Diabetic Retinopathy PDF

DIABETIC RETINOPATHY SUBGROUP A GROUP MEMBERS 1. SAMUDRALA SASI PRABHA 2. MOHAMED SOFIAN 3. NUR ADNIE RAIHANA 4. NURUL SYUHADA 5. DANIA HUDA 6. NUREEN DHIA BATRISYIA 7. SYAMIMI SYAMILAH 8. MUHAMMAD AMIR SHAH CONTENTS 1. DEFINITION AND EPIDEMIOLOGY 2. PATHOPHYSIOLOGY 3....

DIABETIC RETINOPATHY SUBGROUP A GROUP MEMBERS 1. SAMUDRALA SASI PRABHA 2. MOHAMED SOFIAN 3. NUR ADNIE RAIHANA 4. NURUL SYUHADA 5. DANIA HUDA 6. NUREEN DHIA BATRISYIA 7. SYAMIMI SYAMILAH 8. MUHAMMAD AMIR SHAH CONTENTS 1. DEFINITION AND EPIDEMIOLOGY 2. PATHOPHYSIOLOGY 3. SIGNS AND SYMPTOMS 4. GRADING 5. MANAGEMENT OF NON PROLIFERATIVE DR (NPDR) 6. MANAGEMENT OF PROLIFERATIVE (PDR) 7. MANAGEMENT OF DIABETIC MACULAR EDEMA 8. MANAGEMENT OF ADVANCED DIABETIC EYE DISEASE (ADED) Diabetic Retinopathy Nur Adnie Raihana Binti Mohamed Samud 1129210920420 Diabetic retinopathy is a microvascular complication of diabetes that affects the retina. It's a leading cause of preventable blindness in adults and results from chronic hyperglycemia, hypertension, and dyslipidemia associated with diabetes. Type of DR: 1. Non - proliferative DR (NPDR) 2. Proliferative DR (PDR) 3. Advance Diabetic Eye Disease 4. Diabetic Macular Edema ( DME ) High blood sugar damages retinal blood vessels, causing leakage, ischemia, and abnormal new blood vessel growth (neovascularization). Diabetic Retinopathy in Malaysia 1. Prevalence of Diabetes: ○ Malaysia has one of the highest diabetes prevalence rates in Southeast Asia, with an estimated 18.3% of adults aged ≥18 years diagnosed with diabetes (National Health and Morbidity Survey, NHMS 2019). ○ This high prevalence contributes directly to the burden of diabetic retinopathy. 2. Prevalence of Diabetic Retinopathy: ○ DR affects about 14-20% of individuals with diabetes in Malaysia. ○ The prevalence of vision-threatening diabetic retinopathy (VTDR), which includes proliferative DR and diabetic macular edema, is around 5-10% of diabetics. Risk Factors Identified: Duration of diabetes: DR is more common in patients with diabetes for more than 10 years. Glycemic control: Poor HbA1c levels (>8%) are strongly associated with DR. Hypertension and dyslipidemia: These are significant contributors to DR progression. Age: Older adults with diabetes are at higher risk. Urban vs. Rural: Access to healthcare and awareness may influence DR rates, with lower detection in rural areas.  Pathophysiology of Diabetic Retinopathy Mohamed Sofian Abudaia a. Polyol Pathway process. ○ Excess glucose is converted to sorbitol by aldose reductase, consuming NADPH in the ○ This depletes antioxidants like glutathione, leading to oxidative stress and cellular damage. b. Advanced Glycation End Products (AGEs) ○ Hyperglycemia causes the glycation of proteins and lipids, forming AGEs. ○ AGEs interact with their receptor (RAGE) on endothelial cells, triggering inflammation and oxidative damage, further disrupting vascular homeostasis. c. Protein Kinase C (PKC) Activation ○ Hyperglycemia activates PKC isoforms, which contribute to: ○ Increased vascular permeability. ○ Inflammation. ○ Angiogenesis (via VEGF production). d. Hexosamine Pathway Activation ○ Some excess glucose is diverted into the hexosamine pathway, where it is converted into glucosamine derivatives. ○ These derivatives modify transcription factors (e.g., Sp), increasing the expression of pro-inflammatory cytokines and transforming growth factor-beta (TGF-ß), which contribute to vascular dysfunction and fibrosis. e. Renin-Angiotensin-Aldosterone System (RAAS) ○ Hyperglycemia upregulates the intraocular RAAS. ○ Angiotensin II (a key RAAS component): ○ Promotes oxidative stress. ○ Stimulates VEGF production, enhancing vascular permeability and neovascularization. ○ Increases inflammation and fibrosis, worsening retinal damage. 