1. Topic assignment : medical ophthalmology
Diabetic retinopathy
D 1.1 30/3/2011

2. Contents
Diabetes
Definition
Risk factors
Pathogenesis
Classification : proliferative / non-proliferative
Sign & symptoms
DDx & other ocular complication of DM
Treatment & follow up
Screening for DR
Apply with case study

3. Diabetes mellitus
Group of common metabolic disorders
Caused by a complex interaction of genetics and environmental factors
Lack of insulin  hyperglycemia
Diagnostic criteria : Fasting plasma glucose > 126 mg/dl
Type 1 DM – Insulin-dependent diabetes (IDDM)
Results from pancreatic beta-cell destruction, usually leading to absolute or near total
insulin deficiency
Type 2 DM - Non-insulin-dependent diabetes (NIDDM)
Variable degrees of insulin resistance and impaired insulin secretion, resulting in
hyperglycemia and other metabolic derangements due to insufficient insulin action.

4. Diabetes mellitus
Long-standing hyperglycemia leads to multiple organ damage
Macrovascular complications
Stroke
Heart disease and hypertension
Peripheral vascular disease
Foot problems
Microvascular complications
Diabetic eye disease : retinopathy and cataracts
Renal disease
Neuropathy
Foot problems

5. Diabetic retinopathy
The most severe of ocular complications of diabetes
Caused by damage to blood vessels of the retina, leads to
retinal damage
Microvascular complication of longstanding diabetes mellitus [1]
Most prevalence cause of legal blindness between the ages of
20 and 65 years
Common in DM type 1 > type 2

6. Risk factors
Duration of diabetes
Most important
Pt diagnosed before age 30 yr
50% DR after 10 yrs
90% DR after 30 yrs
Poor metabolic control
Less important, but relevant to development and progression of DR
 HbA1c ass. with  risk
Pregnancy
Ass with rapid progression of DR
Predicating factors : poor pre-pregnancy control of DM, too rapid control
during the early stages of pregnancy, pre-eclampsia and fluid imbalance

7. Risk factors
Hypertension
Very common in patients with DM type 2
Should strictly control (<140/80 mmHg)
Nephropathy
Ass with worsening of DR
Renal transplantation may be ass with improvement of DR and
better response to photocoagulation
Other
Obesity, increased BMI, high waist-to-hip ratio
Hyperlipidemia
Anemia

8. Pathogenesis
Microvascular occlusion
Microvascular leakage

9. Microvascular leakage
Degeneration and loss of pericytes Capillary wall weakening
Plasma leakage microaneurysm
Retinal edema
Hard exudate Intraretinal hemorrhage
(Circinate pattern)

10. Non-proliferative diabetic retinopathy
Right eye: Micro aneurysm, few flame-shaped and dot-blot hemorrhages and hard
exudate [with hard exudate in macula area] , neovascularization
moderate non proliferative diabetic retinopathy
Left eye: Micro aneurysm, numerous flame-shaped and dot-blot hemorrhage [more than
20 dots in 4 quadrant], hard exudate [with hard exudate in macula area]
neovascularization severe non proliferative diabetic retinopathy

11. Microvascular occlusion
Endothelial cell damage and proliferation
Capillary basement membrane thickening
Decreased capillary blood flow
Increased plasma viscosity and perfusion
Deformation of RBC
Increased platelets stickiness Retinal hypoxia
VEGF
A-V shunt Neovascularization
IRMA* and fibrovascular proliferation
Rubeosis Proliferative
iridis retinopathy
*intraretinal microvascular abnormalities

12. Vitreous hemorrhage Tractional retinal detachment

13. Classification
Non-proliferative diabetic retinopathy (NPDR)
Proliferative diabetic retinopathy (PDR)

14. Non-proliferative diabetic retinopathy
Mild NPDR
Moderate NPDR
Severe NPDR

15. Sign NPDR
Microaneurysm
Retinal hemorrhage
“Dot or Blot” Spot
“Flame or Splinter shape” hemorrhage
Hard exudate
Cotton wool Spot
Venous beading
Intra-retinal microvascular abnormalities (IRMA)

16. Mild NPDR
Microaneurysm

17. Moderate NPDR
More microaneurysms
Scattered hard exudates
Cotton-wool spots

18. Severe NPDR
4-2-1 rule
4 quadrants of severe retinal hemorrhages
2 quadrants of venous beading
1 quadrant of IRMA
Very severe NPDR  more than 1 of above

19. Microaneurysm
Localized saccular outpouchings of capillary wall  red dots
Focal dilatation of capillary wall where pericytes are absent
Fusion of 2 arms of capillary loop
Usually seen in relation to areas of capillary non-perfusion
at the posterior pole esp temporal to fovea
The earliest signs of DR

