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Diabetic Retinopathy & Effects of Diabetes on the Eye

Mar 07 | 2:00 PM

Diabetes induces metabolic and physiological changes in the retina, and these alterations point to the role of inflammation in the development of diabetic retinopathy. An increasing number of therapeutic approaches exist to inhibit the early stage complications of diabetic retinopathy, particularly occlusion and degeneration of retinal capillaries. Join Dr. Shachi Desai live on Medflix to discuss the latest pathophysiological findings and potential treatment options for this ocular illness!

[Music] very good evening everyone it's good to have you all here we are looking forward for a wonderful discussion today i'd like to introduce myself first i'm dr shaina verma saroya so i'm a third year resident at mmi msr mulana at ambala so uh i'm delighted to introduce uh dr uh sanji desai she's a vr consultant from ahmedabad with many years of expertise in this area and so we'll be talking about diabetic retinopathy and its various effects on eye on the eyes thank you dr shaina for the introduction and good evening everyone and welcome to today's session on uh diabetic retinopathy we'll be covering mainly about diabetic retinopathy and we'll go briefly uh through the other effects of diabetes on the eye as we all know that number of diabetic patients are increasing day by day and now the scene is such that every third or fourth household has a diabetic patient and diabetes is a lifelong disease which leads to over a period of years it leads to microvascular as well as microvascular complications and microvascular complications are mainly cardiovascular disorders and cerebrovascular disorders which patients and physicians are always very concerned and aware about it but microvascular complications which includes retinopathy nephropathy and neuropathy patients are usually not aware about such conditions and that's and it definitely affects the quality of life of a patient diabetes is such a disease that overall it affects the every part of the eye and every part of the body if we uh just go through the overall symptoms of effect of diabetes on the eye it affects each and every structure of the eye starting from anterior most part that is leads it it can lead to recurrent sty or you can blepharitis from if we talk about tear film abnormalities it can lead to tear film instability which leads to dryness and patient complains of foreign body sensation and um blurring of vision if we talk about cornea then there is reduced sensation corneal sensation which leads to corneal erosions and patients are more prone to develop infection which leads to corneal ulceration coming to iris iris of diabetic patients are usually not responding to mediatic drugs that is because of autonomic nervous system damage which affects the dilator and sphincter people in muscle over a period of time in long term diabetic retinopathy can leads to no vascularization of iris and angle invascularization which ultimately leads to neovascular glaucoma and affects the optic nerve optic nerve is also affected because of the swelling of optic nerve fibers and it is known as diabetic papillopathy and diabetic nerve damage in form of pupils pairing third now pulses also commonly seen of all these symptoms usually patients frequent change in glasses recurrent style and blepharitis and early cataract these are all presenting signs of diabetic patients which helps in diagnosing diabetic patients coming to diabetic retinopathy today we'll be uh covering topics like prevalence of diabetic retinopathy it's pathogenesis and classification uh what all the clinical features are there with which diabetic patients present and what investigations which do or which we do to diagnose patients with diabetic retinopathy and how we manage the case so diabetic retinopathy is seen in around 20 of the diabetics and it is the leading cause of blindness in around in working age group that is 25 to 65 years of age and at least 50 percent of the diabetics are not aware about this condition that is the sad part of it that they are not at all aware about the condition that their eyes or their vision or the retina can get affected because of diabetes so they themselves they don't go to uh retina specialist or ophthalmologist for their retina checkup and once the patient is affected with diabetic retinopathy patient is at 25 times higher risk of becoming blind so it's very important and if we diagnose the patient at timely then we can actually prevent an further complications early stage of the diabetic retinopathy is known as non-proliferative stage in this stage there is uh as uh we all know that diabetes is a micro vascular disorder small vessels of the retinas retina is affected there is loss of parasites of the vessel wall which makes it weaker so there is secular out pouching of the vessel wall which is which forms the micro aneurysm now this micro aneurysm is the earliest sign of diabetic retinopathy this micro aneurysm is usually very leaky along with there is damage of the vessel wall which leads to leakage and which leads to swelling of retinal layers over a period of time along with the leakage of the fluid there is also leakage of lipoproteins which gets accumulated in the retinal layers and it forms hard exudates this hard exudates microaneurysms and along with that over a period of time these micro aneurysms they