DR VIVEK WANI TALK ON DIABETIC RETINOPATHY FOR KLE MBBS STUDENTS UG KAHER.pptx

Diabetic Retinopathy
Dr. Vivek B Wani MS FRCSEd
Asst Prof JNMC
Consultant Vitreoretina surgeon
KLES Dr. Prabhakar Kore Hospital and MRC
Belagavi

OBJECTIVES OF THIS TALK
• Give a brief account of various aspects of
diabetic retinopathy
• At the end of talk the students should be able
to recognize DR as an important cause of
visual impairment
• Should be aware of referral protocols
• Also be aware of treatments available
10th August 2023 DR.Wani on DR for UGs KAHER 2

What is DR?
• It is a microangiopathy , affects retinal
vessels and results in typical clinical features
called DR
• DR is the most common retinal vascular
disease
• Most common cause of visual impairment in
persons aged 20-64 years
• If detected in time it can be treated to
improve or preserve the vision

DM affects several OTHER organs

Diabetic retinopathy
I) Epidemiology and the burden of Diabetic
Retinopathy(DR)
II) Risk factors for DR
III) Pathogenesis
IV) Clinical features
V) Classification of DR
VI) Investigations
VII)Treatment of Diabetic macular edema(DME)
and Diabetic retinopathy

Burden of DM (epidemiology)
• Nearly 8.5% of adults above 18
years have DM in the world
https://www.who.int/news-room/fact-sheets/detail/diabetes
• In India 7.3% of population aged
>20 years have DM
RM Anjana et al. Lancet diabetes endocrinology. 2017 online
• An estimated 6.5 crore people are
diabetic in India

How many DM patients have Diabetic
Retinopathy(DR)-prevalence?
• 34% of DM patients had DR and 10% of them
had sight threatening DR –world statistics
Yau et al Diabetes Care. 2012 Mar; 35(3):556-64.
• In India about 18% DM patients had
DR and 4% had sight threatening DR
Jotheeshwaran et al Indian J Endocr Metob 2016;20:51-8
PK Rani et al Middle East Afr J Ophthalmol .2012;19(1):129-34

II) What are the risk factors for
development of DR in diabetics?
• Duration of DM- longer the duration more DR
• Control of DM –persistent hyperglycemia is a risk
factor for DR
• Hypertension- Higher the BP more the risk of DR
• Pregnancy –if a DM lady becomes pregnant
• Hyperlipidaemia
• h/o Cataract surgery-worsens DR
• M<F –not very strong factor
• Genetic factors – clustering of cases is seen

a) Duration of DM and DR in Type I DM
Duration
of DM
ANY DR PDR DME
<5 YEARS 2% 0 0
>15 YEARS 97% 67% 23%
Klein et al Diabetes in America, 2nd ed. Bethesda, Maryland: National Institute of Health.
1995;293-338
Klein R et al Arch Ophthalmol. 1984;102:520-52

DR Insulin takers Non insulin
takers
DM>15 years
Any DR 87% 57%
10 years incidence
of PDR
24% 10%
10years incidence
DME
18% 9%
Klein R et al Arch Ophthalmol. 1984;102:527-532
Klein R et al Arch Ophthalmol. 1994;112:1217-1228, Klein R et al Ophthalmol. 1995;102:7-16)
Duration of Type II DM And Incidence of DR

b) Control of DM –applies to MD of both
type I and II
UKPDS study (United Kingdom
Prospective Diabetes Study)of type
II DM patients
• If we reduce HbA1C by 1% the
risk of DR was reduced by 37%
Stratton IM, Adler AI, Neil HA, et al BMJ 2000 Aug 12;321(7258):405-12)

c) Hypertension in DM of type 2
• In patients with hypertension and DM if we
reduce BP by 10 mm of Hg(154/97 to 144/82)
Progression of DR reduced by 34%
Reduced VA deterioration by 47%
Reduced need of laser by 35%
UKPDS group BMJ. 1998;317:703-713.

How does hyperglycemia
cause Diabetic retinopathy?

