diabetic retinopathy (opthalmology)

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DIABETIC RETINOPATHY

B Muhd Ariff Mahdzub

DIABETIC RETINOPATHY

DIABETIC RETINOPATHYRetinal 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 agePrevalence is closely-related to duration of diabetesAt 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 perfusionRelease vascular endothelial growth factorNew blood vessels grow and proliferate inside the retina and vitreous humorHowever, these new blood vessels can easily rupture and bleed, cloud vision and damage retinaFibrovascular proliferation occurs as part of healing process due to rupture vesselsNeovascular glaucoma occur if the new blood vessels grow in the anterior chamberTractional retinal detachment

Figure (i) LoopingFigure (ii) BeadingFigure (iii) Severe segmentationVenous changes

Cotton woolNeovascularizationArises from the optic nerve head along the large vessels

CLASSIFICATION

SCREENING

FOLLOW UPDiabetic persons should be screened at least every 2 yearsHigh risk individuals should be examined annually which areIndividuals with longer diabetes durationIndividuals with poor glucose controlIndividuals with poor blood pressure controlIndividuals with poor serum lipid controlThe examination should includeVisual acuity assessment (Snellen chart and equivalent)Fundus photography or dilated fundus examinationIndividuals with any signs of NPDR should be examined at 6-12 months intervalEarlier follow-up may be required in those of / withHigh risk groupsPresence of renal complicationsProgression of DR

REFERRAL CRITERIAIndividuals with any of the criteria below should be referred to ophthalmologistAny level of diabetic maculopathySevere NPDRAny PDRUnexplained visual lossIf screening examination cannot be done, including ungradable fundus photo

TREATMENTDR is reversible with early detectionLaser photocoagulation is the standard practice for treating DRHowever, there are different types of treatment of DR based on its stages as shown in the table beside

TREATMENT (cont.)Laser photocoagulationWidely used for early stages of proliferative retinopathySealing of leaking blood vesselsTreat macular edemaHalt neovascularizationVitrectomyRemoval and replacement of cloudy vitreous due to blood accumulation with normal salineDone in patients with proliferative diabetic retinopathyAble to restore vision, specially effective for insulin-dependent diabetic patientAnti-VEGF therapyMultiple injections of anti-VEGF drugs used in combination with laser photocoagulation for diabetic macular edema