Eye L3: Diabetic Retinopathy and Age-Related Macular Degeneration

Diabetic Retinopathy:
Type 1 rare at diagnosis, 90% at 15 years Type 2: 20% at diagnosis and 60% at 15
years
Risk Factors: duration, glycemic control, hypercholesterolemia, HTN, nephropathy,
pregnancy
Cause:
- oxidative stress + sorbitol accumulation microvascular occlusion and leakage
at capillary level
- Vessels supported by talley site
- loss of pericytes microaneurysms haemorrhages, exudates and edema
- proliferation of endothelial cells leads to occlusion ischaemia
- microinfarction of the nerve fibre layer form cotton wool spots.
- Neovascularization
o Capillary non-perfusion retinal hypoxia stimulate angiogenesis
neovascularization
o Stimulated by VEGF
Stage
1. Maculopathy: macular side swells
venous beading, vision blurs, presents early
a. Macular edema and exudates
b. Macular ischemia
2. Non-proliferative diabetic retinopathy (NPDR)
a. Mild: microaneurysms only
b. Moderate: + haemorrhages, exudates, cotton wool spots
c. Severe: venous beading, IRMA (intraretinal microvascular abnormality)
3. Proliferative diabetic retinopathy (PDR)
a. New vessels at disc
b. New vessels elsewhere
Central Retina: leakage, edema, macular ischemia
Peripheral Retina: non-proliferative, venous beading, presents late
Advanced Diabetic Eye disease
i)
Retinal detachment
a. Vitrectomy + retinal detachment repair
b. Because proliferations of blood vessel into vitreous causes traction of
retina
ii)
Vitreous haemorrhage
a. Follow-up with repeated ultrasound scan
b. Vitrectomy + endolaser if persistant
c. Because new blood vessels are friable can bleed
iii)
Neovascular glaucoma
Investigations
- Optical coherence Tomography
o Non-invasive, non-contact imaging system
o Provides high resolution cross sectional imaging of the retina
o Analogous to B-scan ultrasonography but uses near-infrared light rather
than sound waves
o Look for macular edema
- Fundus fluorescein Angiography
o Fluorescein is an orange water-soluble dye
o When injected iV, remains mainly intravascular, to back of eye
o Disruption of inner blood retinal barrier will permit leakage of fluorescein
o Look for signs of ischaemic retina, leakage from blood vessels. new vessel
growth, macular ischemia
o Hypofluorescence of fovea

Management
- Lifestyle: smoking, exercise, weight
- Glycemic control: HbA1c: 6.5-7%
- Blood pressure control (each leak, high pressure will drive leakage)
- Cholesterol control
- Maculopathy
o Intravitreal anti-VEGF: avastin, lucentis
o Focal laser photocoagulation (for single spot that is leaking)
- Non-proliferative: follow-up
- Proliferative: pan retinal photocoagulation: burn the peripheral ischaemic retina
- Laser
o Induce involution of new vessels
o Photocoagulates and burns retinal tissue
o Reduces oxygen demand of retina and so less stimulation for
neovascularization

Age Related Macular Degeneration

Risk Factors: Age!, smoking race (Caucasians), HTN, Diet (high fat and obestity,
antioxidants good)
Histopathology
- Drusen: extracellular deposits located at the interface between RPE and Bruchs
membrane
- Loss of RPE
Symptoms
- Loss of central vision: unable to read or recognize faces, reading
- Metamorphopsia (distorted vision)
Dry AMD
o More common 90%
o Characterized by drusen (yellowish
deposits form under RPE) and RPE
changes (atrophy)
o Slowly progressive deterioration in
central vision over years
o Advanced stage: Geographic atrophy
o Possible to become wet AMD
o Smoking big risk factor for
progression

Wet AMD
o Less common 10%
o Rapidly progressive over days and
weeks leading to sight loss
o If break occurs in Bruchs membrane,
vessels can grow from choroidal
circulation into the retina, forming
Choroidal neovascular membrane
which can bleed and cause acute loss
of central vision
o Pigment epithelial detachment
o Early treatment important

Management
- Prophylactic use of antioxidant in patients with unilateral advanced AMD to save
the second eye
- Modifiable risk factors controlled
- Amsler grid chart given to patients check weekly, squares should be regular
- Low vision aids
- Anti-VEGF (avastin and lucentis)
o Intravitreal injection best

90% preservation, 30% gain vision

Risks: retinal detachment, damage to lens, endopthalmitis (1/300),
Elevated IOP and uveitis may occur
Micro-incision Hubble implant
o Implantable miniature telescope
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