rupture the vessel structure and relate to formation dot or formations of dot and blood hemorrhages so all these micro aneurysms hard exudates and daughter blood hemorrhages this or they all comprise of my non-proliferative form of diabetic retinopathy once the damage continues over a period of time these small vessels get blocked because of endothelial cell damage and once they are blocked there is occlusion of the vessel wall occlusion of the vessels which leads to hypoxia distal to the ocular occluded vessel and the retina is affected that is ischemia because of ischemia there is secretion of vascular endothelial growth factor and this vascular endothelial growth factor leads to proliferation of the new vessels this proliferation after with uh development of these new vessels uh the diabetic retinopathy enters into a stage of proliferative form and uh along with new vessels there are also signs of histamine which we see on fundus examination that is venus beading winners looping and cotton wool spots so these are all findings of prohibitive stage of diabetic retinopathy now other important entity is diabetic maculopathy which can be seen uh sorry i would like to inform that these changes of diabetic uh non-proliferative diabetic retinopathy as well as proliferative diabetic retinopathy they usually starts in peripheral part of retina so vision is mainly because of the central part of retina which is known as macula so when these changes are going on in the peripheral part of retina patients are usually asymptomatic and they are not aware about this condition so for that for diagnosis of this stage we need a dilated fundus examination to diagnose early changes of diabetic retinopathy which is happening in the peripheral part now when macula is involved it is known as diabetic mycolopathy and when achilles is involved then patient has symptoms of numbness of vision macular can be affected by two ways it can there can be swelling of macular layers or there can be ischemia swelling leads to diabetic macular edema and ischemic mechanopathy is where the perfusion is affected now diabetic maculopathy is a separate entity and it can be seen along with proliferative as well as non-proliferative diabetic retinopathy uh now when these patients are not diagnosed timely over a period of time a non-predative proliferative stage will enter into proliferative and then truly ferative will further advances and there is this new vessels which have developed in the proliferative phase they can bleed and with the bleeding there can be hemorrhage in the vitreous cavity uh because of which there is certain loss of fission uh along with the vessels new vessels development there can be fibrous tissue proliferation which leads to uh pulling on the retina and which leads to tractional retinal detachment which again leads to loss of vision again at what both these stages if patient is not diagnosed timely if the new vessels will grow more and more anteriorly and it involves the anterior part of the eye the new vessels will develop on the surface of the iris and in the angle of anterior chamber which leads to rise in the intraocular pressure and which leads to neovascular glaucoma and as i is a closed chamber the rise in the intraocular pressure leads to pressure on the optic nerve and the optic now gets affected which leads to ultimately vision loss so if if not treated or diagnosed timely we might lose the eye but the good part is that it doesn't happen overnight it it passes through the stage and so it's a that's why it's very important to timely diagnose the uh diabetic retinopathy now when we are dealing with patients having diabetic retinopathy it's very important to have a systemic evaluation to rule out other risk factors because diabetes uncontrolled diabetes duration of diabetes is important but apart from that if there are additional risk factors like dyslepidemia hypertension anemia then it can additionally affect the virgin versions and increases the risk of progression of diabetic retinopathy smoking and obesity is also a risk factor and recently we have studies have shown that sleep apnea is also one of the risk factors where if we treat sleep apnea they have seen improvement in uh diabetic retinopathy as well so uh managing the in during the managing the patient of diabetic retinopathy systemic evaluation is equally important to uh just see how patients metabolic control is coming to ophthalmic investigations now two main authentic investigations are used one is optical coherence omega tomography and one is fundus flores in angiography now oct is very commonly used and oct has revolutionized the management of um diabetic retinopathy as well as every retinal disorders uh it is a machi it hardly takes three to five minutes it is very rapid it's completely non-invasive the scan is taken even without touching patient's eye and it scans the macular part of the retina and it helps in diagnosing whether patient is having diabetic macular edema or not so and once we diagnose the patient with macular edema it also helps in assessing the response to treatment like in this in this photograph the above photo is of patient having diabetic macular edema so if we see a normal scan there is always a dip in the center which is a phobia deep and that is a normal contour of phobia which is again a center most part of macula so that is a normal scan but when patients has developed edema there is swearing of