Simpo 13.3 - DR Rova - How To Avoid Blindness in Diabetic Eye Disease - PIT IDI Jabar 2018
Simpo 13.3 - DR Rova - How To Avoid Blindness in Diabetic Eye Disease - PIT IDI Jabar 2018
Simpo 13.3 - DR Rova - How To Avoid Blindness in Diabetic Eye Disease - PIT IDI Jabar 2018
Rova Virgana
FK Unpad
Pusat Mata Nasional RS Mata Cicendo
Bandung Eye Center (Hospital and Clinic)
• Papilopathy
• CN disturbances
• Glaucoma
Figure 4: How vision may
be affected by diabetic retinopathy
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.
Anatomy of The Eye
The retina – senses light &
transmits images to the
brain
http://www.who.int/bulletin/volumes/82/11/en/844.pdf
http://www.ncbi.nlm.nih.gov/pubmed/19896746
http://www.who.int/bulletin/volumes/82/11/en/844.pdf
Prevalence
• Blindness is 25 more common in diabetics
than non diabetics.
• Prevalence of PDR is much more in type I than
type II.
• Diabetic retinopathy more sever in type I than
type II.
Prevalence
• Macular edema :
NPDR : 2 -6 %
PDR : 20-63 %
• Macular edema :
20.1 % in younger onset group.
25.4 % in older onset group taking insulin
13.9 % in older onset group not taking insulin
Prevalence
• The 25-year cumulative rate of progression of DR
in Type I was:
- progression of DR was 83%.
- progression to PDR was 42%.
- macular edema was 26%.
Diabetes Control and Complications Trial Research Group N Engl J Med 1993; 329:977-986.
RISK FACTORS
3 . Miscellaneous factors :
- pregnancy (Hormonal changes )
- systemic hypertension
- renal disease
- anaemia ( ↓oxygen )
- elevated serum lipid
- carotid artery occlusive disease
- obesity
- barriers to care
Ocular Risk Factors
PVD :
• due to degenerative changes in the vitreous.
• significantly more common in diabetic
subjects.
• complete PVD may prevent the development
of PDR because the hyaloid is needed as a
scaffold for retinal neovascularization.
• attached posterior hyaloid has also been
associated with an increased risk for DME
Ocular Risk Factors
High myopia :
• choroidal degeneration and extensive old
chorioretinopathy protect against DR.
• believed to act in the same manner as pan
retinal photocoagulation by reducing the
metabolic needs of the retina
Ocular Risk Factors
• Removal of cataract :
• DR may progress after cataract surgery.
• Patient who have CSME, SNPDR or PDR should
undergo photocoagulation if the media is
sufficiently clear.
• If the cataract preclude retina evaluation and
treatment, prompt postoperative retinal
evaluation and treatment should considered.
Diabetic retinopathy symptoms
Diabetic retinopathy is asymptomatic in early stages of the disease
As 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
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
Microvascular
Occlusion
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
Retinal
Edema Hard exudates
hemorrhage
Retina in systemic disease : a color manual of ophthalmoscopy / Homayoun Tabandeh, Morton F. Goldberg 2009.
RECOMMENDED
DiabeticEYE EXAMINATION
Eye Disease
SCHEDULE Key Points
Diabetes Type Recommended Time of Recommended Follow-
First Examination up*
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
Microaneurysms
Moderate Nonproliferative Diabetic
Retinopathy (NPDR)
Microaneurysm
Hard exudates
Flamed shaped
hemorrhage
Severe Nonproliferative Diabetic Retinopathy
(NPDR)
Venous
beading
PROLIFERATIVE
DIABETIC
RETINOPATHY Cotton-wool
spot
Neovascularization
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
Diabetic Macular Edema
• Most common cause of decreased VA in DR
• Can occur in any DR stage
• Diabetic retinopathy occurs in 1 out of 3
people with diabetes, with reported rates of
DME reaching 7% in this group of patients
• In fact, DME is the leading cause of visual loss
and legal blindness in people with diabetes
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
Pathogenesis of DME
• Vascular endothelial growth factor (VEGF) is believed to be a key mediator
• These tight junctions are critical to the function and regulation of the BRB