1/5/2018 Diabetic Retinopathy - EyeWiki(/Main_Page) Log in (/w/index.php?title=Special%3AUserLogin&returnto=Diabetic+Retinopathy) Search Page (/Diabetic_Retinopathy) Discussion (/w/index.php?title=Talk%3ADiabetic_Retinopathy&action=edit&redlink=1) View form (/w/index.php?title=Diabetic_Retinopathy&action=formedit) Edit source (/w/index.php?title=Diabetic_Retinopathy&action=edit) History (/w/index.php?title=Diabetic_Retinopathy&action=history) Diabetic Retinopathy Original article contributed by Judy E. Kim, MD (/User%3AJudy.E.Kim.CMT) (/Property%3AAuthors): Brad H. Feldman, M.D. (/User%3ABrad.H.Feldman.DEC), Jennifer I Lim MD (/User%3AJennifer.I.Lim.CMT) and Vinay A. All contributors: Shah M.D. (/User%3AVinay.A.Shah.SEC) Assigned editor: Jennifer I Lim MD (/User%3AJennifer.I.Lim.CMT) Assigned status Up to Date by Jennifer I LIm MD (/w/index.php? Review: title=User%3AJennifer_I_LIm_MD&action=edit&redlink=1) on February 19, 2015. Diabetic Retinopathy Classi cation and external resources Diabetic retinopathy refers to retinal changes that occur in patients with DiseasesDB 29372 diabetes mellitus. These changes affect the small blood vessels of the retina (http://en.wikipedia.org/wiki/Diseases_Database) (http://www.diseasesdatabase.com/ddb29372.htm) and can lead to vision loss through several different pathways. Visit EyeSmart from the American Academy of Ophthalmology for a brief, patient-friendly summary of diabetic retinopathy (http://www.aao.org/eye- health/diseases/what-is-diabetic-retinopathy). Contents 1 Disease Entity 1.1 Disease 1.2 Etiology 1.3 Risk Factors 1.4 General Pathology 1.5 Pathophysiology 1.6 Primary prevention 2 Diagnosis 2.1 History 2.2 Physical examination and Signs 2.3 Symptoms 2.4 Clinical diagnosis 2.5 Diagnostic procedures 2.6 Laboratory test 2.7 Differential diagnosis 3 Management 3.1 General treatment 3.2 Medical therapy and follow up 3.3 Surgery and Surgical follow up 3.4 Complications 3.5 Prognosis 4 Additional Resources 5 References Disease Entity Disease Etiology Retinal disease that occurs in patients with diabetes mellitus. Risk Factors http://eyewiki.org/Diabetic_Retinopathy 1/4 telangiectasia present). Symptoms Clinical diagnosis The central retina area that located between the main branches (superior and inferior arcades) of the central retinal vessels (central retinal artery and central retinal vein) in the eye is known as the “macular area”.0001).0001).new blood vessel formation Primary prevention Control of glucose and blood pressure.referred to as macular edema. Diagnosis History Ask for symptoms of decreased vision or uctuating vision. These changes in the macula include the presence of abnormally dilated small vessel outpouchings (called microaneurysms).6. One should look carefully for the presence of abnormal blood vessels on the iris (rubeosis or NVI). P<0. cataract (associated with diabetes) and vitreous cells (blood in the vitreous or pigmented cells if there is a retinal detachment with hole formation). The optic disc and area surrounding it (for one disc diameter) should be examined for presence of abnormal new blood vessels (neovascularization of the disc. Management http://eyewiki. 14% for myocardial infarction (8% to 21%. UKDPS. NVD/NVE from vein occlusion. sarcoidosis. The macula can get thicker than normal.1/5/2018 Diabetic Retinopathy .0001). Non-proliferative retinopathy can be classi ed into mild. The remainder of the retina should also be examined for presence of abnormal new blood vessels (neovascularization elsewhere. WESDR references below) General Pathology The main types of diabetic retinopathy are non-proliferative and proliferative diabetic retinopathy. The retina beyond this is considered “peripheral retina”. NVD).0 % is ideal. presence of oaters. IOP should be checked especially when NVI is seen. and 37% for microvascular complications (33% to 41%. hard exudates. The main distinguishing feature between these two categories is the presence (proliferative) or absence (non-proliferative) of abnormal new (neovascular) blood vessels (retinal neovascularization). The OCT can be sequentially obtained to determine whether the macular thickening is responding (swelling/ edema is decreasing) to therapy. retinal vasculitis. retinal swelling (edema)/ cystoid macular edema. P<0. NVE). ashes of light (photopsias) or defects in the eld of vision. It is important to know the hemoglobin A1c and whether the patient’s blood pressure is under control. vein occlusion (occluded vessel seen. P<0. Ocular coherence