2. Capillary Damage ○ Loss of Pericytes: Pericytes, critical for capillary stability, undergo apoptosis due to oxidative stress and AGEs. ○ Endothelial Cell Dysfunction: Chronic metabolic stress damages endothelial cells, causing: ○ Blood-retinal barrier breakdown → Leakage of fluid and proteins into the retina. ○ Basement membrane thickening → Impaired oxygen and nutrient exchange. 3. Microvascular Occlusion ○ Capillary Non-perfusion: Damage to endothelial cells and pericytes leads to capillary occlusion, creating ischemic areas in the retina. ○ Microaneurysms: Weakness in the capillary walls results in microaneurysms, which can rupture and cause retinal hemorrhages. 4. Retinal Ischemia and VEGF Release ○ Retinal ischemia stimulates the production of vascular endothelial growth factor (VEGF), leading to: ○ Neovascularization: Growth of fragile, abnormal blood vessels prone to leakage and rupture. ○ Increased vascular permeability, contributing to retinal edema. 5. Progression to Advanced Disease ○ Non-Proliferative Diabetic Retinopathy (NPDR): ○ Microaneurysms, retinal hemorrhages, hard exudates, and cotton wool spots (indicative of ischemia). Proliferative Diabetic Retinopathy (PDR): ○ Neovascularization leads to: ○ Vitreous hemorrhage: Bleeding into the vitreous cavity. ○ Tractional retinal detachment: Fibrous tissue from new vessels pulls on the retina. ○ Diabetic Macular Edema (DME): ○ Fluid accumulation in the macula causes central vision loss. Signs and Symptoms of Diabetic Retinopathy Nureen Dhia Batrisyia Binti Roslan 1129210920465 Signs of Diabetic Retinopathy Early Stage (Non-Proliferative Diabetic Retinopathy - NPDR): Microaneurysms: - Tiny bulges in the blood vessels of the retina, often the earliest sign. - Occur due to weakening of the blood vessel walls caused by high blood sugar levels. - Often located in the inner layers of the retina and may leak fluid into surrounding tissue. Retinal Hemorrhages: - Small, dot- or blot-shaped spots of bleeding in the retina. - Result from the rupture of damaged capillaries. - May indicate worsening vascular damage and increased retinal stress.  Hard Exudates: - Composed of lipids and proteins that leak from damaged blood vessels. - Appear as yellow, shiny deposits, often clustered or forming a ring-like pattern around the macula. - Linked with macular edema, they interfere with central vision if they accumulate near the macula. Cotton-Wool Spots: White, fluffy lesions on the retina caused by microinfarctions in the retinal nerve fiber layer. Represent localized ischemia (poor blood supply) leading to axonal swelling. Often associated with more severe vascular damage and can indicate systemic microvascular complications.  Macular Edema: - Swelling of the macula due to leakage of fluid and protein from damaged blood vessels. - Commonly associated with blurred or distorted central vision. - Diagnosed using optical coherence tomography (OCT), which measures retinal thickness and fluid accumulation. - Can occur at any stage of diabetic retinopathy but is a leading cause of vision loss in NPDR. Advanced Stage (Proliferative Diabetic Vitreous Hemorrhage: Retinopathy - PDR): - Occurs when new blood vessels break and Neovascularization: bleed into the vitreous humor (gel-like - Growth of abnormal, fragile blood vessels on substance in the eye). the retina or optic disc. - Can cause sudden vision changes, such as a - These vessels form in response to retinal dark curtain or shadows obstructing part of the ischemia, as the retina attempts to visual field. compensate for a lack of oxygen. - In severe cases, can lead to complete vision - Prone to rupture, leading to bleeding and loss until the blood clears or surgical further complications. intervention is performed.  