Diabetic retinopathy

¨India has 38.7million diabetics, the highest in world.
¨By 2030, - going to be79.4million.
¨ Western studies show Diabetic retinopathy to be the cause ofvisual impairment in 86% of type I & 33% of type II diabetics.
¨Indian studies reports of prevalence ofDiabetic retinopathy (DR) vary from 23.7% to 34.1%.
¨With our changing demographic structure,
¨Changing  life styles ,
¨ Increasing Geriatric population
¨Genetic predisposition of Indians for dyslipidemia , ---- all diabetics will develop DRwithin 20 years from diagnosis.
¨ Unlike cataract, DR is a life longdisease that requires early diagnosis and constant follow up to prevent theavoidable blindness.

What we require
¨ Awareness of the problem.
¨ intervention at avery early stage.  
¨ Our honorable ex president, Dr A.P.J Kalam has said, inaugurating65th AIOS
¨ “Every MBBS student should be taught to use the directophthalmoscope and should screen for Diabetic retinopathy”.
Screening and mass awareness
 The most important aspect in our fight against blindness.
 This is one crucial area where we all can contribute. How?
Talk about the need of eye examination in DM patients even if asymptomatic.

Fundus examination

Repeat fundus examination annually if it is normal 

“The eyes don’t see what the mind don’t know is a well known saying.  to know a little bit more about DR

The basic pathology is the microvascular angiopathy  causes loss of pericytes and capillary basement thickening .
Lead to capillary occlusion causing tissue ischemia.
 Capillary leakage causing exudation and edema.
The ischemia produces vasoproliferative factors, which produces neovascularization andproliferative retinopathy
Duration of diabetes –direct correlation with frequency and progression of DR.
Glycemic control –decrease in glycosylated Hb levels  significantly reduces progression of PDR
Age & Sex –Severity increases in type I with age.
Hypertension –Reduction of BP causes 34% reduction in progression of DR
Nephropathy –Presence of gross or micro albuminuria at baseline, 95%increased risk.
Serum lipid –Higher total cholesterol increases hard exudates at macula.
AnemiaAnemia induced hypoxia causes microaneurysms and other retinopathy changes.
Puberty –13 years or older at diagnosis of DM are at high risk of DR than younger age.
PregnancyPregnant women with type I are at double the risk of PDR thannon-pregnant patient.
Types of diabetic retinopthy
ModerateNonproliferative Diabetic Retinopathy (NPDR)
SevereNonproliferative Diabetic Retinopathy (NPDR)PDR(Proliferative DR)(with or without CSME)
Causesof sudden blindness in diabetes
Vitreous hemorrhage and retinalhemorrhage
Central retinal venous obstruction(CRVO)
Central retinal arterial obstruction
Retinal detachment
Optic neuritis
Acute glaucoma
Management–Role of Gen. ophthalmologist
Emphasis on strict metabolic control including hyperglycemia, hyperlipedemia and hypertension control.
Cessation of smoking.
Periodic complete ophthalmic checkupwith dilated fundus examination of every diabetic pt irrespective  of his symptoms.
Early retinal reference for active management in cases of retinopathy.

Proper history  of DM with duration and level of control.

History of co morbidity, HT, Renal disease, Dyslipedemia

Documentation of Base line VA,log mar charts Pupil reaction, any presence of NVI

OCT – in cases of detected macular abnormalities.

FFA- for garding and documentation ( if available)

USG- in opaque media (mature cataract, Vitreous hemorrhage)

Present management options

¨Laser photocoagulation, focal or panretinal (PRP)

Gold standard of treatment. Meant to prevent progression of retinopathy and prevent severe blindness.

Convert hypoxic retina to anoxic retina

Newer strategy

Intravitreal injection  triamicinalone acetate.
Intarvitreal steroid implant Ozudex
Anti Vascular Endothelial GrowthFactors ( VEGF) injections eg Ranibizumab (Avastin), Bevacizumab,(Lucentis)Pegaptanib sodium (Macugen)
Use of PKC beta inhibitor likeruboxistaurin to control endothelial permeability
 Surgery-Vitrectomyfor Diabetic Retinopathy
Vitreoretinal surgery for
 Vit. Hemorrhage, Tractional RetinalDetachment.
Release of vitreomacular traction
Increases oxygenation to the macula –inhibits VEGF
Increased perifoveal blood flow
Removal of toxic substances .

 In the present emerging scenario of Indian diabetics it is fast becoming empirical that a holistic approach is required where a general ophthalmologist has a pivitol role.