DIABETIK RETINOPATI
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Diabetic retinopathy
Habibah S. MuhiddinDept. of Ophthalmology
Fac. of MedicineHasanuddin University
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• Blindness is one of the microangioapathy complications of diabetes, but also one of the most preventable.
• Diabetic retinopathy is the commonest cause of blindness in people aged 30 to 69 years.
• 20 years after the onset of diabetes almost all patients with Type 1
• over 60% of patients with Type 2
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Histopathologic findings
- Early signs → leucocytes stasis and adhesion in retinal vasculature
- Loss of pericytes- Thickening of basement membrane- Hyperpermeability- Microaneurysm formation- Microvascular occlusion- Infarct retina- Fibrovascular formation
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Hematologic/ biochemical abnormalities
• Increased platelet adhesiveness• Increased erythrocyte aggregation• Abnormal serum lipid• Increased mediator inflammation, ICAM-1,
VEGF, TNF-α ext• Defective fibrinolysis• Abnormalities in serum and whole blood
viscosity
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Pathologic changes in diabetic retinopathy
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PATHOGENESIS OF DR
• The exact cause is unclear• Several biochemical mechanisms have been
proposed as pathogenic background of DR- inflammatory process- oxidative damage- extensive hyperglycemia- VEGF- growth hormon- renin angiotensin system- genetic factors
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Proliferation DR
More inflammation mediators, growth factors(TNF-, ICAM-1, VCAM-1, IL-1, IL-6, IL-18 ) (VEGF, IGFs, TGF-)
Non Proliferative DR
Protein Kinase C (PKC) activation (AGEs), Polyol accumulation,Hexoamine pathway, oxidative stress Stress Oxidative
Increased inflammation mediators (TNF-, ICAM-1, VCAM-1, IL-1, IL-6, IL-18 )
Retina haemodynamic damage
Vascular endothelial dysfunction
Retinal hypoxia
Biochemical changes
Hyperglycemia
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CYTOKINES / MOLECULAR ADHESION
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Monocyte Chemotactic Protein-1(MCP-1) ( aqueous humor, vitreous )
Macrophage Migration Inhibitory Factor (MIF) vitreous
Interleukine-6 (IL-6) ( vitreous )Interleukine-8 (IL-8) (vitreous )Tumor necrosis factor α (TNFα) (epiretinal
memb/ aqueous humor)Icam-1 in aqueous humor Tashimoto et al. (Diabetic Med, 2005)Elner et al. (Curr Eye Res, 1995)Abu El-Asrar et al (Am J Ophthalmol, 1997) Capeans et
al (Retina,1998) Mitamura et al (Ophthalmologica, 2001) Tashimo et al. (Diabetic Med, 2005) Mitamura et al. (Br J Ophthalmol, 2000), Funatsu et al. (Retina, 2001), Abu El-Asrar et al. (Am J Ophthalmol, 1997), Elner et al. (Curr Eye Res, 1995), Yuuki et al. (J Diabetic Complications, 2001), Limb et al. (Br J Ophthalmol, 1996), Muhiddin, disertasi, 2007
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Classification of DR
• due to microangiopathy affecting the• retinal precapillary arterioles, capillaries, and venules.
Damage is caused by both microvascular leakage due to break down of the inner blood-retinal barrier and microvascular occlusion.
• These two pathological mechanisms can be distinguished from
• each other by fluorescein angiography, which is the “gold• standard” for assessing diabetic retinopathy.
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• Hard exudates are yellow lipid deposits with relatively discrete margins.
• Retinal oedema is due to microvascular leakage and indicates breakdown of the inner blood-retinal barrier.
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Background retinopathy
• Microaneurysms are small saccular pouches possibly caused by local distension of capillary walls. They are often the first clinically detectable sign of retinopathy, and appear as small red dots commonly temporal to the macula.
• Haemorrhages may occur within the compact middle layers of the retina, and appear as “dot” or “blot” haemorrhages, or
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Clinically significant macular oedema (CSMO)
• retinal oedema within 500m (one-third of a disc diameter) of the fovea
• hard exudates within 500m of the fovea, if associated with adjacent retinal thickening
• retinal oedema that is one disc diameter (1500m) or larger,
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Exudative maculopathy
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Pre-proliferative retinopathy
Signs of ischaemia include:• cotton wool spots, which appear as white patches
with rather feathery margins and represent nerve fibre layer micro infarcts; they become highly significant when there are more than five
• large dark “blot” haemorrhages• venous beading and looping• intraretinal microvascular abnormalities (IRMA).
