Diabetic retinopathy

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Introduction:

  • MC complication of diabetes: Neuropathy
  • MC ophthalmic complication of diabetes: Retinopathy
  • MC cause of gradually progressive painless loss of vision in diabetes: Cataract
  • MC cause of sudden painless loss of vision in diabetes: Vitreous hemorrhage.

 

Stages:

  1. Nonproliferative diabetic retinopathy (NPDR):
    • Microaneurysm
    • Intraretinal hemorrhages
    • Hard exudates
    • Venous beading.
  1. Proliferative diabetic retinopathy (PDR):
    • Hallmark is neovascularization.

Changes in retina in Diabetic retinopathy:

NPDR

  1. Earliest clinical sign: Microaneurysm formation
  2. Microaneurysm contains weak dilated vessel wall, which easily ruptures; giving rise to intraretinal hemorrhages
  3. Intraretinal hemorrhages are of 2 types:
    • Superficial → Affects nerve fibre layer → Flame shaped hemorrhages
    • Deep → Affects outer plexiform layer → Dot -Blot hemorrhages.
  4. Leaking microaneurysms leads to accumulation of lipoproteins → This gives rise to “hard exudates” [yellowish in color]
  5. Ischemia of nerve fibres leads to formation of “soft exudates” → Another name of which is “cotton wool spots” [whitish in color]

PDR

In the late proliferative stage of diabetic retinopathy, neovascularization occurs (which is the hallmark of PDR). This is of 3 types:

  1. Neovascularization at disc (NVD)
  2. Neovascularization elsewhere (NVE)
  3. Neovascularization at iris (NVI).

Impact of neovascularization on retina:

  • Newly formed blood vessels are weak, ruptures easily → Vitreous hemorrhage
  • The vessels pull the underlying retina → Tractional retinal detachment

  • Newly formed vessels over iris and iridocorneal angle can obstruct aqueous humor outflow and lead to increased IOP → Neovascular glaucoma.

 

  • MC complication of diabetic retinopathy: Vitreous hemorrhage
  • MC cause of visual impairment in diabetic retinopathy: Macular edema
  • MC cause of neovascular glaucoma: PDR.

 

Treatment:

NPDR:

  1. Glycemic control
  2. No treatment
  3. Only periodic follow up.

PDR:

  1. Strict glycemic control
  2. Panretinal photocoagulation (PRP):
    • Principle: PRP destroys peripheral retina → Maximum oxygen goes to the central part
    • Best laser: Argon
    • No. of burns: 1200-1600
    • Duration of burns: 100 ms
    • Size of burns: 500 microns.
  3. Anti-VEGF-Ab (Ex: Bevacizumab).

 

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