composed of lipoprotein and lipid-filled macrophages

located mainly within the outer plexiform layer

Non-proliferative Clinical Features contd

Haemorrhage bull lsquoDot and blotrsquo ndash in

the compact middle layers from venous end of capillariesbull lsquoflame shapedrsquo as

they are placed superiorly in nerve fibre layer (RNFL)

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Non-proliferative Clinical Features contd

Haemorrhage bull lsquoDot and blotrsquo ndash in

the compact middle layers from venous end of capillariesbull lsquoflame shapedrsquo as

they are placed superiorly in nerve fibre layer (RNFL)

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Non-proliferative DR Treatment

bull Usually not requiredbull Only when exudatesoedema in macula

(clinically significant macular oedema)bull Pt followed up every 6-12 months

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Diabetic Maculopathybull Involvement of the fovea by oedema hard exudates or

ischaemiabull Most common cause of visual impairment in diabetic patients

with type 2 diabetes

1Focal maculopathy bull well-circumscribed retinal thickening associated with bull complete or incomplete rings of hard exudates

2 Diffuse maculopathy bull diffuse retinal thickening which may be associated with

cystoid changesbull landmarks are obliterated by severe oedema which may

render localization of the fovea impossible

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Focal maculopathy

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Diffuse maculopathy

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Maculopathy

3 Ischaemic maculopathybull The signs are variable and the macula may look

relatively normal despite reduced visual acuity bull In other cases pre-proliferative diabetic

retinopathybull FA shows capillary non-perfusion at the fovea

and frequently otherbull Areas of capillary non-perfusion at the posterior

pole

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Ischaemic Maculopathy

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Clinically significant macular oedema

4 CSMObull Retinal oedema within 500μm

of the centre of the maculabull Hard exudates within 500μm

of the centre of the macula if associated with retinal thickening (which may be outside the 500μm)

bull Retinal oedema one disc area (1500μm) or larger any part of which is within one disc diameter of the centre of the macula

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Maculopathy Treatment

bull All cases of CSMO are treatedbull Aim of treatment is to maintain current level of

visionbull Argon laser photocoagulation

raquoFocal applicationraquoGrid application

bull Intravitreal Triamcinalone ndash effect lasts 612

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Maculopathy ndash Focal Treatment

Focal Treatment Grid Laser Treatment

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Non-proliferative Pre-proliferative changes in DR

bull DR that exhibits signs of imminent proliferative diseasebull Clinical signs indicate progressive retinal ischaemi Cotton-wool spots - composed of accumulations of neuronal

debris within the nerve fibre layer bull Signs Small whitish fluffy superficial lesions which

obscure underlying blood vessels

Intraretinal microvascular abnormalities (IRMA) are arteriolar-venular shunts that run from retinal arterioles to venules thus by-passing the capillary bed Signs Fine irregular red lines that run from arterioles to venules

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Non-proliferative Pre-proliferative changes in DR

Other featuresa Venous changes consist of dilatation and tortuositylooping beading and lsquosausage-likersquo segmentationb Arterial changes include peripheral narrowingc Dark blot haemorrhages represent haemorrhagic retinal infarcts and are located within the middle retinal layers

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

NPDR

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Proliferative DR (PDR)PDR affects 5ndash10 of the diabetic population Type 1 diabetics are at particular risk with an incidence of about 60 after 30 years

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

PDR

bull Pathogenesis - Primary feature is neovascularization caused by angiogenic growth factors elaborated by hypoxic retinal tissue in an attempt to re-vascularize hypoxic retina

bull Clinically raquoNew vessels at the disc (NVD)raquoNew vessels elsewhere (NVE)

bull Leaks in FA

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

PDR

NVD NVE

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

PDR

bull Treatmentbull Laser therapy is aimed at inducing involution

of new vessels and preventing visual lossbull Pan retinal laser photocoagulation PRP ndash

delivery at slit lamp or via Indirect Ophthalmoscope

bull About 2500 burns over 2 sessions

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

PDR - treatment

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

PDR - consequences

bull Vitreous Haemorrhage ndash retrohyaloid intragel or both

bull Tractional RD bull Rubeosis Iridis and

Neovascular Glaucoma (NVG)