tomography (OCT) is useful to determine the retinal thickness measurements. Physical examination and Signs Slit lamp examination and dilated fundus examination should be performed. Diagnostic procedures Fluorescein angiography is used to determine the degree of ischemia or the presence of retinal vascular abnormalities. (UKDPS report 35). Dilated fundus examination should include a macular examination (contact lens or non-contact examination lens) to look for microaneurysms. NVI from vein occlusions. VEGF leads to a) increased vascular permeability resulting in retinal swelling/edema and b) angiogenesis. Proliferative retinopathy is progressive and requires treatment to prevent bleeding and scar tissue formation. 21% for deaths related to diabetes (15% to 27%. These ndings can be present in the non-proliferative or the proliferative forms of the disease.0001). sickle cell retinopathy. although dif cult to achieve in some patients. moderate or severe stages based upon the presence or absence of retinal bleeding.5 % . The areas of microaneurysms appear as hyper uorescent spots and may leak on the late frames resulting in areas of retinal edema clinically.org/Diabetic_Retinopathy 2/4 . The areas of NVD/ NVE show leakage on the FA. ocular ischemic syndrome. Differential diagnosis Macular edema from radiation retinopathy (history of radiation). No treatment is usually done at this stage. parafoveal telangiectasia (telangiectatic vessels seen). Each 1% reduction in updated mean HbA(1c) was associated with reductions in risk of 21% for any end point related to diabetes(95% con dence interval 17% to 24%. A goal of 5. P<0. retinal bleeding (retinal hemorrhages) and yellow lipid and protein deposits (hard exudates). The central retinal area can develop abnormal ndings in diabetic retinopathy. ocular ischemia. abnormal venous beading of the vessel wall (venous beading) or abnormal vascular ndings (intraretinal microvascular anomalies or IRMA). cotton wool spots. hemorrhage. Laboratory test Hemoglobin A1c is a measure of the degree of glycemic control over the past 3 months.EyeWiki Diabetes Uncontrolled glucose or blood pressure levels are associated with increased risk (see NHANES. Pathophysiology Vascular endothelial growth factor (VEGF) is secreted by ischemic retina. 46:1829-39. 1987 Jul. Intraoperatively. Anti-VEGF are also given prior to vitrectomy surgery in selected cases. Ophthalmology. 1449. Early Treatment Diabetic Retinopathy Study Research Group. A recent study by the DRCR network has shown all three drugs (bevacizumab. surgery is necessary (see vitrectomy for more information). Feiner L. 1995 Sep. Classi cation of diabetic retinopathy from uorescein angiograms. Relationship of treatment effect to uorescein angiographic and other retinal characteristics at baseline: ETDRS report no.Ophthalmology. 1998 Feb.e1-10. but real. Epub 2010 Apr 28. RISE. Remaley NA. Epub 2013 May 22. Hartnett E. Ophthalmology. Sometimes the proliferative disease is advanced and there is bleeding lling the eye (and preventing laser to be done) or scar tissue that wrinkles the retina or pulls it off the eyewall surface. Marcus DM. Barton F.html) San Francisco: American Academy of Ophthalmology. intraocular gas or silicone oil may be needed to reattach the retina to the underlying layers and eyewall. American Academy of Ophthalmology. Simons BD. da Vinci Study Group.02. 10. 4. Berliner AJ. 2017.1/5/2018 Diabetic Retinopathy . ETDRS report number 9. Nguyen QD. Epub 2012 Apr 24.aao. Early Treatment Diabetic Retinopathy Study Research Group. Prognosis ETDRS studies show that the stage of retinopathy is correlated with progression to more advanced stages or retinopathy and visual loss.vitrectomy accelerates the rate of cataract formation. 2015DOI: 10. February 18. Complications There is always the low. Arch Ophthalmol. ETDRS report number 17. (DRCR.net). Ruckert R. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Glassman AR. Brown DM.120(10):2013-22. ranibizumab and a ibercept) are effective for macular edema therapy. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. Kim JE. Several studies indicate that anti-VEGF drugs are more effective than focal laser (DRCR. Ophthalmology.115(9):1447-9.1016/j.117(6):1064-1077. Arch Ophthalmol. 2007 Apr. risk of infection of the eyeball (endophthalmitis) with any injection of drugs into the eye or with eye surgery.98(5 Suppl):823-33. Diabetic Retinopathy Clinical Research Network. DAVINCI and ETDRS studies). Ehrlich JS. Hopkins JJ. Nguyen QD. Schmelter T. Brown DM1. Scott IU. 1991 May. Patients are seen monthly if being injected or every 3 months post-laser for macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2. Focal photocoagulation treatment of diabetic macular edema. 