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Pre-proliferative retinopathy with venous bleeding, cotton wool spots and some hard exudates
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Proliferative diabetic retinopathy
• More progressive condition,• Retina more ischemic, induced higher
production of VEGF (vascular endothelial growth factor)
• Stimulate formation of neovascular (new vessel) else where (NVE)
• And/or new vessl of the disc (NVD)
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Disc new vessels (NVD) New vessels elsewhere (NVE)
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Advanced eye disease
• In advanced proliferative diabetic retinopathy, progressive fibrovascular proliferation leads to blindness due to vitreous haemorrhage and traction retinal detachment.
• Rubeosis iridis and neovascular glaucoma occur when new vessels form on the iris and in the anterior chamber drainage angle, leading to a most painful blind eye which occasionally requires enucleation.
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Rubeosis iridis
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Blindness in diabetic patients
• VITREOUS HEMORRHAGE• RETINAL DAMAGE• HARD EXUDATE• MACULOPATHY,ISCHEMIC AND OEDEma• Traction retinal detachment• Neovascular glaucoma
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DR screening
• Visual acuity
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• Funduscopy/ fundus photograph• Fundus fluorescein angiography• OCT
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Indications for referral to an ophthalmologist
• For adult DM, without regular medical check up : as soon as diagnose
• With anual regular medical check up : after 3 to 5 years.
• DM in children : after 3 to 5 years OR
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• Reduced visual acuity from any cause• Presence of proliferative or pre-proliferative changes• Presence of clinically significant macular oedema• Presence of hard exudates near the macula• Presence of any form of progressing or extensive
diabetic• retinopathy especially when the lesions are near the
macula
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TREATMENT
The UKPDS/ DCCT• tight control of the diabetes and of
hypertension, with reduction of other “risk factors” : dyslipidemia, smoking
• Even when the complications are established, their progression leading to
serious damage can be delayed.• The Diabetes Control and Complications Trial (DCCT) - 6.5 years of follow-up• * * United Kingdom Prospective Diabetes Study (UKPD) – 9 years of follow-up
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Primary interventionGlycemic control Intensive control (HbA1c = 7.2%) vs conventional control (HbA1c = 9.1%)* – Reduction of incidence of DRP by 76% – Reduction of progression of DRP by 54%
Blood pressure controlTight blood pressure (<150/<85 mm Hg) control vs conventional control
(<180/<105 mm Hg) **– 34% reduction in DRP progression– 47% reduction in visual actuity deterioration– 35% reduction in laser photocoagulation
• Lipid-lowering therapyDyslipidemia increases the risk of DRP, especially diabetic macular edema
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Secundary intervention
Medical intervention– Anti-platelet agents– Protein Kinase C inhibitors (Ruboxystaurin)
Laser intervention– Severe nonproliferative and proliferative DRP– Diabetic macular edema• Interventions with intravitreal agents– Corticosteroids– Anti-angiogenesis agents
Surgical intervention– Vitrectomy for diabetic macular edema– Vitrectomy for vitreous hemorrhage and proliferatieve DRP
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Medical interventionAntiplatelet agents– 650 mg aspirin has no effect on DRP (positive or negative) – ETDRS
– Circumstantial evidence that aspirin may delay the incidence of DRP
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Protein kinase C (PKC) inhibitors
Hyperglycemia
Diacylglycerol (DAG)
Protein kinase C activation
• Decreased retinal bloodflow• Thickening of basement memb• Enhancement of capillarypermeability
Non-selective PKC inhibitors: side-effectsRuboxistaurin (PKC-! inhibitor)– Phase II and III– Therapeutically effective:• Preventing visual loss• Resolution of macular edema• No effect on progression from NPDR to PDR– Limited side-effects
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Glucose
Aldose reductase
Sorbitol
Contribution to diabetic pathology
Polyol pathway
Octreotride (synthetic analogue of somatostatine)
Aldose reductase inhibitors
– RCTs: sordinil and tolrestat
– No effect on DRP incidence or progression 3-5 years
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Nonproliferative and proliferative DRP
Mild and moderate nonproliferative DRP• No photocoagulation (unless for macular edema)
