DIABETIC RETINOPATHY

Definition
Diabetic retinopathy is progressive dysfunction of the retinal vasculature caused by chronic hyperglycemia.

Epidemiology
The first 5 years of type 1 diabetes has a very low risk of retinopathy. However, 27% of those who have had diabetes for 510years and 7190% of those who have had diabetes for longer than 10years have diabetic retinopathy. After 20 30years, the incidence rises to 95%, and about 3050% of these patients have proliferative diabetic retinopathy (PDR). Yanko et al. found that the prevalence of retinopathy 1113 years after the onset of type 2 diabetes was 23%; after 16 or more years, it was 60%; and 11 or more years after the onset, 3% of the patients had PDR. Klein et al. reported that 10years after the diagnosis of type 2 diabetes, 67% of patients had retinopathy and 10% had PDR.

Epidemiology cont.
Thirty-five percent of patients with symptomatic retinopathy have proteinuria, elevated blood urea nitrogen values, or elevated creatinine levels. Systemic hypertension appears to be an independent risk factor for diabetic retinopathy.

Pathogenesis
Aldose reductase Vasoproliferative factors Platelet and blood viscosity

Aldose Reductase

 lens epithelial cells, retinal pericytes and Schwann cells high concentration of aldose reductase sorbitol cannot easily diffuse out of cells, their intracellular concentration increases. Osmotic forces then cause water to diffuse into the cell, resulting in electrolyte imbalance.

Vasoproliferative Factors
Considerable evidence suggests that VEGF has a direct role in the proliferative retinal vascular abnormalities that are found in diabetes. Currently intense interest exists in vasoproliferative factors released by the retina itself, retinal vessels, and the retinal pigment epithelium, which are felt to induce neovascularization. The concentration of VEGF in aqueous and vitreous directly correlates with the severity of retinopathy.

Platelets and Blood Viscosity

It has been postulated that platelet abnormalities or alterations in blood viscosity in diabetics may contribute to diabetic retinopathy by causing focal capillary occlusion and focal areas of ischemia in the retina which, in turn, contribute to the development of diabetic retinopathy.

Ocular Manifestations
Early nonproliferative diabetic retinopathy Advanced nonproliferative diabetic retinopathy Proliferative diabetic retinopathy

Early nonproliferative diabetic retinopathy

Microaneurysms seen as small red dots in the middle retinal layers. It is very difficult to distinguish a small dot hemorrhage from a microaneurysm by ophthalmoscopy. Fluorescein angiography helps to distinguish patent microaneurysms because they leak dye

 Macular edema, or retinal thickening, represents the leading cause of legal blindness in diabetics. Clinically, macular edema is best detected by biomicroscopy with a 60-diopter or contact macular lens. This decreases the retinas translucency such that the normal retinal pigment epithelial and choroidal background pattern is blurred

Advanced nonproliferative diabetic retinopathy

Signs of increasing inner retinal hypoxia appear, including multiple retinal hemorrhages, cottonwool spots, venous beading and loops, intraretinal microvascular abnormalities (IRMA), and large areas of capillary nonperfusion depicted on fluorescein angiography.

 Cotton-wool spots, also called soft exudates or nerve fiber infarcts, result from ischemia, not exudation. Venous beading is an important sign of sluggish retinal circulation. IRMA, multiple retinal hemorrhages, venous beading and loops, widespread capillary nonperfusion, and widespread leakage on fluorescein angiography were all significant risk factors for the development of proliferative retinopathy. Interestingly, cotton-wool spots were not.

Proliferative diabetic retinopathy

Although the macular edema, exudates, and capillary occlusions seen in NPDR often cause legal blindness, affected patients usually maintain at least ambulatory vision. PDR, on the other hand, may result in severe vitreous hemorrhage or retinal detachment, with hand-movements vision or worse. Approximately 50% of patients with very severe NPDR progress to proliferative retinopathy within 1 year.

 The new vessels usually progress through a stage of further proliferation, with associated connective tissue formation. As PDR progresses, the fibrous component becomes more prominent, with the fibrotic tissue being either vascular or avascular. The fibrovascular variety usually is found in association with vessels that extend into the vitreous cavity or with abnormal new vessels on the surface of the retina or disc.

 Vitreous traction is transmitted to the retina along these proliferations and may lead to traction retinal detachment. As the vitreous contracts, it may pull on the optic disc, causing traction striae involving the macular area, or actually drag the macula itself, both of which contribute to decreased visual acuity

 Two types of diabetic retinal detachments occur, those that are caused by traction alone (nonrhegmatogenous) and those caused by retinal break formation (rhegmatogenous).

Other Ocular Complications of Diabetes Mellitus

Corneal sensitivity is decreased Corneal abrasions primary open-angle glaucoma The risk of cataract is 24 times greater in diabetics than in nondiabetics and may be 1525 times greater in diabetics under 40 years old optic neuropathy Extraocular muscle palsies

Diagnosis and Ancillary Testing

In nearly all instances, diabetic retinopathy is diagnosed easily via ophthalmoscopic examination intravenous fluorescein angiography is a widely administered ancillary test. Optical coherence tomography (OCT) is a noninvasive imaging technique that accurately measures retinal thickness, demonstrates macular edema, and details the architecture of the macula and surrounding structures

Differential Diagnosis
Radiation retinopathy Hypertensive retinopathy Retinal venous obstruction (central retinal vein occlusion (CRVO), branch retinal vein occlusion (BRVO)) The ocular ischemic syndrome Anemia Leukemia Coats disease Idiopathic juxtafoveal retinal telangiectasia Sickle cell retinopathy

Treatment
The mainstay of prevention of progression of retinopathy is good control of hyperglycemia, systemic hypertension, and hypercholesterolemia. Photocoagulation visus decreased or cause many complications Vitrectomy

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