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Diabetic Retinopathy: Ines Serrano MD Evan Waxman MD PHD
Diabetic Retinopathy: Ines Serrano MD Evan Waxman MD PHD
Ines Serrano MD
Evan Waxman MD PhD
LEARNING OBJECTIVES
• Recognize the importance of diabetic retinopathy as a public
health problem
• Discuss diabetic retinopathy as a leading cause of blindness in
developed countries
• Identify the risk factors for diabetic retinopathy
• Describe and distinguish between the stages of diabetic
retinopathy
• Understand the role of risk factor control and annual dilated eye
exams in the prevention of vision loss
DIABETES MELLITUS
Diabetes Mellitus is a group of diseases characterized by high blood glucose
levels. Diabetes results from defects in the body's ability to produce and/or use
insulin.
• Type 1 diabetes is usually diagnosed in children and young adults, and was
previously known as juvenile diabetes. In type 1 diabetes, the body does not
produce insulin. 5% of people with diabetes have this form of the disease.
• In Type 2 diabetes, either the body does not produce enough insulin or the
cells ignore the insulin. This is the most common form of diabetes.
http://www.diabetes.org/diabetes-basics/?loc=GlobalNavDB
DIABETIC RETINOPATHY (DR)
DEFINITION
• Progressive dysfunction of the retinal blood vessels
caused by chronic hyperglycemia.
• DR can be a complication of diabetes type 1 or
diabetes type 2.
• Initially, DR is asymptomatic, if not treated though it
can cause low vision and blindness.
http://www.mdconsult.com/das/book/pdf/282715756-3/978-0-323-04332-8/4-u1.0-B978-0-323-04332-8..00092-5..DOCPDF.pdf?isbn=978-0-323-04332-8&eid=4-u1.0-B978-0-323-04332-8..00092-5..DOCPDF
WHAT IS THE RETINA?
• The retina is a multilayered, light sensitive neural tissue
lining the inner eye ball. Light is focused onto the retina
and then transmitted to the brain through the optic
nerve.
• The macula is a highly sensitive area in the center of
the retina, responsible for central vision. The macula is
needed for reading, recognizing faces and executing
other activities that require fine, sharp vision.
RETINA
Healthy Retina Diabetic Retinopathy
DIABETIC RETINOPATHY
EPIDEMIOLOGY
http://www.who.int/bulletin/volumes/82/11/en/844.pdf
http://www.ncbi.nlm.nih.gov/pubmed/19896746
Causes of global blindness in millions of people
(WHO 2002)
20
18
16
14
12
10
8
6
4
2
0
• Duration of diabetes
• Poor Blood Sugar control
• HTN
• Hyperlipidemia
• Barriers to care
http://jama.ama-assn.org/content/304/6/649.short?rss=1
The Effect of Intensive Diabetes Treatment
On the Progression of Diabetic Retinopathy
In Insulin-Dependent Diabetes Mellitus
http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=d0c853d3-219f-487b-a524-326ab3cecd9a
HOW DIABETES CAUSES VISION LOSS
How diabetes cause vision loss
Macular Clinical
significant
edema
macular edema
Vitreous hemorrhage
Preproliferative Proliferative and/or Retinal
DR DR detachment and/or
neovascular glaucoma
PATHOPHYSIOLOGY
Diabetic Retinopathy is a microvasculopathy that
causes:
• Retinal capillary occlusion
• Retinal capillary leakage
MICROVASCULAR OCCLUSION
Microvascular occlusion is caused by:
• Thickening of capillary basement membranes
• Abnormal proliferation of capillary endothelium
• Increased platelet adhesion
• Increased blood viscosity
• Defective fibrinolysis
Ischemia
Infarction
Increased VEFG
Neovascularization
Vitreous Neovascular
Fibrovascular bands
hemorrhage glaucoma
Tractional retinal
detachment Retina in systemic disease : a color manual of
ophthalmoscopy / Homayoun Tabandeh, Morton F.
