DIABETIC RETINOPATHY 2019 WHAT EVERY
DIABETIC RETINOPATHY 2019WHAT EVERY PROVIDER NEEDS TO KNOW ABOUT DIABETICRETINAL EXAMMohan Iyer, MDAthens Retina Center1
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Basic anatomy of the eyeRecognize the importance of diabeticretinopathy as a public health problemLearningObjectivesIdentify the risk factors for diabeticretinopathyDescribe the stages of diabetic retinopathyUnderstand the role of risk factor controland annual dilated eye exams in theprevention of vision loss
What is the most common cause of vision lossamong working age adults in the United States? 1. Glaucoma 2. Cataract 3. Diabetic Retinopathy 4. Retinal Detachment
The most common cause of moderate vision loss indiabetic retinopathy is: 1. Refractive Change 2. Cataract 3. Diabetic Macular Edema 4. Proliferative Diabetic Retinopathy
A patient with Type II diabetes should get their firstdilated eye exam:1. Only when the vision is affected2. In 3-5 years after initial diagnosis of diabetes3. At the time of diagnosis of diabetes4. 1 year after the diagnosis of diabetes
Anatomy of the EyeNational Eye Institute
Anatomy of the Eye
RETINA
Healthy RetinaDiabetic Retinopathy
Diabetes Epidemiology
Age-adjusted Prevalence of Obesity and Diagnosed DiabetesAmong US AdultsObesity (BMI 30 kg/m2)1994No Data 9% 26.0%Diabetes1994No Data2000 4.5%4.5%–5.9%6.0%–7.4%20157.5%–8.9%CDC’s Division of Diabetes Translation. United States Surveillance System available athttp://www.cdc.gov/diabetes/data 9.0%
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Diabetic Retinopathy Epidemiology CDC et.pdf) One in 3 people over the age of 40 years with diabeteshave diabetic retinopathy 4.2 million adults had Diabetic retinopathy 655,000 had vision-threatening diabetic retinopathy The more severe vision-threatening form is more commonin Mexican Americans and African-Americans. Diabetic retinopathy (DR) is the leading cause of blindnessin people of working age in industrialized 96746
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Risk factors for DR Male sex Higher A1C Longer duration of diabetes Insulin use Higher systolic blood pressure Barriers to rt?rss 1
Diabetic RetinopathyEpidemiology The best predictor of diabetic retinopathy is the duration of the disease After 20 years of diabetes, nearly 99% of patients with type 1 diabetesand 60% with type 2 have some degree on diabetic retinopathy 33% of patients with diabetes have signs of diabetic retinopathy People with diabetes are 25 times more likely to become blind than thegeneral population.Ophthalmology Myron Yanoff MD and Jay S. DukerBasic and Clinical Science Course, Section 12: Retina and Vitreous th-Fact-Sheet.pdf -
Prevalence of diabetic retinopathyafter 20 years of diagnosis
Diabetic RetinopathyPathophysiology Elevated blood glucose results in physiologic changes that causevascular endothelial damage. Loss of pericytes Basement membrane thickening Pathologic processes associated with diabetic retinopathy Formation of microaneurysmsClosure of retinal capillaries and arteriolesIncreased vascular permeability of retinal capillariesProliferation of new vessels and fibrous tissueContraction of vitreous and fibrous proliferation leading to tractionalretinal detachment
Diabetic Retinopathy Risk Factors associated with progression of diabetic retinopathy : HypertensionElevated triglyceridesElevated lipids,Gross proteinuria Patients with Proliferative Diabetic Retinopathy are at increasedrisk of myocardial infarction, stroke, diabetic nephropathy,amputation, and death NOTE: No ocular contraindications to aspirin when required forcardiovascular disease or other medical conditions.
