DIABETIC RETINOPATHY

Progressive dysfunction of the retinal blood vessels caused by chronic hyperglycaemia.

Definition

1. Hyperglycaemia Duration of diabetes - 50% develop DR after 10 yrs- 70 % after 20 yrs- 90 % after 30 yrs 2. Hypertension 3. Hyperlipidaemia4. More in females than males5. Pregnancy may accelerate DR6. Smoking, Obesity, Anaemia7. Poor metabolic control8. Hereditary – more on proliferative DR

Risk Factors

Classification of Diabetic Retinopathy

• Non-proliferative diabetic retinopathy

I. Mild nonproliferative retinopathyII. Moderate nonproliferative retinopathyIII.Severe nonproliferative retinopathyIV.Very severe nonproliferative retinopathy

• Proliferative diabetic retinopathy

• Diabetic maculopathy

• Advanced diabetic eye disease

No retinopathy

I. Mild nonproliferative retinopathy

• Atleast one microaneurysm or intraretinal haemorrhage

• Hard/ Soft exduates may or may not be present

II. Moderate nonproliferative retinopathy

• Micro aneurysms / intraretinal haemorrhages in 2 or 3 quadrants

• Early mild IRMA Intra retinal Microvascular abnormalities

• Hard / Soft exudates may or may not be present

III. Severe nonproliferative retinopathy

• Four quadrants of severe micro aneurysms / intraretinal haemorrhages

• Two quadrants of venous bleeding

• One quadrant of IRMA changes

Any one of the following :

IV. Very severe nonproliferative retinopathy

• Four quadrants of severe micro aneurysms / intraretinal haemorrhages

• Two quadrants of venous bleeding

• One quadrant of IRMA changes

Any two of the following :

Proliferative diabetic retinopathy

PDR

PDR without HRC PDR with HRC

NVD ¼ to 1/3 of disc area with or without VH or PRH

NVD < ¼ disc area with VH or PRH

NVD < ¼ disc area with VH or PRH

Extensive vitreous haemorrhage obscuring most of fundus (white circle)

Diabetic Maculopathy

On Slit lamp examination with 90D lens :

1. Thickening of retina at or within 500 micron of the centre of fovea

2. Hard exudates at or within 500 micron of the centre of fovea associated with adjacent retinal thickening

3. Development of a zone of retinal thickening one disc diameter or larger in size, at least a part of which is within one disc diameter of foveal centre.

Maculopathy within 1 disc diameter of the fovea.

Advanced diabetic eye disease

1. Persistent vitreous haemorrhage

2. Tractional retinal detachment

3. Neovascular glaucoma

Investigations

1. Urine examination2. Blood sugar estimation3. 24 hour urinary protein4. Renal function tests5. Lipid profile6. Haemogram7. Glycosylated Haemoglobin (HbA1C)8. Fundus Fluorescein angiography – to

elucidate areas of neovascularisation, leakage and capillary nonperfusion

9. Optical Coherence Tomography to study detailed structural changes in diabetic maculopathy

Prevention1.Primary Prevention –

Strict glycemic control, Blood pressure control, correction of dyslipidaemia, control of associated anaemia, control of hypoproteinemia

2.Secondary Prevention – Annual eye exams

3.Tertiary Prevention – Retinal laser photocoagulation , Vitrectomy

Treatment of Diabetic Retinopathy

1. Anti – vascular endothelial growth factors

2. Others under evaluation – Protein Kinase C inhibitors, Aldose reductase, ACE inhibitors, Antioxidants such as vitamin E

3. Role of intravitreal steroids – Flucinolone acetonide intravitreal implant, Inj. Triamcinolone intravitreal

Laser Photocoagulation

Vitrectomy

September 16, 2014

Eylea Granted Breakthrough Therapy for Diabetic RetinopathyFood and Drug Administration (FDA) has granted Eylea (afilbercept) Injection Breakthrough Therapy designation for the treatment of diabetic retinopathy in patients with diabetic macular edema (DME).

Eylea is a vascular endothelial growth factor (VEGF) inhibitor designed to block the growth of new blood vessels and decreases vascular permeability in the eye by blocking VEGF-A and placental growth factor (PlGF), two growth factors involved in angiogenesis.

Eylea helps prevent VEGF-A and PlGF from interacting with their natural VEGF receptors as shown in preclinical studies.

Eylea is already approved for the treatment of neovascular (wet) age-related macular degeneration (AMD) and macular edema following central retinal vein occlusion (CRVO).

Latest Treatment modalities for Diabetic Retinopathy

Human trials are set to begin for a new medication, currently called KVD001, which treats diabetic macular edema, a form of diabetic retinopathy.

Human trials begin for promising diabetic retinopathy treatmentFri, 05 Sep 2014

KVD001 is an intravitreal plasma kallikrein inhibitor drug that is given byinjection into the eye. Whilst injections into the eye may sound painful, in practice they are not as eye-watering as they sound.

There is currently only one medication, Lucentis, has been officially licensed for treatment of diabetic macular edema. Having another medication such as KVD001 would give doctors more choice over which treatment to give and, because it works in a different way to Lucentis, it means that it could help save thesight of people for whom Lucentis is not effective.

KVD001 has been developed by KalVista Pharmaceuticals, a company in Hampshire. The clinical trials, which will be run across five different centres within the United States, are being funded by the type 1 diabetes charity, the JDRF.

Conclusion

Diabetic Retinopathy is preventable through strict glycemic control and annual dialated eye exams by an opthalmologist.