Goldberg 2009
MICROVASCULAR LEAKAGE
Microvascular leakage is caused by:
• Impairment of endothelial tight junctions
• Loss of pericytes
• Weakening of capillary walls
• Elevated levels of vascular endothelial growth factor (VEGF)
Retinal
Edema Hard exudates
hemorrhage
Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales
Ophthalmology Volume 110, Number 9, September 2003
No retinopathy
MILD NONPROLIFERATIVE
DIABETIC RETINOPATHY
Characteristics
• Microaneurysms only
MILD NONPROLIFERATIVE DIABETIC
RETINOPATHY
Microaneurysms
MODERATE NONPROLIFERATIVE DIABETIC
RETINOPATHY (NPDR)
Characteristics
• More than just microaneurysms but less than severe NPDR but
less than severe NPD
MODERATE NONPROLIFERATIVE DIABETIC
RETINOPATHY (NPDR)
Microaneurysm
Hard exudates
Flamed shaped
hemorrhage
MODERATE NONPROLIFERATIVE
DIABETIC RETINOPATHY (NPDR)
Hard exudates
microaneurysm
SEVERE NONPROLIFERATIVE
DIABETIC RETINOPATHY (NPDR)
Any of the following:
• More than 20 intraretinal hemorrhages in each of four
quadrants
• Definite venous beading in two or more quadrants
• Prominent Intraretinal Microvascular Abnormalities
(IRMA) in one or more quadrants
• And no signs of proliferative retinopathy
Severe Nonproliferative Diabetic Retinopathy
(NPDR)
Venous beading
Proliferative Diabetic Retinopathy (PDR)
Characteristics
• Neovascularization
• Vitreous/preretinal
hemorrhage
PROLIFERATIVE
DIABETIC
RETINOPATHY Cotton-wool
spot
Neovascularization
Neovascularization
Hard exudate
Blot hemorrhage
HIGH-RISK PROLIFERATIVE DIABETIC
RETINOPATHY
Basic and Clinical Science Course, Section 12: Retina and Vitreous AAO
DIABETIC MACULAR EDEMA
• Diabetic macular edema is the leading cause of legal
blindness in diabetics.
• Diabetic macular edema can be present at any stage of
the disease, but is more common in patients with
proliferative diabetic retinopathy.
Meta analysis and review on the effect on bevacizumab id diabetic macular edema
Graefes Arch Clin Exp Ophthalmol(2011) 249:15-27
Why is Diabetic macular edema so important?
• The macula is responsible for central vision.
• Diabetic macular edema may be asymptomatic at
first. As the edema moves in to the fovea (the center
of the macula) the patient will notice blurry central
vision. The ability to read and recognize faces will be
compromised.
Macula
Fovea
Normal Macular Edema
CLINICALLY SIGNIFICANT MACULAR EDEMA
(CSME)
• Thickening of the retina at or within 500 µm of the
center of the macula.
• Hard exudates at or within 500 µm of the center of the
macula, if associated with thickening of the adjacent
retina.
• Area of retinal thickening 1 disc area or larger, within 1
disc diameter of the center of the macula.
ETDRS
INTERNATIONAL CLINICAL DIABETIC MACULAR EDEMA
DISEASE SEVERITY SCALE
http://www.aao.org/newsroom/release/20091030.cfm
Primary prevention
Strict glycemic control
Blood pressure control
Secondary prevention
Annual eye exams
Tertiary prevention
Retinal Laser photocoagulation
Vitrectomy
DIABETIC RETINOPATHY TREATMENT
http://drcrnet.jaeb.org
CONCLUSIONS
Diabetic Retinopathy is
preventable through strict
glycemic control and annual
dilated eye exams by an
ophthalmologist.
"Alone we can do so little, together we can do so
much.”
Helen Keller
The Guerrilla Eye Service of the UPMC Eye Center is dedicated
to eliminating barriers to eye care for patients in the Western
Pennsylvania area.
Authors
Ines Serrano, is am ophthalmologist trained in Peru
at the Universidad Nacional Mayor de San Marcos.
She is currently pursuing her multidisciplinary
Masters in Public Health at the Graduate School of
Public Health at the University of Pittsburgh. She
has a long standing interest in minority health and
health care disparities.