layers retinal layers and there are species or this cystoid species or hyporeflective areas which shows collection of fluid within the retinal layers it is seen and there is loss of phobial contour and once the injection is given after uh the injection after one month if we want to see the response we can again easily do the scan and see how good the response is and it is also better in explaining patient that see we can always show the patient that this was your pre-injection uh scan which shows macular demand now it has gone so it has it is really really helpful in managing the diabetic patients another test which is commonly used is fundus fluorescent angiography which helps in assessing retinal circulation so oct and ffa both are complementary to each other one gives us anatomical information that how edema is how much edema we can quantify the edema while fundus fluoresce in angiography shows us the area where the damage is from where the leakage is where if they can also helps us showing where the perfusion is affected again it is an opd procedure it can be done in it is done in a sitting position it hardly takes 10 to 15 minutes in which the dye is injected 20 fluorescent dye is injected in the peripheral part of the vein and after that serial photographs are taken for another 10 to 15 minutes um there are a patient common side effects include nausea and vomiting for which patient is asked to come fasting uh and serum creatinine needs to be checked because majority of the dye is excreted through kidney so if a patient is having some nephropathy or any problem then we usually get clearance from nephrologists for doing the angiography if it is very much required general contraindications are like pregnancy because there is lack of data about safety of fluorescent angiography all the fruits will die in pregnancy and if a patient has already undergone angiography once and patient has developed any allergy or enough electric reaction then usually it is avoided if possible so these are normal uh these are few photographs of fluorescent angiography uh the left one is normal and geography photo where we can see the dye within the vessel wall and um there is no leakage and we can actually distinctly see all the vessels while right side photographs are of diabetic retinopathy where we can see uh there are multiple small pinpoint uh hyper fluorescent areas which are of which are basically micro aneurysms and in right in further right we can see that these areas they leak so that shows that these are leaky micro aneurysms uh one in the the middle photograph is showing the superior half that is neovascularization which is leaking and one area the other arrow is showing where then there is non perfusion so basically if uh fundus fluorescent geography helps us in uh checking uh what areas are affected and the extent of uh diabetic retinopathy grossly now there is one newer technology available in at many places that is oct angiography uh here we know don't have to inject dye for doing the for to check the perfusion but uh it is used mainly to assess the macular perfusion because it's it it scans the small part of macula and we can actually see macular perfusion only for peripheral areas ffa still is superior than oct and geography uh it is especially useful where ffa cannot be done that is uh especially patients pregnant females where we want to check the macular perfusion this can be of really help but in rest of the cases ffa is still superior to ocd and geography in checking the uh extent of diabetic retinopathy coming to management part of diabetic retinopathy uh first and foremost always remains the good metabolic control along with ophthalmic management why because all major trials have clearly shown uh that intensive control of diabetes has uh can reduce the risk of development of retinopathy and it can also slows the progression of retinopathy now none of the ophthalmic management has any preventive role or any uh role in slowing the progression of retinopathy so metabolic control is extremely important in early stages of diabetic retinopathy where uh there is no ophthalmic management is required but if you control the diabetes you can actually uh reduce the risk of further progression and usual target hpmc kept is around less than seven uh in normal in most of the patients while if it is a patient is very old or frail and having a lot of comorbidities then less than eight is the target and studies have also shown that every one percentage point decrease in hbmc reduces the incidence of diabetic retinopathy by 35 and it also reduces the progression of diabetic retinopathy by 15 to 25 so good glycemic control is extremely important in prevention of progression and development of diabetic retinopathy now along with uh glycemic control there are other two factors which needs to be controlled that is blood pressure and dyslipidemia now blood pressure uh usually uh preferably the target is less than 140 by 90 and for dyslipidemia the lipid profile should be under control uh there is additionally it is seen that certain uh anti-hypertension hypertensive drugs like ac inhibitors and angiotensin receptor blockers they they are found to slow the progression of diabetic retinopathy and similarly in lipid lowering agents statins were found to reduce the risk of diabetic macular edema and pheno fibroids are strongly they have strongly shown studies have shown that we know fabrics has significant