1. Slides current until 2008 Diabetic retinopathy

2. Curriculum Module III-7a – Diabetic retinopathy Slide 2 of 39 Slides current until 2008 Diabetic eye disease Diabetic retinopathy Diabetic cataract: –early senile –true diabetic (Snowflake) Recurrent iritis

3. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 3 of 39 Slides current until 2008 Diabetic retinopathy A silent complication with no initial symptoms When symptoms occur, treatment is more complicated and often impossible Screening for retinopathy is of the utmost importance

4. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 4 of 39 Slides current until 2008 When to screen for retinopathy Type 1 diabetes: within 5 years of diagnosis Type 2 diabetes: at time of diagnosis Thereafter, every 1 to 2 years, depending on the status of the retina

5. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 5 of 39 Slides current until 2008 Diabetic eye disease Blurred vision: common symptom of hyperglycaemia Epidemiology: – any retinopathy: 21-36% – vision-threatening retinopathy: 6-13%

6. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 6 of 39 Slides current until 2008 Risk factors Poor glycaemic control Long duration Hypertension Dyslipidemia Nephropathy Pregnancy

7. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 7 of 39 Slides current until 2008 Intensive therapy DCCT – type 1 diabetes: Primary prevention cohort: reduced risk of developing retinopathy by 76% Secondary intervention cohort: reduced risk of progression of retinopathy by 54% DCCT 1993

8. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 8 of 39 Slides current until 2008 Intensive therapy UKPDS – type 2 diabetes: Good glycaemic control: reduced progression of retinopathy by 20-30% Tight blood pressure control: reduced progression of retinopathy by 34% UKPDS 1998

9. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 9 of 39 Slides current until 2008 Screening tests Visual acuity Direct fundoscopy (through dilated pupils) Indirect fundoscopy Retinal photography Testing intra-ocular pressure

10. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 10 of 39 Slides current until 2008 Diabetic retinopathy Non-proliferative diabetic retinopathy: minimal, mild, moderate, severe Proliferative Diabetic Retinopathy (PDR): high-risk PDR, advanced PDR Macular oedema, clinically significant macular oedema

11. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 11 of 39 Slides current until 2008 Normal retina Macula Optic disc

12. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 12 of 39 Slides current until 2008 Non-proliferative diabetic retinopathy Hard exudates

13. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 13 of 39 Slides current until 2008 Severe non-proliferative retinopathy Haemorrhage Cotton wool spot

14. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 14 of 39 Slides current until 2008 Classifications Proliferative retinopathy: new vessels

15. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 15 of 39 Slides current until 2008 Proliferative retinopathy New vessels Pre-retinal haemorrhage

16. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 16 of 39 Slides current until 2008 Advanced proliferative retinopathy Scar tissue

17. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 17 of 39 Slides current until 2008 Vitreous haemorrhage See a black mark across the vision Some blood will be reabsorbed Vitrectomy may be necessary

18. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 18 of 39 Slides current until 2008 Early macular oedema

19. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 19 of 39 Slides current until 2008 Investigations Fluorescein angiogram: provides more detailed information

20. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 20 of 39 Slides current until 2008 Fluorescein leakage Dot haemorrhage Blot haemorrhage

21. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 21 of 39 Slides current until 2008 Fluorescein leakage

22. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 22 of 39 Slides current until 2008 Clinical trials DRSDiabetic Retinopathy ETDRSEarly Treatment Diabetic Retinopathy Study WESDRWisconsin Epidemiology Study of Diabetic Retinopathy

23. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 23 of 39 Slides current until 2008 Treatment Laser therapy: –Pan-retinal for proliferative retinopathy –Focal or grid for macular oedema

24. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 24 of 39 Slides current until 2008 Pan-bombing for proliferative retinopathy

25. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 25 of 39 Slides current until 2008 Pan-retinal laser bombing

26. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 26 of 39 Slides current until 2008 Grid laser for macular oedema

27. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 27 of 39 Slides current until 2008 Laser therapy Side effects Loss of peripheral vision, tunnel vision, night blindness Colour blindness Vision can get worse but “laser saves sight” in long term

28. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 28 of 39 Slides current until 2008 Treatment Blood pressure: reduces macular oedema Blood glucose control: slows progression Control lipids Use of aspirin

29. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 29 of 39 Slides current until 2008 Pregnancy Pregnancy can cause transient deterioration of diabetic retinopathy but generally not permanent damage Baseline retinal assessment should be performed before pregnancy Retinopathy is not a problem in gestational diabetes

30. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 30 of 39 Slides current until 2008 In the older person Presence of cataract makes visualisation of fundi more difficult Cataract surgery may cause macular oedema NPDR with macular oedema is the main cause of visual loss

31. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 31 of 39 Slides current until 2008 Summary 100% of people with diabetes will develop some retinopathy The higher the blood glucose level the greater the risk Different grades of retinopathy Laser therapy saves sight Timely treatment is most effective Regular screening is a must

32. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 32 of 39 Slides current until 2008 Review question 1.What is the defining characteristic of proliferative retinopathy? a.Numerous microaneurysms b.Large amount of exudates c.Destruction of retinal capillaries d.Formation of new blood vessels

33. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 33 of 39 Slides current until 2008 Review question 2.A young woman with type 1 diabetes has been told by an eye specialist that she has microaneurysms in her eyes. Which of the following would be an appropriate answer to her concerns about losing her vision? a.Microaneurysms in the eye can suddenly bleed causing temporary or permanent loss of vision b.You will soon require laser therapy that may prevent the number of microaneurysms from increasing and delay vision loss c.You may not experience vision loss but the condition could gradually worsen d.Microaneurysms are of no significance and are often found in people who do not have diabetes

34. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 34 of 39 Slides current until 2008 Review question 3.Which of the following activities would probably be ill-advised in a person with type 1 diabetes and severe proliferative retinopathy? a.Walking on a treadmill b.Jogging on the spot c.Riding a stationary bicycle d.Swimming

35. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 35 of 39 Slides current until 2008 Review question 4.Which of the following changes is most likely to increase the severity of existing mild non-proliferative retinopathy? a.Pregnancy b.Weight gain c.Weight loss d.Increased exercise

36. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 36 of 39 Slides current until 2008 Review question 5.A woman with type 1 diabetes has been diagnosed with mild non-proliferative retinopathy. What information should she receive regarding laser therapy? a.Laser therapy is not often used in type 1 diabetes b.Laser therapy is not considered necessary at your early stage of retinopathy c.The eye specialist may choose to delay laser therapy until there is visual impairment d.There are new therapies available for retinopathy that your eye specialist may be planning to use

37. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 37 of 39 Slides current until 2008 Answers 1.d 2.c 3.b 4.a 5.b

38. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 38 of 39 Slides current until 2008 References 1. DCCT Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complication in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-86. 2. UK prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. UKPDS 38. BMJ 1998; 317: 708-13. 3. Effect of intensive diabetes treatment on development and progression of complications in adolescents with insulin dependent diabetes mellitus: DCCT. Journal of Pediatrics 1994; 125: 177-88. 4. Klein R, Klein B, Moss SE, Linton KL. The Beaver Dam Eye Study in adults with newly discovered and previously diagnosed diabetes mellitus. Ophthalmology 1992; 99(1): 58-62. 5.Nathan DM. The pathophysiology of diabetic complications: how much does the glucose hypothesis explain? Ann Intern Med 1996; 124(1Pt2): 86-9. 6. Ohkubo Y, Kishikawa H, Araki E, Miyata T, Isami S, Motoyoshi S, Kojima Y, Furuyoshi N, Shichiri M. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin diabetes mellitus. A randomised prospective 6 year study. Diabetes Res Clin Pract 1995; 28: 103-17.

39. Diabetic retinopathy Curriculum Module III-7a – Diabetic retinopathy Slide 39 of 39 Slides current until 2008 References 7. Mitchell P. Development and progression of diabetic eye disease in Newcastle 1977 to 1984: rates and risk factors. Aust NZ J Ophthalmol 1985; 13: 39-44. 8. The Diabetic Retinopathy Study Research Group. Preliminary report on the effects of photocoagulation therapy. Am J Ophthalmol 1976; 81(4): 383-96. 9.The Diabetic Retinopathy Study Research Group. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. Ophthalmology 1981; 88(7): 583-600. 10.Klein R, Klein BEK, Moss SE, Davis MD, et al. The Wisconsin Epidemiologic study of diabetes retinoapthy III. Prevalence and risk of diabetic retinopathy when age at diagnosis more than 30 years. Arch Ophthalmol 1984; 182: 527-32. 11.UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macro and microvascular complications in type 2 diabetes. UKPDS 38. BMJ 1998; 317: 703-13.