Diabetic RetinopathyCauses of vision loss Macular edema (thickening of central retina)Macular ischemiaMacular/foveal hemorrhageVitreous or preretinal hemorrhageRetinal traction and detachment
Diabetic retinopathy symptomsDiabetic retinopathy is asymptomatic in early stages of the diseaseAs the disease progresses symptoms may include Blurred vision Floaters Fluctuating vision Distorted vision Dark areas in the vision Poor night vision Impaired color vision Partial or total loss of vision
4 Stages of Diabetic Retinopathy:1.2.3.4.Mild Nonproliferative Retinopathy (NPDR)Moderate Nonproliferative RetinopathySevere Nonproliferative RetinopathyProliferative Retinopathy (PDR)Goal is to diagnose as early aspossible!National Eye Institute
Risk of Progression from NPDR to PDR1 year5yrsMild NPDR5%15%ModerateNPDRSevereNPDRVery SevereNPDR27%33%52%60%75%
No retinopathy
MILD NONPROLIFERATIVEDIABETIC RETINOPATHYCharacteristics Microaneurysms only
MILD NONPROLIFERATIVE DIABETICRETINOPATHYMicroaneurysms
Moderate NonproliferativeDiabetic Retinopathy (NPDR)Characteristics More than just microaneurysms but less than severe NPDRbut less than severe NPD
Moderate NonproliferativeDiabetic Retinopathy (NPDR)MicroaneurysmHard exudatesFlamed shapedhemorrhage
Severe Nonproliferative DiabeticRetinopathy (NPDR)Any of the following: More than 20 intraretinal hemorrhages in each offour quadrants 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 DiabeticRetinopathy (NPDR)Venous beading
PROLIFERATIVEDIABETICRETINOPATHYNeovascularization
Diabetic macular edema Diabetic macular edema is the leading cause oflegal blindness in diabetics. Diabetic macular edema can be present at anystage of the disease, but is more common inpatients with proliferative diabetic retinopathy.
NormalMacular Edema
Imaging of macular edema with opticalcoherence tomography
Meta analysis and review on the effect on bevacizumab on diabetic macular edemaGraefes 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 atfirst. As the edema moves in to the fovea (thecenter of the macula) the patient will notice blurrycentral vision. The ability to read and recognizefaces will be compromised.MaculaFovea
Normal VisionVision with DiabeticRetinopathyNational Eye Institute
Macular Ischemia can lead toprofound vision loss
Diabetic Retina Exam Slit-lamp examination (dilated eye exam) Optical Coherence tomography (OCT) Fluorescein angiography New technology OCT-angiography (non-invasive angiography) AI/Deep learning system
Association Between Vessel Density and Visual Acuity in Patients With Diabetic Retinopathy and Poorly Controlled Type 1Diabetes.Bénédicte Dupas, MD; Wilfried Minvielle, MD; Sophie Bonnin, MD; Aude Couturier, MD; Ali Erginay, MD; Pascale Massin,MD, PhD; Alain Gaudric, MD; Ramin Tadayoni, MD, PhDJAMA Ophthalmol. 2018;136(7):721-728. doi:10.1001/jamaophthalmol.2018.1319
JAMA 201771 896 images; 14 880 patients. DLS had90.5% sensitivity and 91.6% specificity for detecting referable diabeticretinopathy;100% sensitivity and 91.1% specificity for vision-threatening diabeticretinopathy;96.4%sensitivity and 87.2%specificity for possible glaucoma;93.2%sensitivity and 88.7% specificity for age-related macular degeneration,compared with professional graders.Sensitivity – true positive rate (high sens few false negatives)
DIABETIC RETINOPATHYTREATMENTThe best measure for prevention of lossof vision from diabetic retinopathy isstrict glycemic control
The Effect of Intensive Diabetes TreatmentOn the Progression of Diabetic RetinopathyIn Insulin-Dependent Diabetes MellitusThe Diabetes Control and Complications TrialThe Diabetes Control and Complications Trial Research GroupIntensive control reduced the risk of developing retinopathy by 76%and slowed progression of retinopathy by 54%; intensive controlalso reduced the risk of clinical neuropathy by 60% and albuminuriaby 54%.Arch Ophthalmol. 1995; 113:36-51
Primary preventionStrict glycemic controlBlood pressure controlSecondary preventionAnnual eye examsTertiary preventionRetinal Laser photocoagulationAnti-VEGF injectionsVitrectomy
Treatment OptionsETDRSDRCR.netProtocol B19852008laserIntravitrealtriamcinolone
Protocol T DRCR.Net 2 year resultsAflibercept, Bevacizumab, or Ranibizumab for Diabetic Macular Edema Two-Year Results froma Comparative Effectiveness Randomized Clinical TrialWells JA, et al for the DRCR network Ophthalmology 2016
Protocol T DRCR.Net2 year resultsBaseline VA: 20/50 or worseBaseline VA: 20/32 to 20/40
1 month after antiVEGF treatment
28 y.o WM with blurry vision right eye for 6 months, left eye for 1 weekDiagnosed with DM 2 weeks agoVision 20/400 OD; 20/200 OSPlan:PRP Left eye same dayVitrectomy, membrane peel, laser, gas Right eye in 10 days
Follow-up GuidelinesAge of Onset0 to 30 years (Type 1)31 years and older (Type 2)Prior to pregnancy (Type 1 or 2)Severity of RetinopathyDiabetes onlyMild-moderate NPDRSevere NPDRPDRFirst ExaminationWithin 5 yearsUpon diagnosisPrior to conception or early 1sttrimesterFollow-upYearlyYearlyNo retinopathy to mild-moderateNPDR: 3-12 monthsSevere NPDR or worse: 1-3monthsYearlyEvery 6 monthsEarly 3-4 monthsEvery 3 months
CONCLUSIONSDiabetic Retinopathy ispreventable through strictglycemic control and annualdilated eye exams by anophthalmologist.