role in reducing the progression of diabetic retinopathy apart from lowering triglyceride levels and to an extent that in australia it is approved for use of diabetic retinopathy is one of the indications for use of phenotherates so they they have role so wherever uh it is possible the drugs can be included in patients control of lipid lowering therapy coming to ophthalmic management there are three treatment modalities available one is intravitreal injections of drugs two main group of drugs are used that is anti-veg anti-vascular endothelial growth factor drugs and steroids uh other modalities photocoagulation by laser therapy and third one is vitrectomy we'll go through it one by one uh treatment selection basically a treatment selection depends on the stage of diabetic retinopathy so when the patient presents uh with non-proliferative form of diabetic retinopathy we assess the stage irrespective of the stage and if there is no macular edema then as i said that we don't have to give any ophthalmic treatment we just have to control the diabetes and in those cases the good diabetes is very good metabolic control is extremely important and patient is periodically called for follow-up if patient is already having proliferative diabetic retinopathy then photocoagulation is done with the help of laser if patient has macular edema then we have to address that first by giving intravetrial injections and if patient is having advanced diabetic retinopathy that is vitreous hemorrhage or directional attachment then we and we go ahead with which ectomy so as i said diabetic macular edema is the cause of vision loss in patient and it has to be addressed first so if patient has diabetic mechanima interventional drugs are given and we have two options with us that is one is anti-vegf drugs and one is steroids uh interview injection is a daycare procedure and it is uh it hardly takes again three to five minutes but we have to give it in the ot under aseptic condition because infection in the eye can lead to endothermitis and while we are dealing with diabetic macular edema one thing we should keep in mind that thyroglytazome group of drug is such which has been seen to be associated with worsening of diabetic macular edema especially in patients who also develops leg edema or peripheral edema which shows the fluid retention of thyroglutarism so if patient has already peripherality and not responding to diabetic macular edema check their regimen if patient is on thyroglytazone if possible we can change we can ask treating physician to change the drug uh now anti-vagina drugs are the first choice in management of diabetic macular demand we have a lot of options with us starting with bibassi zuma uh vivacizumab is actually not approved for intraocular use but it is off label used because it is economical and ranibizumab is the first drug which was approved fd approved for the use of for the treatment of diabetic macular edema uh cost remains a factor and now the bios similar randy zumas are also available uh and these are all monoclonal antibodies and they uh they inhibit the vascular this wedge f molecules while afflicted is the most recent one which has an additional inhibiting effect on platelet-derived growth factor and it has higher affinity for vegf receptors so it is more effective in treating diabetic macular edema all these group of drugs are to be repeated four to six weekly because they works for four to six weeks and but if patients are not responding to uh antiviral group of drugs then uh steroids remains the optional treatment of choice uh because it has been seen that uh in chronic macular edema inflammation is the main component apart from the uh vascular endothelial growth factor so there are two options or two drugs available in steroids there one is trim signal on acetonite we can give its the dose is 2 milligram per 0.05 ml and preservative free form is usually used not a routine can accord uh we have a special preparations for use in the eye that is preservative form and second option is ozotex implant now this is a an implant you can play the video i think yes this is a video showing the injection of ozotex implant now when the button is pressed the implant is released in the vitreous cavity now this is the stick like thing is an implant which is injected in the vitreous cavity of the eye now this implant remains in the eye for four to six months where on angiography we find that there are small small areas or leaky areas which leads to uh focal leakage and uh which are responsible for macular edema after giving injection we usually treat this uh focal points by giving focal laser to that particular point and closing the micro aneurysm uh second one is grid laser where uh on angiography there is diffuse leakage from vessel wall as well as micro aneurysm there is no pinpoint leaking area then uh see the laser is uh done in a c shape manner which is known as a great laser and here the mechanism is that it irritates the retinal pigment epithelium which helps in pumping out uh the collected retinal fluid uh now third one is pan retinal photocoagulation that is done in proliferative stage of diabetic retinopathy or a pre-proliferative stage which is severe non-proliferative diabetic retinopathy uh where there are a lot of ischemic areas in the periphery but new vessels are still not developed so in both the cases severe non pre proliferative stage or proliferative stage we