11. Pars plana vitrectomy in the Early Treatment Diabetic Retinopathy Study. Barton FB. Treatment includes the use of lasers or injection of drugs that cause the swelling (from leaking blood vessels) to go resolve. One-year outcomes of the da Vinci Study of VEGF Trap-Eye in eyes with diabetic macular edema. Gangnon RE. Fundus photographic risk factors for progression of diabetic retinopathy. Gao B.2012. Sun JK. Ophthalmology. Early Treatment Diabetic Retinopathy Study Research Group. 6. Schlottmann PG. Additional Resources See references. Diabetic retinopathy Practicing Ophthalmologists Learning System. Bressler NM. Vitti R. Aiello LP. There is also the risk of cataract progression with retinal surgery. In cases of NVD/ NVE with NVI. Aiello LP. 2009 Mar. Comparison of the modi ed Early Treatment Diabetic Retinopathy Study and mild macular grid laser photocoagulation strategies for diabetic macular edema. Friedman SM. The Diabetic Retinopathy Clinical Research Network. Early Treatment Diabetic Retinopathy Study Research Group. The Early Treatment Diabetic Retinopathy Study Research Group. Patel S. READ2. If successful. 2010 Jun. Chew EY. Diabetic Retinopathy Clinical Research Network (DRCR. 5. In these situations. anti-VEGF injections into the eye can also be used. Bevacizumab. Kollman C. Beck RW.127(3):245-51. 1992 Sep. Ferris FL 3rd.1016/j.EyeWiki General treatment Medical therapy and follow up Treatment of macular edema is usually needed in order to prevent loss of vision or to try to improve vision. Heier JS.ophtha. Glassman AR. Miller KM. doi: 10. Early Treatment Diabetic Retinopathy Study Research Group Early photocoagulation for diabetic retinopathy. 1991 May. Ophthalmology. 2. RIDE. 39:233-52 3.119(8):1658-65. Ophthalmology. 94:761-74. Beck RW.org/practicing- ophthalmologists-learning-system-2017-2019. 113:1144-55. Bressler NM. 7. Rubio RG. References 1. 2008 Sep. 13. Ophthalmology. Sandbrink R. 2013 Oct. 8. Surgery and Surgical follow up The goal of surgery is to remove blood and scar tissue from the retinal surface and to place laser treatment as needed. 2017 . Clustering of long-term complications in families with diabetes in the diabetes control and complications trial. 1991 May. Edwards AR. Ip MS. Aiello LM. Arch Ophthalmol. Elman MJ. Diabetes Control and Complications Trial Research Group. Fisher MR.2013. Ferris FL 3rd.1056/NEJMoa1414264 14. ETDRS report number 12. Diabetic Retinopathy Clinical Research Network Writing Commttee. Ferris F.ophtha. 15. RIDE and RISE Research Group. doi: 10. Adamis AP. Diabetes.02. or Ranibizumab for Diabetic Macular Edema. ETDRS report number 11.010. 19. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema.2019 (http://store.Long-term outcomes of ranibizumab therapy for diabetic macular edema: the 36-month results from two phase III trials: RISE and RIDE. Treatment of PDR is laser photocoagulation of the peripheral retina. Do DV1. Boyer D. Risk factors for high-risk proliferative diabetic retinopathy and severe visual loss: Early Treatment Diabetic Retinopathy Study Report #18. Epub 2008 Jul 26. 12. DAVINCI).. The laser is used to create scars on the peripheral retina. Schmidt-Erfurth U.034. RISE. Diabetic Retinopathy Clinical Research Network. Three-year follow-up of a randomized trial comparing focal/grid photocoagulation and intravitreal triamcinolone for diabetic macular edema. Ferris FL 3rd. The use of anti-VEGF drugs in PDR is being investigated by the DRCR network. 1997 Nov. Stockdale CR. Edwards AR.98(5 Suppl):807-22. Boyer DS. Flynn HW Jr. Invest Ophthalmol Vis Sci. RIDE.e35.org/Diabetic_Retinopathy 3/4 . Bressler SB.98(5 Suppl):766-85. 2012 Aug. Rundle AC. 125:469-80. A ibercept. Davis MD. Ophthalmology. Anti-VEGF injections are sometimes used in concert with laser when rubeosis and neovascular glaucoma are present. Chew EY. Zeitz O. http://eyewiki. 9. bleeding and scarring is averted. Zhang J. 99:1351-7. Knatterud GL. Effect of focal/grid photocoagulation on visual acuity and retinal thickening in eyes with non-center-involved diabetic macular edema. 1982 Jul.e1. 29(10):841-51. Sherwin RS. Holman RR. Photocoagulation for diabetic macular edema. 25. Campochiaro PA. Browning DJ. Matthews DR. 24. Nguyen QD. 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