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Treatment of Complications of PDR

bull Persistent Vit Haemraquo Vitrectomyraquo Endophotocoagulation

bull Tractional RD raquo Vitrectomyraquo +- Oil

bull Rubeosis Iridis NVGraquo Adequate PRP +- Intravitreal Avastin (anti-angiogenic factor)raquo Medical management of glaucomaraquo Surgical management of glaucoma raquo Cyclodestructive laser

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Screeningbull All diabetic patients aged over 12 years andor entering puberty should be screenedGeneral screening and referral to Specialistbull 1 Annual review

1048653 Normal fundus 1048653 Mild NPDR with small haemorrhages andor small hard exudates more than one disc diameter from the fovea

bull 2 Routine referral (weeks)1048653 NPDR with large exudates within the major temporal arcades but not threatening the fovea1048653 NPDR without maculopathy but with reduced visual acuity impairment

bull 3 Early referral (days)1048653 CSMO1048653 Severe and very severe NPDR

bull 4 Urgent referral (same day)1048653 PDR1048653 Preretinal or vitreous haemorrhage1048653 Rubeosis iridis1048653 Retinal detachment

Screening in pregnancy Diabetic retinopathy can significantly worsen during pregnancy

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

HT Retinopathy

bull Untreated systemic hypertension is associated with ndash retinopathy ndash optic neuropathy and ndash choroidopathy

bull Retinopathy consists of a spectrum of retinal vascular changes that are pathologically related to microvascular damage from elevated blood pressure

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Pathogenesis

Arteriolar narrowingbull Arteriolar narrowing may be focal or

generalized bull Ophthalmoscopic diagnosis of generalized

narrowing is difficult although the presence of focal narrowing makes it highly probable that blood pressure is raised

bull Severe hypertension may lead to the development of cotton-wool spots

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Vascular leakagebull Vascular leakage leads to flame-shaped retinal

haemorrhages and retinal oedema bull Chronic retinal oedema may result in the

deposition of hard exudates around the fovea with a macular star configuration

bull Swelling of the optic nerve head is the hallmark of accelerated hypertension

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Grades of HT Retinopathy

bull Grade 1 consists of lsquomildrsquo generalized retinal arteriolar narrowing

bull Grade 2 consists of lsquomore severersquo generalized narrowing focal areas of arteriolar narrowing and arterio-venous (AV) nicking

bull Grade 3 consists of grade 1 and 2 signs plus the presence of retinal haemorrhages microaneurysms hard exudates and cotton-wool spots

bull Grade 4 also called accelerated (malignant) hypertensive retinopathy consists of signs in the preceding three grades plus optic disc swelling

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

Treatment

bull Major aim of treatment is to preventlimit patient lsquos high blood pressure and reduce high risk of cardiovascular disease and death

bull Anti ndashhypertensive drug treatment required to control the high blood pressure

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38

• Diabetic Retinopathy amp Hypertensive Retinopathy
• Diabetic Retinopathy
• DR - Pathogenesis
• Slide 4
• Diabetic Retinopathy (DR) ndash Risk factors
• Classification
• Non-proliferative changes- clinical
• Slide 8
• Non-proliferative changes ndash Clinical Features contd
• Non-proliferative Clinical Features contd
• Non-proliferative DR Treatment
• Diabetic Maculopathy
• Focal maculopathy
• Diffuse maculopathy
• Maculopathy
• Ischaemic Maculopathy
• Clinically significant macular oedema
• Maculopathy Treatment
• Maculopathy ndash Focal Treatment
• Non-proliferative Pre-proliferative changes in DR
• Non-proliferative Pre-proliferative changes in DR (2)
• NPDR
• Proliferative DR (PDR)
• PDR
• PDR (2)
• PDR (3)
• PDR - treatment
• PDR - consequences
• Treatment of Complications of PDR
• Screening
• HT Retinopathy
• Pathogenesis
• Slide 33
• Grades of HT Retinopathy
• Slide 35
• Slide 36
• Treatment
• Slide 38