give a pan retinal photocoagulation in which laser is done in all four quadrants 360 degree sparing the center most part which is responsible for vision and here the purpose is to convert the peripheral ischemic hypoxic area to anoxic area so that it doesn't uh release vascular endothelial growth factor and it stops there and it doesn't lead to further complications of new proliferation or vitreous hemorrhage so to prevent further damage we just damaged convert this hypoxic retina into anoxic retina coming to the surgical management now if a patient is having uh the indications remain uh for surgical management or non-resolving vitreous hemorrhage so when patient first develop presence with vitreous hemorrhage if we wait for some time and most of the patients they the we trace hemorrhage improves on its own but if it is not responding non-resolving on its own then we have to under uh we have to go ahead with surgical management then fractional retinal detachment which is involving and threatening macula uh combine regulators as well as traditional retinal detachment and in late stages where there is non-resolving diabetic macular edema we uh the surgery remains the treatment of choice uh um in surgical uh management of diabetic retinopathy uh has also uh revolutionized a lot in last few years uh now uh more small and smaller gauge instruments are available which has made it completely sutured sutureless surgeries and with better viewing system uh through which we can actually visualize the inner part of the eye the photographs are showing that the topmost top left photograph is showing that we make we have to make three ports uh to go inside the eye one is of continuous infusion where the fluid is continuously going in because when we remove the damage between us the eye might get collapsed so to prevent it happening uh we have to put a continuous infusion on and then other two ports are one is for end eliminator and one is for cutter which removes the damage vitreous as well as damaged part of retina and the bottom right photograph is showing the viewing system which helps us visualize the structures inside the eye sharing few photographs of patients like this patient uh presented with vitreous hemorrhage the vision was reduced to counting fingers but after surgery the vision improved too or this was restored to six by nine and this is another photograph of a patient having tractional retinal detachment where vision was reduced to uh hand movements and after surgery uh the vision improved to six by 18 a patient had cataract for which patient was operated after three to four months and vision improved to six nine uh so overall the advance is in the diagnosis uh and management of diabetic retinopathy overall the scenario has changed in earlier days the perception was that if patient is having diabetes and patient has developed retinopathy know the vision is uh or the eye is lost but with newer investigative tools we can actually timely diagnose the uh the stage of diabetic retinopathy with newer drugs and surgical machines we can actually restore we can save the eye we can restore the vision but it is everything is possible possible only when we can timely detect diabetic retinopathy and that is only possible when fundus examination of all the diabetics is done by ophthalmologists uh having said that uh we do see uh frequently uh such patients where both the eyes are having proliferative diabetic retinopathy and first time first retina checkup is uh is done at very late stage patient again they are not aware of that the rice can get affected because of the diabetes so if we go through this screening guidelines for first retina checkup for diabetic patient for type 1 diabetes it is after 5 years of diagnosis now for type 1 diabetes it is important uh that to keep in mind that puberty is a high risk period for diabetes diabetic retinopathy progression and period between 16 to 18 is particularly critical so if a patient is diagnosed having type 1 diabetes by the age of failures or something then a patient should be sent for a fundus examination earlier than uh five years of diagnosis so it is very important to keep that in mind uh type 2 diabetes always at the time of diagnosis and in pregnancy if a diabetic patient gets pregnant then patient should be checked regularly uh at regular interval because they are more prone uh there are more chances of development of diabetic retinopathy and if patient is already having some form of diabetic retinopathy then there are more chances of progression because of pregnancy so this thing should be kept in mind so to conclude uh that a patient having diabetic retinopathy is at very high risk of becoming blind so it's very important to control all the risk factors support from diabetes uh hypertension anemia and pregnancy have a role in worsening the outcome there are mainly two types non-proliferative diabetic retinopathy and proliferative diabetic retinopathy and diabetic macular edema is a separate entity which can present with both npdr and pdr we have two investigations ophthalmic investigations which are cost effective and non-invasive which helps us in diagnosing and uh and see the extent of diabetic retinopathy uh management includes a good control of diabetes and other system parameters and ophthalmic management mainly includes local treatment in the form of intervertebral injections laser photocoagulation and surgical management and for