Severe and very severe nonproliferative DRP • Consider panretinal photocoagulation, especially for:– Type II diabetes– Impending cataract surgery– Pregnancy
Proliferative DRP• Panretinal photocoagulation generally indicated. High risk proliferative DRP• Panretinal photocoagulation• Vitrectomy
Severe NPDR
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Laser photocoagulation
Reduced ischemic area, reduced oedema, reduced VEGF and other inflammationmediators
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Diabetic macular edema
• Clinical significant macular edema (CSME)– Focal laser treatment– Grid laser treatment
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Intravitreal injection
• Triamcinolone acetonide (corticosteroid) decrease inflammation mediators, reduced
oedema
• Anti VEGF : prevent new vessels development, obliterate NV, reduced vitreous hemorrhage
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Triamcinolon (IVTA)
• Suggestions for use:– In diabetic macula edema– An option in refractory cases– An option in very pronounced, diffuse edema– Consider a combination with focal / grid laser after 4-6
weeks
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Triamcinolon (IVTA)• Several small RCTs show improvement in macular edema and visual acuity
• RCT (n=69, follow-up 2 years)– Twice the chance of improved visual acuity– Half the chance of visual loss
• Significant disadvantages– Significant side-effects
• Cataract (50%)• Elevated intraocular pressure (40%)• Medically uncontrollable glaucoma (1-2%)• Endophthalmitis (1:1000)
– Repeat injections may be necessary (duration of effect is approximately 6-9 months for 20 mg – 2-4 months for 4 mg)
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Anti-angiogenic agents• Three trials– Finished (phase II) Pegaptanip (Macugen®)- 172 patients with DME- 34% versus 10% improvement of " 10 letters- decrease in macular thickness– Ongoing Ranibizumab (Lucentis®) - RESOLVE study Bevacizumab (Avastin®) - US National Eye Institute
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Anti-angiogenic agents
Suggestions for use:
– Perhaps in diabetic macular edema (glaucoma patients / steroid responders)
– In case of very severe proliferationsa. Neovascular glaucomab. Very severe retinal proliferatiesc. Always additional treatment necessary!
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1. Tn. L. H. OS
PRE POST
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Diabetic macular edema
?
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vitrectomy
VITRECTOMY
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• Evacuate vitreous bleeding• Evacuate fibrosis• Redetach retina• Endolaser photocoagulation
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Vitrectomy
• Guideline indications– Dense nonclearing vitreous hemorrhage– Tractional retinal detachment involving or
threatening the macula
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Vitrectomy
• The role of vitrectomy has expanded:– Recurrent vitreous hemorrhage despite maximal PRP– Diabetic macular edema in combination with vitreous
traction– Diabetic macular edema evidence of traction– Progressive PDR despite laser (especially type I)
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Vitrectomy
• Important:– Create a posterior vitreous detachmant– In case of traction, consider removing the ILM
to ensure complete removal oftractional membranes
– Consider very peripheral laser
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Prognosis
• Mild/ moderate back ground DR : prognosis is good to dubia
• Severe NPDR (preproliferative) : bad• Vitreoretinal fibrosis : very bad• Neovascular glaucoma : the worst
• References• ABC diabetes• AAO 2008
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GRAVE’SOPHTHALMOPATHY
Habibah S. Muhiddin
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Anatomy of the orbit
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Introduction
Graves’ ophthalmopathy : = Thyroid-associated orbitopathy (TOA) = Thyroid Eye Disease
An autoimmune inflammatory disorders whose underlying cause remain unclear
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Typically associated with hyperthyroid,May accompany hypothyroidism Hashimoto thyroiditis Euthyroid
The courseof the eye disease doesn’t alwaysParaller the activity of the thyroid gland orThe treatment of thyroid abnormalities
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Referred to as :
• Grave’s Disease• Thyroid Orbitopathy• Thyroid Eye Disease (TED)• Thyroid Associated Ophthalmopathy (TAO)
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What is it ?
Grave’s Disease is an autoimmune disease, which involves both orbital tissues and the thyroid gland.
Produce a variety of eye problems ranging from periocular swelling to blindness caused by optic nerve compression
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Who gets Grave’s Ophthalmopathy ?