Cheung et al Lancet. 2010;367:124-136
Leucocyte
Adhesion
Platelet
Aggregation
RBC roulex
Formation
PDGF
Vascular occlusion
Causes hypoxia-VEGF up-regulated
New vessels produced-PDR
Leakage from retinal capillaries causes hgs,
exudates and Diabetic macular edema n DV
III) Pathogenesis of DR

VEGF –VASCULAR ENDOTHELIAL
GROWTH FACTOR

IV) Clinical Features of DR
SYMPTOMS
AND SIGNS

A)SYMPTOMS
May be asymptomatic even with advanced disease and
DR may be detected in routine screening
Decreased vision is the most common symptom
 GRADUAL onset of DV in DME or slowly developing
tractional RD
 Sudden DV –is usually due to vitreous hemorrhage
Floaters – due to small vitreous hemorrhages
Distorted vision-metamorphopsia –pulling of retina by
TRD
Pain and redness- sudden onset indicates
development of neovascular glaucoma –late stage

B) Examination -Signs of DR
In the anterior segment-
i) We first measure visual acuity both eyes
ii) Slit lamp examination to look for
neovascularisation of iris (NVI) or rubeosis
iridis
Gonioscopy- look for neovascularisation of
angle ---NVA

Dilated fundus examination is must for
detection of signs of DR
1. Microaneurysms
2. Retinal hemorrhages-dot and blot and flame shaped hgs
3. Cotton wool spots(CWS)
4. Hard exudates
5. Venous changes –venous dilatation, beading, looping,
doubling,
6. Arterial changes-closure
7. WHEN PDR sets in - Neovascularization and its complications
– vitreous hemorrhage, tractional RD
8. Diabetic Macular edema -DME –can be present both in NPDR
AND PDR
9. Diabetic papillopathy -disc swelling causing DV in diabetic
patients

1. Retinal microaneurysms
• Are the first sign of DR
• Seen as red dots of 10-
125 microns
• Out-pouching or
fusiform dilation of
capillaries
• They leak and cause
retinal hemorrhages,
hard exudates and
retinal edema
Out pouching Fusiform dilation

2. Retinal hemorrhages
 Superficial hgs - flame
shaped-they are in
retinal nerve fiber layer
 Deep hgs- dot and blot
hgs –present inner
plexiform, inner nuclear
layers
Superficial hgs
Dot and blot hgs

3. Cotton wool spots (CWS)
White superficial lesions with
brush like borders
Located in retinal nerve fiber layer
(RNFL)
Are due to axoplasmic flow
stoppage in retinal nerve fibers
CWS
Dot and blot hgs
Superfical hgs

Multiple small
hard exudates in
ring shape
Note hgs and
microaneurysms
in the center
Retina in center
is thickened
4. Hard exudates are in middle layers

Hard Exudates
Waxy, yellow lesions arranged in clumps
and/or rings in the posterior pole-circinate
retinopathy
In the center of the ring are present leaking
MA or capillaries also retina shows edema
Hard exudates are made up of lipoproteins
and lipid ingested macrophages

5. Intra Retinal Microvascular abnormality
(IRMA)
• Important signs of advancing disease
• They are intraretinal
• They are shunt vessels
• Fine, reddish, irregular blood vessels that run
from arterioles to venules
• They bypass the capillary bed

Redfree photo showing multiple areas of IRMAs

6. Venous changes
• Dilatation
• Venous beading
• Venous looping
Venous beading and looping
signify worsening DR
Venous looping

7. Arterial changes
• Arteriolar closure is main reason for hypoxia
of retina

Signs of DR
• MA
• Retinal hgs –superficial and deep
• Cotton wool spots
• Hard exudates
• IRMA
• Venous changes
• Arterial changes
All the above changes occur in non Proliferative
DR -NPDR
There are no new vessels of fibrous tissue

PDR
• When new blood vessels appear on the
surface of retina- we call it as PROLIFERATIVE
DIABETIC RETINOPATHY ------PDR
• All signs of NPDR may be present during PDR
• IN ADDITION TO THEM we will have --