National Eye Institute
National Eye Institute
Presented by: Mohan N. Iyer, M.D.National Eye Institute
National Eye Institute
Who is at risk for diabetic retinopathy? All people with diabetes Type 1 AND Type 2 During pregnancy, diabetic retinopathy may be aproblem for women with diabetes.Between 40 to 45 percent of Americansdiagnosed with diabetes have somestage of diabetic retinopathy.National Eye Institute
! Important ! It is important to diagnose or catch diabeticretinopathy before symptoms occur! You may see great – and still have the early stages ofdiabetic retinopathy.Key is to catch and manage thedisease early in its stages topreserve vision.National Eye Institute
Presented by: Mohan N. Iyer, M.D.National Eye Institute
Presented by: Mohan N. Iyer, M.D.National Eye Institute
Risk factors Diabetic RetinopathyDuration of diabetes is a major riskfactor associated with the developmentof diabetic retinopathyThe severity of hyperglycemia is the keyalterable risk factor associated with thedevelopment of diabetic s/PPP Content.aspx?cid d0c853d3-219f-487b-a524-326ab3cecd9a
Diabetic Retinopathy Diabetes is the leading cause of blindness in patients aged 20-64 years. Patients can have severe diabetic retinopathy and still be asymptomatic.Early detection and treatment can help prevent vision loss. Regular exams, treatment guidelines for medical and surgicalmanagement of diabetic eye disease are capable of reducing the risk ofsevere vision loss and blindness by 90% Treatment options for diabetic macular edema and proliferative diabeticretinopathy include laser photocoagulation, intravitreal injection ofsteroid or anti-VEGF agents, and vitrectomy surgery.
What is the most common cause of vision lossamong working age adults in the United States? 1. Glaucoma 2. Cataract 3. Diabetic Retinopathy 4. Retinal Detachment
The most common cause of moderate vision loss indiabetic retinopathy is: 1. Refractive Change 2. Cataract 3. Diabetic Macular Edema 4. Proliferative Diabetic Retinopathy
A patient with Type II diabetes should get their firstdilated eye exam:1. Only when the vision is affected2. In 3-5 years after initial diagnosis of diabetes3. At the time of diagnosis of diabetes4. 1 year after the diagnosis of diabetes
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The best predictor of diabetic retinopathy is the duration of the disease After 20 years of diabetes, nearly 99% of patients with type 1 diabetes and 60% with type 2 have some degree on diabetic retinopathy . PowerPoint
Diabetic Retinopathy Study (DRS) PRP reduces the risk of severe visual loss by 50 % in high‐risk proliferative diabetic retinopathy Early Treatment Diabetic Retinopathy Study (ETDRS) 1.Focal photocoagulation treatment for macul
The number of people with diabetes in the UK has more than doubled over the past two decades,1 with 3.8 million ( 6%) of the population currently diagnosed with diabetes. Diabetic eye disease (comprising diabetic retinopathy and diabetic macular oedema) is a microvascular complication of type 1 and type 2 diabetes mellitus.
in rural areas of India. Also, detecting retinopathy is a time-consuming process and is difficult even for an ophthalmologist to evaluate and examine digital color fundus photographs of retina. Most of the AI solutions for detecting Diabetic Retinopathy, available in market, are cloud deployed making rural enablement difficult.
comes through two main routes: growth of new vessels leading to intraocular . (ETDRS)3 aimed at grading retinopathy in the context of overall severity of ophthalmoscopic signs. Modified and simplified versions have been developed and . A Scottish Diabetic Retinopathy Grading Scheme has also recently been introduced7.
Diabetic retinopathy involves changes to retinal blood vessels that can cause them to bleed or leak fluid, distorting vision With good glycemic control, regular eye exams and early treatment, the risk of vision loss is reduced Diabetic retinopathy often goes unnoticed until vision loss occurs, therefore people with diabetes should get a
Diabetic Diet Diabetic Diet for diabetics is simply a balanced healthy diet which is vital for diabetic treatment. The regulation of blood sugar in the non-diabetic is automatic, adjusting to whatever foods are eaten. But, for the diabetic, extra caution is needed to balance food intake with exercise, insulin injections and any other glucose .
clinical research of diabetic retinopathy, diabetic macular edema, and associated conditions. Supports the identification, design, and implementation of multicenter clinical research initiatives focused on diabetes-induced retinal disorders. Emphasizes clin
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