• Eye problems are most commonly associated w/ Grave’s Disease (up to 50% of patients may have signs if examined carefully )
• In rare cases it can affect patients with thyroid carcinoma
• Women are much more commonly affected then men
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What causes Grave’s Ophthalmopathy ?
Complex and not fully understoodOccurs about 12 -18 month after the development of hyperthyroidsmCan affect → people with Euthyroid or Hypothyroid
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Antibodies → like those active against the thyroid → damage the soft tissues in the orbit ( the bony socket of the eye )
producing inflammation with enlargement of the muscle and the fat around the eye
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Factors that affect the development Grave’s Ophthalmopathy
1. Heredity ( 30% have a family history )2. Stress3. Smoking4. Environment
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ORBITA
• Orbita is a space filed in eye ball extra ocular musclevesselsnervesfat etc
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Signs and Symptoms
• Non infiltrative Ophthalmopathy
- widening of the palpebral fissure- lag of the globe on upward gaze, or- lag of the upper lid on downward gaze
cause the eyes to appear exophthalmic, but there is no proptosis
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• Infiltrative Ophthalmopathy
- Edema of the palpebra contents- Protrusion of the globe- Infiltration of the extra ocular muscle- Damage to the optic nerve and the retina- Increased IOP
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Classification of the Ocular Changes in Grave’s Disease
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Many problems from Grave’s Ophthalmopathy
• Lid retraction ( upper lid too high or lower lid too low )
• Double vision• Bulgy eyes• Swelling of the eyelids and
eyeballs• Blurry vision or loss of vision• Trouble closing the eyelids
and dryness of the eyes / watering of the eyes
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The photo show a patients with marked upper lid retraction and bulging of the eyes
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Bulging red eyes in thyroid eye disease
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23 y/o woman presents with
the chief complaint of nervousness.
She has a one month history of increased
nervousness associated with a short temper, crying easily, and tremor. In addition she states she has lost 25 poundswithout dieting, and is always hot. Her eyes protrude and feel dry.
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Pathology
Involves histologic abnormalities in orbital tissue including :
- extraocular muscles- orbital fat- lacrimal glands ,and - interstitial connective tissue
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Extraocular muscle from a patients with grave’s disease and
infiltrative ophthalmopathy
Edematous orbital fat and cellular infiltrate
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Lacrimal gland with
mononuclear infltrate, fibrosis and an increase
in ground substance
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End stage in severe involvement of extra ocular muscles in ophthalmopathy
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Tests are performed in patients with Grave’s Ophthalmopathy
- Re-check of thyroid function- VA- Assessment of eyelid position /function- Slit lamp exam. of the surface the eye- Pupil test (a test of optic nerve function )- Test of IOP- Color vision test- Eye movement assessment- CT or MRI of orbits (to look at the tissue around
the eyes )- Ultrasound scan of the eye muscles
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Enlarged muscle on the left side compared to the right on an MRI scan
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Clinical Activity Score ( CAS )( Table 1 )
• To assess treatment of active inflammatory ophthalmopathy
• To predict therapeutic outcome• To select patient for surgical or non surgical
treatment
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Table 1. Proposed classification System to assess Disease activity in Grave’s ophthalmopathy
Pain
Painfull, oppresive feeling on or behind the globe
Pain on attempted up, side, or down gaze
Redness
Redness of the eyelids
Diffuse redness of the conjunctiva
Swelling
Chemosis
Edema of the eyelids
Increase proptosis of 2 mm or more during a period between 1 and 3 Months
Impaired function
Decrease in VA OF 1 or more lines on the Snellen Chart during a period between 1 and 3 months
Decrease of the eye movements in any durection equal to or more 5 degrees during a period of time between 1 and 3 months
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One point is given for each sign present. The sum of these points defines the activity
score.
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Treatment
Depends on the severity of signs and symptomsAcute episodes of inflammation result in double vision and optic nerve compression recommend HIGH DOSE-ORAL STEROIDS ( PREDNISON )
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Radiation therapy !!! radiation retinopathy
Surgical procedures :- orbital decompression ( to decrease
proptosis )- strabismus surgery ( to realign the eyes ) repair of double vision- lowering of the upper eyelids- raising the lower eyelids, and- blepharoplasty
3 to 5 years after onset
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