Diabetic retinopathy (DR)
Transcript of Diabetic retinopathy (DR)
Diabetic retinopathy (DR) & interpretasi fundus photo
Dr Nurulhuda Ariffin MD UKM, Doctor of Oph UKM
Ophthalmology Department HSAJB
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References
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www.drsmodule.org.my
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Table of content
Anatomy of the eye
DM and the eye
• Prevalence
• Pathogenesis
• Risk factor
• Grading
• Assessment
• Follow up
• Management
DR
Recap- fundus photos Diabetic Retinopathy- DEMO JKNJ 2021 4
AIM of today’s talk
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1. Identify patient at risk of DR
2. Schedule 1st DR assessment & interpret fundus photo
3. Decide on DR follow up & refer urgent cases
4. Create awareness & counsel DR patients
1. Anatomy of the eye
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Vitreous cavity
Fundus photography
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Right eye
Retinal vein and artery
NASAL
2. DM and the eye
Cornea
• Dry eye
• Neurotrophic keratitis
Aqueous
• Anterior uveitis
Lens
• Refractive changes
• Cataract
Retina
• DR vitreous haemorrhage retinal detachment
OD
• Glaucoma
• Diabetic papillitis
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3. Prevalence of DR1
• Worldwide 6.8-44.4%
• Malaysia 36.8% (Diabetic Eye Registry 2007)
• Singapore 35% (Singapore Malay Eye Study 2006)
• Early DR in young? New South Wales, Australia.
– 8% in children (less than 11yrs)
– 25% in adolescent (older than 11yrs)
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Sight threatening
15.6% (NED 2007)
Blind 9%
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4. Pathogenesis of DR
Intercellular sorbitol accumulation,
free radicals,
glycated end products,
disruption of ion channel function,
protein kinase C activation
HY
PER
GLY
CA
EMIA
2. Hematological & Rheological
changes
1. Microangiopathy (damage to capillary wall)
3. Direct effect on retinal cells
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Microangiopathy
(damage to capillary wall)
Intraretinal haemorrhage
Edema, Exudates Microvascular
Occlussion, Ischaemia, IRMA,
Neovascularization, Fibrosis *VEGF
Hematological & Rheological changes
*VEGF- vascular endothelial growth factor
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5. Risk factors for DR2
•Smoking •Inactive lifestyle/ obese
• HPT, CKD, CVA, CVD
• Hyperlipidaemia
• Anaemia
• Longer duration
• Poor control
DM Co-
morbid
Lifestyle Pregnancy
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6. Grading of DR1 (International Clinical Diabetic Retinopathy and Diabetic Macula Oedema Disease Severity Scale)
Dia
bet
ic R
etin
op
ath
y
Retinopathy
No apparent DR
Non proliferative DR
Mild
Moderate
Severe
Proliferative DR Advanced diabetic eye
disease (ADED)
Maculopathy
Absent
Present Diabetic Retinopathy- DEMO JKNJ 2021 14
Mild NPDR (microaneurysm only)
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Moderate NPDR
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• More than just microaneurysm • Less than severe NPDR
Microaneurysm
Severe NPDR (4:2:1 rule)
Any of the following: • more than 20
intraretinal haemorrhage in each 4 quadrant, or
• venous beading in 2 or more quadrant, or
• Intraretinal microvascular abnormality (IRMA) in 1 or more quadrant
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*IRMA is a shunt vessel
PDR Any of the following: • Neovascularization , or • vitreous/ preretinal haemorrhage
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NVD
NVE NVE
NVD: New vessel on dic, NVE: new vessel elsewhere
Preretinal haemorrhage
ADED Any of the following: – Fibrous tissue, or – dragging of retina, or – retinal detachment, tractional or rhegmatogenous
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Fibrous tissue
Fibrous tissue with tractional retinal detachment
Mild maculopathy
• Distant from centre
Moderate maculopathy
• Approaching centre
Severe maculopathy
• Involving centre
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Hard exudates at fovea
Diabetic maculopathy present:
• Hard exudates, or
• Oedema (retinal thickening)
7. Assessment of DR
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Ophthalmoscopy (BIO)
Slit lamp machine
Fundus camera
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8. Follow up for DR
Referral to ophthalmologist
•Unexplained visual loss
•PDR
•Diabetic maculopathy
•Severe NPDR
•Screening examination cannot be performed
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1 week
1 month
Next review? D
iab
eti
c R
etin
op
ath
y
Retinopathy
No DR
12-24 months
3 months if in pregnancy
Non proliferative DR
Mild 9-12 months
Moderate 6 months
Severe
Proliferative DR Advanced diabetic eye disease
Maculopathy Present
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OPHTHALMOLOGIST
9. Management of DR
How to manage?