all these things to happen screening is very important timely diagnosis is very important so patients should be screened regularly thank you thank you so much ma'am uh the presentation was wonderful and the entire topic was beautifully covered so as you you've rightly said i think the basic uh today's need is right screening screening at the right time so early detection that is very very important and eventually staging with the help of various ffa or ocd's various diagnostic techniques and eventually the the treatment so ma'am there are few questions uh in the comment sections i'll just read it out so uh ma'am the first one is do diabetes mellitus type 2 patients need to undergo eye examination every year yes if that type 2 diabetic should be should get the rice check immediately at the time of diagnosis now if they don't have any form of diabetic retinopathy then they should really get the rice check yearly and if they have any early changes of non-proliferative diabetic retinopathy then six monthly and if it they have more uh higher rate of diabetic retinopathy then ophthalmologist or retina specialist will anyway call them for a regular checkup at three months or two monthly or three monthly right so they should be checked regularly yes for diabetic right and when the next question is how will you manage the patient of uh in a pa or the diabetes in a patient of glaucoma because i think lasers because due to the inflammation will also uh they will rise in the pressure and the the giving these steroids or anti-any that will also lead to rising pressure so the question is how will you manage the case in glaucoma glaucoma patients like what should be treated see if patient is having diabetic macular edema then antivirgif drugs are usually not associated with rising the intraocular pressure there can be temporary rise when we inject the drug and that can be managed by giving pre opera pre injection anyone post injection pressure lowering agents so anti vegeta for use of antibacter drugs is not a problem and i think steroids are better avoided in patients with uh having already uh glaucomatous now damaged so we have the option of individual drugs in patients having diabetes with glaucoma okay and ma'am uh why pregnant diabetic women are more prone to the diabetic retinopathy because see if all hormonal changes are affected hemodynamic changes are there during pregnancy so these factors leads to uh if patient is having some form of diabetic retinopathy there are definitely chances of worsening during pregnancy to an extent that sometimes if patient is already having severe form of hypertension diabetic retinopathy then patient is usually discouraged to get pregnant also to that extent it can affect the uh progression of retinopathy right and uh ma'am what what should we do the duration between the lasers and the uh antivirgif if you want to give it can we give it simultaneously see if patient is having diabetic macular edema in uh and patient is also a patient is also having diabetic retinopathy at a stage where laser is also to be given then first we give injections because laser can lead to worsening of diabetic macular edema so first injection is given and under the cover of injection laser therapy can be can be given after one week or even within after one day we can go ahead and start the laser therapy right and uh mam after vitrectomy uh whether the diabetes can be replaced that is the question it means probably it means uh can can the diabetes will can be treated like no more uh changes can will be there after diabetes after after we treat me is it possible see overall uh uh we see pathogenesis of diabetic retinopathy vitreous remains a culprit because when the new vessels are growing it grows along with vitreous and it is the changes in the vitreous is responsible for bleeding and further damage so when we remove vitreous and it gets under control then chances of happening again and again are usually reduced okay right ma'am uh i think ma'am that will be it for the questions uh just a second man out of diabetes and hypertension uh if patient is highly myopic retinal checkup is recommended how frequently if patient is high myopic then how frequently they should get there see high myopic patients diabetic retinopathy as such has less occurrence in mahai myopia because the changes doesn't happen that frequently in myopic patients but still again the screening criteria remains the same if patient has no retinopathy then early written checkup if we do the lasers will it prevent further uh the development of neo vascularization or just the present vascularization your vascularization will be damaged no no it will lead to both it will prevent further neuroscalarization and it will help in regression of neuroscalarization both uh next question is diabetic number is genetic uh is it it does it run in the family diabetic diabetes is has a genetic factors and if patient has diabetes which runs in the family then patient uh they have a risk of developing diabetic retinopathy so retinopathy is because of diabetes and diabetes has a genetic uh uh inheritance so that can be the i mean the patient can develop diabetic but if patient has diabetes so they should get the rice checked thank you so much that was an excellent presentation most of the comments are for your presentation only so thank you so much ma'am the talk was very nice

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