Diabetic Retinopathy

DIABETIC RETINOPATHY
DIABETIC RETINOPATHY
1. Epidemiology and risk factors
2. Classification and features of Diabetic

retinopathy (DR)
3. Complications of DR and their prevention
4. Screening protocol for DR and referral to

Ophthalmologist
5. Direct ophthalmoscopy and identification of fundus

findings
Epidemiology of DR
RISK of developing DR:
• Type I or IDDM – 70%
• Type II or NIDDM - 39%
• Type II on insulin – 70%

Prevalence of the type of Diabetes
 Type 2 – in 90% of diabetic patients
Diabetic retinopathy - most common cause of

legal blindness between ages 20 and 70
years.
RISK FACTORS:
1. Duration of diabetes
2. Poor control of Diabetes
3. Hypertension
4. Nephropathy
6. Obesity and hyperlipidemia
7. Smoking
8. Pregnancy
Pathogenesis
Microangiopathy which has features of
both microvascular leakage and occlusion
Larger vessels may also be involved

Microvascular leakage
Loss of pericytes results in distention of
weak capillary wall producing
microaneurysms which leak.
Blood-retinal barrier breaks down causing

plasma constituents to leak into the retina
– retinal oedema, hard exudates
Microvascular occlusion
Basement membrane thickening,
endothelial cell damage, deformed RBCs,
platelet stickiness and aggregation
Vascular Endothelial Growth Factor

(VEGF) is produced by hypoxic retina
VEGF stimulates the growth of shunt and

new vessels
Classification of DR
I. Non-proliferative DR (NPDR)
• Mild
• Moderate
• Severe
• Very severe
II. Proliferative DR (PDR)
III. Clinically significant macular oedema

(CSME)
- May exist by itself or along with NPDR and PDR
Mild NPDR
• At least one microaneurysm - earliest clinically detectable
lesion
 Retinal hemorrhages
 Hard or soft exudates
Moderate NPDR
• Microaneurysms
and/or dot and blot
hemorrhages in at
least 1 quadrant
• Soft exudates
(Cotton wool spots)
• Venous beading or
IRMA (intraretinal IRMA
microvascular
abnormalities)
Mild and Moderate Non- proliferative DR
was previously known as Background DR
Severe NPDR
Any one of the following 3 features is present
• Microaneurysms and intraretinal
hemorrhages in all 4 quadrants
• Venous beading in 2 or more quadrants
• Moderate IRMA in at least 1 quadrant
Known as the 4-2-1 rule

Very severe NPDR
Any two of the features of the 4-2-1

rule is present
Severe and Very severe Non-proliferative
DR was known as the Pre-proliferative DR
Clinically significant Macular
Oedema
• Retinal oedema close to fovea
• Hard exudates close to fovea
• Presents with dimness of vision
• By itself or along with NPDR or PDR

CSME – Hard exudates close to fovea and
associated retinal thickening
Proliferative DR
(PDR)
Characterized by
Proliferation of
new vessels from
retinal veins
• New vessels on
the optic disc
• New vessels
elsewhere on the
retina
Proliferative DR
NVD
COMPLICATIONS OF DIABETIC
RETINOPATHY
• Vitreous hemorrhage
• Tractional retinal detachment
• Rubeosis Iridis
• Glaucoma
• Blindness
Vitreous Hemorrhage
SUBHYALOID HEMORRHAGE
Tractional retinal detachment
Rubeosis Iridis
Neovascular Glaucoma
• Complication of rubeosis iridis
• New vessels cause angle closure
• Mechanical obstruction to aqueous outflow
• Intra ocular pressure rises
• Pupil gets distorted as iris gets pulled
• Eye becomes painful and red
• Loss of vision
Blindness
• Non-clearing vitreous hemorrhage
• Neovascular glaucoma
• Tractional retinal detachment
• Macular ischemia
PREVENTION OF COMPLICATIONS
• By early institution of appropriate treatment
• This requires early detection of DR in its

asymptomatic treatable condition
• By routine fundus examination of all

Diabetics (cost effective screening)
• And appropriate referral to ophthalmologist