Systemic
Glycaemic control
Fenofibrate
Ocular
Laser
Medical
Surgical
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Retinal Laser Photocoagulation
Pigmented: old laser mark
White: new laser mark
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Vitreoretinal surgery
Intravitreal anti-VEGF/ steroid
Case scenario
• NF, 32 M F • Type 1 DM- since 16yo • HPT
• Ophthal Hosp Batu Pahat • BE PDR, lasered • Referred to VR HSAJB in 2019
• RV 6/60 ph 6/18 • LV 6/60 ph 6/60 • RE ADED with subtotal TRD/ RRD • LE ADED with total TRD/ RRD
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• Dec 2019: LE VR surgery + SO
• June 2020: RV 6/60 ph 6/60 • Oct 2020: RE VR surgery + gas
• Nov 2020 • RV 6/60 ph 6/24 • LV 6/60 ph 6/24 • She was happy- able to see her
baby again
Unfortunately, • Mar 2021 May 2021 • RV HM HM • LV CF PL
• BE cataract L (mature) > R
• Aug 2021: LE cataract surgery + removal of SO
• # Progression from BE PDR to ADED in 2019 was likely due to her pregnancy Diabetic Retinopathy- DEMO JKNJ 2021 29
10. Recap- fundus photos
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Photo 1
• RE/ LE?
• Retina
– PDR/ NPDR?
– NPDR: mild/ moderate/ severe?
• Maculopathy
– Yes/ no?
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Diagnosis: Left moderate NPDR with
moderate maculopathy
Photo 2
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• RE/ LE?
• Retina
– PDR/ NPDR?
– NPDR: mild/ moderate/ severe?
• Maculopathy
– Yes/ no?
Diagnosis: Right
moderate NPDR, no maculopathy
Photo 3
• PDR
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• RE/ LE?
• Retina
– PDR/ NPDR?
– NPDR: mild/ moderate/ severe?
• Maculopathy
– Yes/ no?
Diagnosis: Right ADED with macular oedema,
lasered, not yet quiescent
Photo 4
• ADED
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• RE/ LE?
• Retina
– PDR/ NPDR?
– NPDR: mild/ moderate/ severe?
• Maculopathy
– Yes/ no?
Diagnosis: Right ADED with TRD threatening
macula
Photo 5
• ME
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• RE/ LE?
• Retina
– PDR/ NPDR?
– NPDR: mild/ moderate/ severe?
• Maculopathy
– Yes/ no?
Diagnosis: Left moderate NPDR with
moderate diabetic maculopathy.
Photo 5
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• RE/ LE?
• Retina
– PDR/ NPDR?
– NPDR: mild/ moderate/ severe?
• Maculopathy
– Yes/ no?
Diagnosis: Right PDR/ severe NPDR- lasered,
stable. No maculopathy
Photo 6
• CRVO
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• RE/ LE?
• Retina
– PDR/ NPDR?
– NPDR: mild/ moderate/ severe?
• Maculopathy
– Yes/ no?
Diagnosis: Left non ischaemic central
retinal vein occlussion with macular oedema
Photo 7
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• RE/ LE?
• Retina
– PDR/ NPDR?
– NPDR: mild/ moderate/ severe?
• Maculopathy
– Yes/ no?