20. Microaneurysm

21. Scattered hyperfluorescent
Microaneurysms may leak
plasma constituents into
the retina

22. Retinal Hemorrhage
Capillary or microaneurysm is weakened  rupture 
intraretinal hemorrhages
Dot & blot hemorrhages
Deep hemorrhage - inner nuclear layer or outer plexiform layer
Usually round or oval
Dot hemorrhages - bright red dots (same size as large microaneurysms)
Blot hemorrhages - larger lesions
Flame-shape or splinter hemorrhages
More superficial - in nerve fiber layer
Absorbed slowly after several weeks
Indistinguishable from hemorrhage in hypertensive retinopathy
May have co-existence of systemic hypertension  BP must be checked

23. Dot & blot VS splinter hemorrhage

24. Dot Spot VS Flame Shape

25. Dot Spot VS Flame Shape

26. Hemorrhage

27. Hard exudate
Intra-retinal lipid exudates
Yellow deposits of lipid and protein within the retina
Accumulations of lipids leak from surrounding capillaries and
microaneuryisms
May form a circinate pattern
Hyperlipidemia may correlate with the development of hard
exudates

29. Cotton Wool Spot
White fluffy lesions in nerve fiber layer
Result from occlusion of retinal pre-capillary arterioles
supplying the nerve fibre layer with concomitant swelling of
local nerve fibre axons
Also called "soft exudates" or "nerve fiber layer infarctions"
Fluorescein angiography shows no capillary perfusion in the
area of the soft exudate
Very common in DR, esp if pt with HT

31. Hard Exudate VS Cotton Wool Spot

34. Venous beading
Dilatation and beading of retinal vein
Appearance resembling sausage-shaped dilatation of
the retinal veins
Sign of severe NPDR

36. Intra-retinal microvascular
abnormalities (IRMA)
Abnormal dilated retinal capillaries or may represent
intraretinal neovacularization which has not breached
the internal limiting membrane of the retina
Indicate severe NPDR  rapidly progress to PDR

38. Area of capillary non-perfusion
FA shows extensive areas of hypofluorescence due to
capillary non-perfusion and venous beading

39. Diabetic maculopathy
Macular ischemia
Retinal capillary non-perfusion
Progressive NPDR
Macular edema
Increased retinal vascular permeability
Seen in both NPDR and PDR
Focal or diffuse or mixed
Cause of visual loss in DR
Ass with planning for treatment

41. Focal macular edema
Diffuse macular edema

42. Macular ischemia

43. Clinical Significant Macular Edema
(CSME)
1 of 3
Retinal edema Hard exudates within Retinal edema > 1 disc
within 500 microns 500 microns of fovea diameter, any part is
of centre fovea if ass with adjacent within 1 disc diameter
retinal thickening of centre of fovea

44. microaneurysm

45. microaneurysm and
blot dot hemorrhage

46. blot dot hemorrhage

47. IRMAs

48. hard exudate

49. Cotton wool spots

50. Venous beading

51. Proliferative diabetic retinopathy
5% of DM pt.
Finding
Neovascularization : NVD, NVE
Vitreous changes
Advanced diabetic eye disease
Final stage of Uncontrolled PRD
Glaucoma (neovascularization)
Blindness from persistent vitreous hemorrhage,
tractional RD, opaque membrane formation,

53. Neovascularization of disc

54. Neovascularization of
elsewhere
Fluorescein dye leakage is
seen in neovascularized
area

57. Rubeosis iridis Neovascular glaucoma
(neovascularisation of the iris)

59. Vitreous changes

60. Vitreous hemorrhage Tractional retinal detachment

61. NVE
Venous
beading
IRMA

62. New vessels elsewhere

63. New vessels elsewhere

64. New vessels of the disc

65. New vessels of the disc (advanced)

66. Subhyaloid hemorrhage

67. Subhyaloid hemorrhage

68. Signs & symptoms of DR
 Blurred or distorted vision or difficulty reading
 Floaters
 Partial or total loss of vision
 a shadow or veil across patient’s visual field
 Eye pain

72. Differential Diagnosis
Diabetic retinopathy

73. Mostly miss
Hypertensive retinopathy
Radiation retinopathy
Central retinal vein occlusion (CRVO)
Branch retinal vein occlusion (BRVO)
Ocular ischemic syndrome
HIV-related retinopathy

74. Hypertensive retinopathy

75. Radiation retinopathy

77. Central retinal vein occlusion (CRVO)

78. Branch retinal vein occlusion (BRVO)

79. For symptoms
Cataract
Glaucoma
Hypertensive retinopathy
Radiation retinopathy
Retinal vitreous obstruction
Retinitis pigmentosa
Senile macular degeneration