Mild and Moderate NPDR
- No specific treatment for retinopathy

- Good metabolic control to delay
progression
- Control of associated Hypertension,
Anemia and Renal failure
Severe and very severe NPDR
– Close follow up by Ophthalmologist

Clinically significant macular oedema
- Laser photocoagulation to minimise risk of
visual loss
Proliferative DR
─ Retinal laser photocoagulation as per the
judgment of ophthalmologist (in high risk eyes)
─ It converts hypoxic retina (which produces

ANGIOGENIC factors) into anoxic retina (which
can’t)
Screening protocol for Diabetic
retinopathy
1. Screening once in a 1 year
• Diabetics with normal fundus

• Mild NPDR
2. Screening once in 6 months
• Moderate NPDR
Referral to Ophthalmologist
• Visual Symptoms
– Diminished visual acuity
– Seeing floaters
– Painful eye
• Fundus findings
- Macular oedema/hard exudates close to fovea
- Proliferative DR
- Vitreous hemorrhage
- Moderate to severe and very severe NPDR
- Retinal detachment
- Cataract obscuring fundus view
Referral to Ophthalmologist
• Presence of Risk Factors
- Pregnancy
- Nephropathy
Simulation of defective vision as experienced by a
Diabetic whose vision has been affected by Diabetic
retinopathy
Normal Defective
DIRECT OPHTHALMOSCOPY
• Examination of the fundus of the eye
• To screen for Diabetic Retinopathy
• After dilatation of both eyes with 0.5%
tropicamide
View of the retina through an
ophthalmoscope
Normal fundus views of Right
and left eye
Mild NPDR – Microaneurysms, Dot and
Blot hemorrhages
Moderate NPDR
Moderate NPDR with CSME
Circinate retinopathy – Hard exudates in a
ring around leaking aneurysms
Age related Macular degeneration: Note the
drusen. Not to be confused with Hard exudates. There
are no microaneurysms or dot/blot hemorrhages.
DRUSEN
Severe NPDR
• Cotton wool patches
• Hemorrhages - 4 quadrants
With CSME
Very severe NPDR
-Venous beading
Cotton-wool patches,
- scars of laser spots
venous segmentation
- Absorbing hemorrhages
CSME –
in
Different
Stages of
NPDR
Proliferative DR – New vessels elsewhere on
the retina along the supero-temporal vessels
PDR – New vessels on disc
PDR – New vessels on disc and new vessels
elsewhere on retina
PDR – with vitreous hemorrhage
Vitreous bleed
Vitreous Hemorrhage
Tractional retinal
detachment Fibro-vascular
proliferation
Thank you!
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DIABETIC RETINOPATHY

2. Classification and features of Diabetic

3. Complications of DR and their prevention

4. Screening protocol for DR and referral to

5. Direct ophthalmoscopy and identification of fundus

• Type I or IDDM – 70%

• Type II or NIDDM - 39%

• Type II on insulin – 70%

 Type 2 – in 90% of diabetic patients

Diabetic retinopathy - most common cause of

Larger vessels may also be involved

Blood-retinal barrier breaks down causing

Vascular Endothelial Growth Factor

VEGF stimulates the growth of shunt and

II. Proliferative DR (PDR)

III. Clinically significant macular oedema

• Venous beading in 2 or more quadrants

• Moderate IRMA in at least 1 quadrant

Known as the 4-2-1 rule

Any two of the features of the 4-2-1

• Hard exudates close to fovea

• Presents with dimness of vision

• By itself or along with NPDR or PDR

• Tractional retinal detachment

• Tractional retinal detachment

• By early institution of appropriate treatment

• This requires early detection of DR in its

• By routine fundus examination of all

• And appropriate referral to ophthalmologist

- No specific treatment for retinopathy

Severe and very severe NPDR

– Close follow up by Ophthalmologist

─ It converts hypoxic retina (which produces

• Diabetics with normal fundus

2. Screening once in 6 months

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