Diagnosis: Left hypertensive
retinopathy grade 4
Take home messages
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1. Serial DR screening- must be done for all diabetic patients
2. Metabolic control- slow down DR progression, avoid recurrent of treated DR
3. Educate patient on blinding DR consequences- asymptomatic even reach PDR state
Thank you
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MCQ 1
1. These are the eye complications of uncontrolled Diebetes Mellitus, EXCEPT
a) Glaucoma
b) Macular Oedema
c) Lens Dislocation
d) Neurotropic keratitis
Answer: C.
Cataract is a known complication of DM through several mechanism but it does not cause lens dislocation
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MCQ 2
2. False statement about Diabetes complicating pregnancy
a) Arrange DR screening prior to a planned pregnancy b) Patient with no DR during 1st trimester can be followed
up yearly c) In no DR or mild NPDR, DR screening should be repeated
every 3 months d) Risk of DR progression expected during pregnancy
Answer: B Due to increase metabolic demand during pregnancy, DR may progress. Even without DR changes, patient need to be followed up 3 monthly.
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MCQ 3
3. Diagnosis of severe NPDR includes any of the following criteria except:
a) more than 20 intraretinal haemorrhage in each 4 quadrant, or
b) venous beading in 2 or more quadrant, or c) Intraretinal microvascular abnormality (IRMA) in 1
or more quadrant d) Presence of hard exudates at the macula
Answer: D Hard exudates is not a criteria to diagnose severe NPDR
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MCQ 4
4. DR progression can be reduced by these management except:
a) Oral steroid prescription b) Oral fenofibrate prescription c) Panretinal photocoagulation laser d) Treatment of anaemia
Answer: A Systemic steroid leads to uncontrolled DM thus DR may progress. Local steroid has less systemic effect. It is used in diabetic macula oedema (given through intravitreal injection) and to control intraocular inflammation e.g. post cataract surgery (topical form- eyedrops)
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MCQ 5
5. False statement about diabetic maculopathy a) Only occurs in patient with severe NPDR or worse
b) Presence of hard exudates or oedema (retinal thickening) at macula area
c) Need to be referred to an ophthalmologist within 4 weeks
d) Can be observed if visual acuity is good (6/12 or better)
Answer: A
Diabetic maculopathy can be present/ absent at any DR stage
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MCQ 6
6. True statement about moderate NPDR, except a) Panretinal Photocoagulation laser need to be given b) Can be followed up 6 monthly under primary care setting c) Optimization of metabolic comorbidities reduce DR
progression d) Presence of of LESS than than 20 intraretinal
haemorrhage in each 4 quadrant
Answer: A Laser PRP will be initiated in severe NPDR if close monitoring unable to be performed. In DR less than severe NPDR, systemic medical optimization is the key management.
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MCQ 7
7. True statement about PDR, except a) Define as presence of neovascularization
b) Vascular endothelial growth factor (VEGF) play a role in the pathogenesis
c) Preretinal haemorrhage or vitreous haemorrhage occurs due to ruptured new vessel
d) All patient has poor visual acuity
Answer: D
PDR patient may be asymptomatic
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MCQ 8
8. 1st DR assessment, except
a) Up to 3 years after diagnosis of type 1 DM in adult
b) Up to 3 years after diagnosis of type 2 DM in children
c) 2-5 years after diagnosis of type 1 DM in children (at age of 10 or at onset of puberty if this is earlier)
d) At the time of diagnosis for GDM diagnosed in 1st trimester
Answer: B
All type 2 DM need to be screen at the time of diagnosis
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MCQ 9
9. Pathogenesis of DR, except a) Intravascular changes includes deformation of red
blood cell, leukostasis and increase platelet stickiness b) Capillary changes includes pericyte loss, endothelial
cell dysfunction and basement membrane thickening c) Retinal neural cells are not affected d) Vascular endothelial growth factor (VEGF) increase
vascular permeability and stimulates new vessels formation
Answer: C Retinal neurodegeneration is part of the DR pathogenesis
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MCQ 10
10. Management of PDR, except a) Laser panretinal photocoagulation
b) Vitreoretinal surgery if patient has persistent vitreous haemorrhage
c) Systemic diabetic control
d) Intravitreal steroid
Answer: D
Intravitreal steroid is a treatment option for centrally involved diabetic macular oedema (1st line treatment is intravitreal antiVEGF).
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