1. Dr.Ravi kant Associate Professor Medicine ,AIIMS Rishikesh
Diabetic Retinopathy
Dr.Ravi kant
Associate Professor
Medicine ,AIIMS Rishikesh

2. Stages of diabetic Retinopathy
Pathogenesis
Stages of diabetic Retinopathy
Stage Pathogenesis Cause of Blindness
Ischemic Small vessel occlusion capilary leakage, macular (nonproliterative) edema and haemorrhages
Ischemia, pericyte degeneration
(microaneurysms and arterivenous shunts)
Angiogenesis factor release
Proliferative Neo vascular prolileration Vitreous haemorrhage
C. Fibrotic Vitreous fibrosis traction-included attachment to retina and contraction retinal detachment

3. Classification of DR Non- proliferative DR (NPDR) Mild Moderate Severe
Very severe
2. Proliferative DR (PDR)
3. Clinically significant macular oedema (CSME)
may exist by itself or along with NPDR and PDR

4. Referral to Ophthalmologist
Presence of Risk Factors
- Pregnancy
- Nephropathy

5. Diabetic Retinopathy
Diabetic retinopathy is a leading cause of new cases of blindness in people aged 20 to 74 years in the USA
Many of the complications of diabetic retinopathy can be prevented or delayed by blood glucose control and timely intervention.

6. Ocular Anatomy

7. Retinal Anatomy

8. Retinal Histology Sclera Choroid RPE Photoreceptor outer segments
inner segment
Outer
Plexiform layer
Bipolar cells
Inner
plexiform layer
Ganglion cells
Nerve fiber
layer

9. Retinal Diagnostic Tests
Fundus Photography
Fluorescein Angiography (FA)
Optical Coherence Tomography (OCT)
Ocular Ultrasonography
Electroretinography (ERG)

10. Fundus Photography

11. Normal FA

12. Optical Coherence Tomography (OCT)

13. Normal OCT

14. Normal Ultrasound

15. Pathogenesis of DR
Prolonged hyperglycemia is the major etiologic agent in all of the microvascular complications of diabetes, including diabetic retinopathy.
The cellular mechanisms through which hyperglycemia acts currently remain unclear

16. Pathogenesis of DR Mechanisms that have been proposed are:
1. hyperglycemia may alter the expression of one or more genes, leading to increased (or decreased) amounts of certain gene products that can alter cellular functions.
2. Glycosylated proteins can undergo a series of reactions, leading to considerable alteration of proteins.
3. Chronic hyperglycemia may produce oxidative stress in cells, leading to the formation of an excess of "toxic end products of oxidation" including peroxides, superoxides, nitric oxide, and oxygen free radicals.

17. VEGF and DR Vascular Endothelial Growth Factor
Promotes vascular growth and permeability
Elevated levels of circulating VEGF in conditions with retinal ischemia

18. Anatomic Changes Microanerysms
Damage to endothelial cells leads to dilated capillaries and venules
These altered vessels allow serum and blood to leak into the retina

19. NPDR

20. NPDR FA

21. NPDR OCT

22. Retinal Ischemia

23. PDR

24. PDR

25. PDR FA

26. Vitreous Hemorrhage (VH)

27. VH ultrasound

28. TRD ultrasound

29. Epiretinal Membrane

30. PDR Retinal Detachment

31. Iris Neovascularization

32. Mechanisms of Vision Loss
Retinal ischemia
Macular edema
Vitreous hemorrhage
Epiretinal membrane formation
Retinal detachment
Neovascular glaucoma

33. Prevention
Prospective controlled interventional studies have shown that strict control of blood glucose and blood pressure significantly reduces and delays the onset and severity of diabetic retinopathy.

34. Screening Type 1 diabetics:
First screen 5 years after onset, then annually.
Type 2 diabetics:
First screen upon diagnosis and then annually.

35. Treatment NPDR without macular edema - Macular edema - Observe
1. Focal/Grid laser photocoagulation
2. Vitrectomy with membrane peeling
3. Intraocular Steroid*
4. Intraocular VEGF inhibitor*
* Off-label use, contraversial

36. DME laser treatment

37. DME laser treatment * * * * * * * * * * * *

38. Treatment Vitreous Hemorrhage - Traction Retinal Detachment -
1. Pan-retinal photocoagulation
2. Vitrectomy with laser photocoagulation
3. Intraocular VEGF inhibitor*
Traction Retinal Detachment -
1. Observation if not involving the macula
2. Vitrectomy with membrane dissection
* Off-label use, contraversial

39. Pan-retinal Photocoagulation

40. Vitrectomy