80. For cotton wool spot
Similar lesions are also caused by the alpha-toxin of
Clostridium novyi

81. For Cotton wool spot

82. For Hard exudates

83. For Hemorrhage

84. Treatment
Laser Photocoagulation**
Vitreoretinal surgery**
Intravitreal triamcinolone acetonide

85. Medical therapy
Prevention
Treat underlying conditions
Control blood sugar – HbA1c < 7
Control blood pressure – SBP < 130 mmHg
Control lipid profile – TG, LDL
Correct anemia
Control diabetic nephropathy
Pregnancy makes DR worsen

86. Laser
Panretinal photocoagulation (PRP)
High-risk PDR (3/4)
Vitreous or preretinal hemorrhage
New vessels
New vessels on optic disc or within 1,500 microns from optic
disc rim
Large new vessels
Iris or angle neovascularization
CSME

87. Photocoagulation
Focal or Grid
CSME in both NPDR and PDR
Panretinal (PRP)
PDR

88. Laser panretinal photocoagulation (PRP)
Inducing involution of new vessels
Preventing vitreous hemorrhage and preventing visual loss
Limitations :
Patient must have clear lens and vitreous
If cataract  treat before laser PRP
If vitreous hemorrhage  vitrectomy + laser photocoagulation

89. Focal photocoagulation

90. Grid photocoagulation

91. Panretinal photocoagulation (PRP)

92. Surgery
Indications for pars plana vitrectomy (PPV) in DR
Severe persistent vitreous hemorrhage
Progressive tractional RD (threatening or involving
macula)
Combined tractional and rhegmatogenous RD
Premacular subhyaloid hemorrhage
Recurrent vitreous hemorrhage after laser PRP

93. Vitreoretinal Surgery
Pars plana vitrectomy (PPV)
Membrane peeling (MP)
Endolaser (EL)
Fluid gas exchange (FGX)
SF6
C3F8

94. Screening for DR
Juvenile onset DM > 5 years then every year
Adult onset DM at diagnosis (> 30) then every year
DM with pregnancy in first trimester then every trimester

95. Follow up
Retinal abnormality Follow up
Normal or rare microaneurysms Once a year
Mild NPDR q 9 months
Mod NPDR q 6 months
Severe NPDR q 4 months or laser
CSME q 2-4 months ** or laser
PDR q 2-3 months ** or laser

96. Advanced diabetic eye disease
Serious vision-threatening complications of DR
persistent vitreous hemorrhage
tractional retinal detachment
opaque membrane formation
neovascular glaucoma
Treatment : complicated vitrectomy
Poor prognosis

97. Case scenario

98. Case
Identification data :
Chief complaint :

99. Present illness
-

100. Past history
Underlying diseases : DM poor controlled ,
HT poor controlled
Current medication
metformin 500 mg 2*1 o pc
Nifedipine 20 mg 1*2 o pc
Amlopine 10 mg 1*1 o pc

101. Physical examination
GA : a middle aged woman with normal
consciousness, good co-operation
V/S : T 36.9 BP 157/83 mmHg P 94/min
RR 16/min
HENT : no discharge per ears, nose, no
bleeding per gum, cervical LN cant’ be
palpable
Heart : normal S1S2, no murmurs
Lungs : clear & equal breath sounds both
lungs

102. Ocular examination
OD OS
VA c C 6/9 -2 Pj
VA c PH 6/9 -
Lids & Lashes & Normal Normal
Conjunctiva
Cornea Clear Clear
Iris
Lens Clear Clear
Anterior chamber Normal depth, clear Normal depth, clear
Pupil 3 mmRTLBE RAPD -
EOM Full Full
IOP 20 20

103. Fundus examination
OD OS
Red reflex Normal Normal
Vessels Normal 2:3 Normal 2:3
Background & Macula Dot & blot hemorrhage dot blot hemorrhage ,
NVE NVE , old hemorrhage
Fibrous and retinal break
involve macula
Disc No NVD , C:D 0.3 No NVD , C:D 0.3

104. Problem lists

105. Problem list
Unilateral chronic painless visual loss
Flashing and Floaters
Poor controlled DM, poor controlled HT
Dot & blot hemorrhages with NVE BE
Fibrous & Retinal break involve macula LE

106. Provisional diagnosis
Right eye : PDR
Left eye : PDR with TRD+RRD

107. Differential diagnosis
Hypertensive retinopathy
Central retinal vein occlusion (CRVO)
Branch retinal vein occlusion (BRVO)
Ocular ischemic syndrome

108. Management in this case
DR
LE
PPV
Pars plana vitrectomy
membrane peeling Indications for PPV in DR
Severe persistent VH
Endolaser Progressive tractional RD
Combined TRD & RRD
silicone oil injection Premacular subhyaloid hemorrhage
Recurrent VH after laser PRP

109. Closed observe (q 2-3 months)
Laser PRP
PPV + MP + EL + SOI

110. 2

111. Thank you