Signs of PDR include
• New vessels and fibrovascular membranes on
the retina
• Vitreous hemorrhage
In the vitreous gel
Subhyaloid hg -between retina and posterior
hyaloid
• Tractional RD
• Combined TRD with rhegmatogenous RD

Neovascularization of disc or NVD
When new vessels grow on the disc or within ONE disc diameter
of the disc

2) NEOVASCULARIZATION ELSEWHERE-NVE -When new vessels
grow outside of ONE disc diameter from the disc

What do the new vessels do?
• They are fragile and may break n bleed
Vitreous hg –sudden loss of vision
Subhyaloid Hg
• Later the new vessels undergo fibrosis and
cause contraction and lift retina-tractional
retinal detachment

Tractional retinal detachment –TRD

PDR- New vessels on iris –NVI and/or in the angle - NVA
• Indicate severe ischemia in the retina and need urgent
attention and treatment
• May cause NVG - painful and blinding disease
NVI
NVA

V) Classification of DR or stages of DR
DR
Non
proliferative
Proliferative

NO DR
• Patient is diabetic but there are no changes of
DR
• Need annual follow ups
• Control BS and BP

V) A. Classification of DR
NPDR
Mild
Very Severe
Moderate
Severe

Mild NPDR
• Only microaneurysms are present - at least
one MA +
• No hgs, CWS, IRMAS, VB ETC
• Need follow up at 6-9months

Moderate NPDR
• Some or all signs of NPDR may be present but
their degree is less than severe NPDR
--MAs, Hgs, IRMAs, H ex, venous beading, CWS
• Follow up -every 4 months if there is no
maculopathy
• If DME present then treat or FU 2-3 months

Severe NPDR
• Is diagnosed by 4-2-1 Rule
• One of the 4-2-1 conditions present
• No new vessels, vitr or subhyaloid hg present
• Standard photos are from ETDRS study

SEVERE NPDR RULE 4- hgs and MA =/>standard photo 2A in all 4
quadrants

RULE 2- venous beading =/>standard photo 6A is present in 2 or
more quadrants

RULE 1-
IRMA ≥ standard photo 8A in at least 1 quadrant

Why it is important to recognize
Severe NPDR ?
• Severe NPDR is a sight threatening DR
• Nearly 50% progress to PDR in one year
• Follow ups are needed every 2-3 months
• Selected cases
LASER treatment pan retinal photocoagulation
Or intravitreal injection of anti vascular
endothelial growth factor

VERY severe NPDR
• For very severe NPDR more than
one condition of the 4-2-1 rule is
present (for example- hgs plus VB or
VB &IRMA or hgs and IRMA )

V) Classification of DR
DR
Non
proliferative
Proliferative

PDR staging
i)Early PDR
ii) High Risk PDR
iii) Advanced PDR
Severe NPDR, PDR & diabetic macular edema
are SIGHT THREATENING DR

i) Early PDR
• There are new vessels but their severity is less
than the next stage of PDR
• Treat or observe closely

ii) High Risk Characteristic (HRC) PDR
• Size of NVD >/=1/4 disc area –disc
diameter(DD)
• Size of NVD <1/4 DD but is associated with
vitreous hemorrhage
• Size of NVE >1/2DD with vitreous hemorrhage

Standard photograph 10A defines the lower border of moderate NVD. NVD covers approximately
one-third the area of the standard disc. This extent of NVD alone would constitute HR PDR
NVD

NVD

iii) Advanced PDR
• Vitreous hemorrhage
• Sub-hyaloid hemorrhage
• Tractional RD
• Combined Tractional and rhegmatogenous RD
• These patients need treatment usually pars
plana vitrectomy

DIABETIC MACULAR EDEMA
• Sight threatening DR
• It is the most common cause of visual
impairment
• So diagnose and treat promptly
• It can be present in both NPDR and PDR stages

