B Muhd Ariff Mahdzub

DIABETIC RETINOPATHY

DIABETIC RETINOPATHY

Retinal changes as a complication of or due to

diabetes mellitus (DM)

• In Malaysia, diabetic eye disease is the commonest cause of visual loss among adults of working age

• Prevalence is closely-related to duration of diabetes• At diagnosis of DM, prevalence is only less than 5% but

after 10 years, it rises up to 40% – 50%• The risk factor includes duration of having diabetes, poor

glucose control, hypertension, obesity, and pregnancy.• Annual screening is recommended for diabetic patient for

early detection enabling well-planned treatment.

PATHOPHYSIOLOGY

Retinal ischemiaReduced blood flow, decreases of vascular endothelial retinal perfusion

Release vascular endothelial growth factor

New blood vessels grow and proliferate inside the retina and vitreous humor

However, these new blood vessels can easily rupture and bleed, cloud vision and damage retina

Fibrovascular proliferation occurs as part of healing process due to rupture vessels

Neovascular glaucoma occur if the new blood vessels grow in the anterior chamber

Tractional retinal detachment

Figure (i) Looping Figure (ii) Beading Figure (iii) Severe segmentation

Venous changes

Cotton wool

Neovascularization

Arises from the optic nerve head along the large vessels

CLASSIFICATION

SCREENING

FOLLOW UP• Diabetic persons should be screened at least

every 2 years• High risk individuals should be examined

annually which are– Individuals with longer diabetes duration– Individuals with poor glucose control– Individuals with poor blood pressure

control– Individuals with poor serum lipid control

• The examination should include– Visual acuity assessment (Snellen chart and

equivalent)– Fundus photography or dilated fundus

examination• Individuals with any signs of NPDR should be

examined at 6-12 months interval• Earlier follow-up may be required in those of /

with– High risk groups– Presence of renal complications– Progression of DR

REFERRAL CRITERIA• Individuals with any of the

criteria below should be referred to ophthalmologist– Any level of diabetic

maculopathy– Severe NPDR– Any PDR– Unexplained visual loss– If screening examination

cannot be done, including ungradable fundus photo

TREATMENT

• DR is reversible with early detection

• Laser photocoagulation is the standard practice for treating DR

• However, there are different types of treatment of DR based on its stages as shown in the table beside

TREATMENT (cont.)

• Laser photocoagulation– Widely used for early stages of proliferative retinopathy

• Sealing of leaking blood vessels• Treat macular edema• Halt neovascularization

• Vitrectomy– Removal and replacement of cloudy vitreous due to blood accumulation with

normal saline– Done in patients with proliferative diabetic retinopathy– Able to restore vision, specially effective for insulin-dependent diabetic

patient• Anti-VEGF therapy

– Multiple injections of anti-VEGF drugs used in combination with laser photocoagulation for diabetic macular edema