Tractional Retinal Detachment: - Scar tissue from neovascularization contracts, pulling on the retina and detaching it from its normal position. - Causes progressive vision loss, often starting with peripheral vision. - A medical emergency that may require surgery (e.g., vitrectomy) to repair.  Fibrous Tissue Proliferation: - Formation of fibrotic (scar) tissue along with abnormal blood vessels. - This tissue can exacerbate retinal detachment or distort the retinal structure, leading to vision distortion or further ischemia. Ischemic Changes: - Areas of the retina suffer from a lack of blood flow due to capillary closure or extensive vascular damage. - Can lead to permanent loss of retinal function in affected areas. - Fluorescein angiography is often used to identify ischemic regions and guide treatment decision. Symptoms of Diabetic Retinopathy Early Stage (Non-Proliferative Diabetic Retinopathy - NPDR): Often asymptomatic or mild symptoms in early stages. Blurry vision: May occur due to macular edema (swelling in the macula). Floaters: Tiny specks or strings that appear to drift across the field of vision. Difficulty seeing at night: Poor vision in low-light conditions. Advanced Stage (Proliferative Diabetic Retinopathy - PDR): Severe floaters or dark spots: Caused by bleeding (vitreous hemorrhage) or retinal damage. Fluctuating vision: Vision may change day to day due to blood sugar levels or retinal swelling. Loss of central vision: Due to macular ischemia or edema. Sudden vision loss: A result of vitreous hemorrhage or retinal detachment. Distorted vision: Straight lines appearing wavy (indicative of macular involvement). Other Symptoms: Redness or discomfort in the eyes (less common). Increased sensitivity to light (photophobia). Difficulty focusing on close or distant objects.  Grading of Diabetic Retinopathy Nurul Syuhada Binti Mohd Sukeri 1129210920428  Grading of Diabetic Retinopathy Retinopathy stage Findings on ophthalmoscope No apparent retinopathy No abnormalities Mild non-proliferative diabetic Microaneurysms only retinopathy (NDPR) Moderate non-proliferative More than just microaneurysms but less than severe NDPR. diabetic retinopathy (NDPR) Severe non-proliferative Any of the following: diabetic retinopathy (NDPR) 1.More than 20 intraretinal hemorrhages in each 4 quadrants 2.Definite venous beading in 2 or more quadrants. 3.Prominent intraretinal microvascular abnormalities in 1 or more quadrants and no signs of proliferative retinopathy..  Proliferative diabetic One of the following: retinopathy 1.Neovascularization 2.Vitreous or preretinal hemorrhage Advanced diabetic eye One of the following: disease (ADED) 1.Formation of fibrovascular tissue proliferation 2.Traction retinal detachment due to formation of posterior vitreous detachment 3.Dragging of retinal or distortion 4.Rhegmatogenous retinal detachment....  Macula oedema Macula oedema Findings on ophthalmoscope Absent No retinal thickening or hard exudate in posterior pole Present 1.Mild- some retinal thickening or hard exudates in posterior pole but distant from macula 2.Moderate- retinal thickening or hard exudates approaching the centre of the macula but not involving the centre 3.Severe- retinal thickening or hard exudates involving the centre of macula..  Management of Non-proliferative Diabetic Retinopathy DANIA HUDA BINTI MOHD AZMI 1129210920415  - Individuals with DM should be screened at least every 2 years - High risk individuals should be examined annually : 1. Longer duration of diabetes 2. Poor control of blood sugar 3. Poor control of blood pressure 4. Poor control of serum lipid - The examination should include: 1. Visual acuity 2. Fundus photography or dilated fundus examination A. General Management 1. Glycemic control : Target A1C