What is DME?
• Diabetic Macular edema is defined as retinal
thickening or hard exudates at or within 1 disc
diameter of the center of the macula
• Clinically Significant Macular edema -CSME is
1) Retinal thickening within 500 mu of the center of the
fovea OR
2) Hard exudates within 500 mu of the center of the fovea
with adjacent retinal thickening OR
3) Thickening of the retina of 1 DD size or more any part of
which falls within 1 DD of center of the macula
Early treatment diabetic retinopathy study group,” Archives of Ophthalmology;1985:
1796-1806

Investigations for DR
1. Optical coherence tomography-OCT-mainly to
detect diabetic macular edema and its features
2. Fundus fluorescein angiography- FFA to look for
leaking areas, capillary non perfusion areas and
assess foveal avascular zone FAZ
3. OCT-angiography –OCT A -is a recent
investigation that studies vessels without
injection of any dye
4. US B scan in cases where cataract or vitreous
hemorrhage prevents view of retina –assess if
vitreous hg or TRD or RD are present

center involving DME
center not involving DME
OCT-very useful in assessing DME, prognostic value, follow up of DME, effect of
treatment of DME

We can detect cystoid changes, subretinal fluid
and thickening of retina

RE CSME-Diffuse n cystoid

DME before and after anti VEGF
INJECTION

FFA- Note VB, capillary drop out areas, leak from
disc, enlarged FAZ, microaneurysms
Capillary drop out
areas
leak from disc –NVD
Enlarged FAZ
–macular
ischemia

Ultrasound B scan
• To assess the retina in cases where the media
is not clear
Cataract
Vitreous hemorrhage
Helps to diagnose V Hg, RD, TRD or PVD

TREATMENT OF DR
• Control of DM, HT and other risk factors in
treatment of DR is important
• Treatable conditions are
• -DME
• -PDR
• Recently cases of severe NPDR are also being
treated

VEGF –VASCULAR ENDOTHELIAL
GROWTH FACTOR

DME
• The leaking microaneurysms are responsible for
DME
• So treat them by
• Closing the MA by applying laser burns to MA
• VEGF is causing increased permeability and
leakage
• So give a anti VEGF drug intravitreally
• Stops leakage –may need repeated treatment
sessions

Intravitreal drugs
Anti VEGF
• Bevacizumab
• Ranibizumab
• Brolucizumab
• Faricimab
Intravitreal steroid depot injection-
dexamethasone is also used

Treatment of PDR

Stop VEGF production
• ‘Kill’ all cells producing the VEGF by doing
laser ablation
• Just leave the macula for central vision
• Affects peripheral visual field but good results
• Or give anti VEGF injections
• Needed repeatedly

3RD NOVEMBER 2022 UG CLASS JNMC DR VIVEK WANI 83

PRPC FOR PDR
3RD NOVEMBER 2022 UG CLASS JNMC DR VIVEK WANI 84

BEFORE AND AFTER ANTI VEGF INJ

Surgical treatment of PDR
• When vitreous hemorrhage does not resolve
for more than 2-3 months
• There is tractional RD involving or threatening
the macula
• Traction on retina has resulted in a break in
retina causing rhegmatogenous RD-combined
RD
WE PERFORM pars plana vitrectomy to treat all
the above conditions

Treatment of DR
control of DM and BP are for all stages
Type Treatment Follow up Remarks
No D R Nil 1 year
Mild NPDR Nil 6-9 mo Look for DME
Moderate NPDR Nil or May give anti VEGF 3-4 mo Look for DME
Severe NPDR May consider PRP or anti VEGF INJ 2-3 mo Look for DME
Very severe NPDR May consider PRP or anti VEGF INJ 2-3 MO Look for DME
Mild PDR May consider PRP or anti VEGF INJ 1-2 mo Look for DME
HRC PDR PPPC laser or anti VEGF inj - Look for DME
Advanced PDR PRPC
May need vitrectomy
- Look for DME
DME
If center involving
(CI)
It not CI
Anti VEGF inj monthly x3 n then as needed or
regular inj
Focal laser treatment
1-2 mo
VA
OCT monitoring

DR VIVEK WANI TALK ON DIABETIC RETINOPATHY FOR KLE MBBS STUDENTS UG KAHER.pptx

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