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Management of diabetic retinopathy

This document provides guidelines for managing diabetic retinopathy from the International Council of Ophthalmology in 2017. It discusses the epidemiology of diabetic retinopathy, noting that it affects 1 in 3 people with diabetes and is a leading cause of preventable blindness. The pathogenesis involves microvascular changes from prolonged hyperglycemia. Treatment involves optimizing blood glucose and blood pressure control, as well as focal laser treatment, panretinal laser photocoagulation, or anti-VEGF injections depending on the severity of the retinopathy and presence of macular edema. Follow-up examinations are recommended based on the classification and severity of the diabetic retinopathy.

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MANAGEMENT OF DIABETIC RETINOPATHY – ICO 2017 Bipin Bista Resident-Ophthalmology NMCTH, Birgunj, Nepal
Guidelines for Diabetic Eye Care Updated 2017 ICO Guidelines for Diabetic Eye Care
Introduction • Diabetes mellitus (DM) is a global epidemic with significant morbidity. • Diabetic retinopathy (DR) is the specific microvascular complication of DM and affects 1 in 3 persons with DM.
Introduction • Optimal control of blood glucose, blood pressure, and blood lipids can reduce the risk of developing retinopathy and slow its progression. • Patients with severe levels of DR are reported to have poorer quality of life and reduced levels of physical, emotional, and social well- being, and they utilize more health care resources.
Epidemiology • Most common cause of preventable blindness in working aged- adults. • A global meta-analysis showed that one in three diabetic had any form of DR. • In the 2010 world diabetes population, more than 92 million adults had any form of DR, 17 million had PDR, 20 million had DME and 28 million had VTDR.
Epidemiology • Studies reported Diabetic Retinopathy (DR) in 19-47% of diabetic patients in Nepal. Eli Pradhan, Barsa Suwal, Govinda Paudyal.Diabetic retinopathy in Nepal: An update Comm Eye Health South Asia Vol. 28 No. 92 2016 • Thapa SS, Thapa R, Paudyal I, Khanal S, Aujla J, Paudyal G, et al. Prevalence and pattern of Vitreo-retinal disorders in Nepal: the Bhaktapur glaucoma study. BMC Ophthalmology. 2013, 13, 9. doi:10.1186/1471-2415-13-9 • Rizyal A. Ocular manifestations in diabetes mellitus: an experience at Nepal Medical College Teaching Hospital. Nepal Med Coll J. 2004;6:136 -138. • Shrestha S, Malla OK, Karki DB, Byanju RN. Retinopathy in diabetic population. Kathmandu Univ Med J. 2007;5:204-209. • Shrestha RK. Ocular manifestations in diabetes, a hospital based prospective study. Nepal Med Coll J. 2011;13:254—256.
Pathogenesis • The exact cause of Diabetic microvascular disease is unknown. • Exposure to hyperglycemia over an extended period – biochemical & physiologic changes in vascular endothelium .
Microvascular occlusion • A. Capillary changes- loss of pericytes, thickening of BM & damage & proliferation of endothelial cells • B. Haematological changes- rouleaux formation of RBC, increased platelets adhesiveness, abnormal serum lipids, abnormal VEGF, abnormalities in serum and whole blood viscosity. • Result-AV SHUNTS –capillary drop- out –IRMA & NEOVASCULIZATION at retina & optic disc -VEGF
Microvascular leakage • Microaneurysms-localized saccular outpouching of vessel wall.
Result a. Diffuse retinal odema –extensive capillary dilatation and leakage. b.Localized retinal odema -caused by focal leakage from microaneursyms and dilated cap. segments. Formation of hard exudates.
Microaneurysms
Retinal hemorrhages
Exudates
Cotton wool spots
Intraretinal microvascular abnormalities (IRMA)
Diabetic maculopathy & macular oedema
Abbreviated Early Treatment Diabetic Retinopathy Study (ETDRS)classification of diabetic retinopathy ( The modified Airlie House classification)
Clinically significant macular oedema (CSMO)
CLASSIFICATION Diabetic Macular Edema Findings Observable on Dilated Ophthalmoscopy No DME No retinal thickening or hard exudates in the macula Non central-involved DME Retinal thickening in the macula that does not involve the central subfield zone that is 1 mm in diameter Central-involved DME Retinal thickening in the macula that does involve the central subfield zone that is 1 mm in diameter
Re-examination & referral schedules Classification Re-examination Or next screening schedule Referral to Ophthalmologist No apparent DR, mild non- proliferative DR and no DME Re-examination in 1-2 year Referral not required Mild non-proliferative DR 6-12 months Referral not required Moderate non-proliferative DR 3-6 months Referral required Severe non-proliferative DR < 3-months Referral required PDR < 1 month Referral required Diabetic Macular Edema (DME) Classification Re-examination Or next screening schedule Referral to Ophthalmologist Noncentral-involved DME 3 months Referral required Central-involved DME 1 month Referral required
SCREENING FOR DR
Detailed ophthalmic assessment of DR • Initial Patient Assessment - complete ophthalmic examination, including visual acuity and the identification and grading of severity of DR and presence of DME for each eye
Detailed history • Duration of diabetes • Past glycemic control (hemoglobin A1c) • Medications (especially insulin oral hypoglycemics, antihypertensives, and lipid-lowering drugs) • Systemic history (e.g., renal disease, systemic hypertension, serum lipid levels, pregnancy) • Ocular history.
Initial physical examination • Visual acuity • Measurement of intraocular pressure (IOP) • Gonioscopy when indicated • Slit-lamp biomicroscopy • Fundus examination
Fundus examination • Two most sensitive methods for detecting DR are retinal photography and slit-lamp biomicroscopy through dilated pupils.
Ancillary Tests • OCT - Most sensitive method. Quantitative assessment of DME to determine the severity. • FA - To evaluate retinal non-perfusion area, presence of retinal neovascularization, and microaneurysms or macular capillary non- perfusion in DME.
Patient’s education • Discuss results. • Encourage patients without DR but with DM for annual eye screening. • Educate patients. • Communicate with the general physician. • Referrals for counseling, rehabilitative, or social services as appropriate.
Follow-up schedules Diabetic Retinopathy Severity Follow-up Schedule for management by ophthalmologists No apparent DR Re-examination in 1-2 years; This may not require re-examination by an ophthalmologist Mild nonproliferative DR 6-12 months; This may not require re-examination by an ophthalmologist Moderate nonproliferative DR 3-6 month Severe nonproliferative DR <3 months; Consider early pan-retinal photocoagulation. Proliferative DR <1 month; Consider pan-retinal photocoagulation. Stable (Treated) PDR 6-12 months Diabetic Macular Edema severity Follow-up Schedule for management by ophthalmologists Noncentral-involved DME 3-6 month; Consider focal laser photocoagulation Central-involved DME 1-3 month; Consider focal laser photocoagulation or anti- VEGF therapy Stable DME 3-6 month
Treatment of Diabetic Retinopathy • Optimize medical treatment : If HbA1c > 58 mmol/mol (>7.5%) • No DR, mild or moderate DR : Follow-up at regular interval • Severe NPDR : Consider early panretinal photocoagulation for patients at high risk of progression to PDR or poor compliance with follow-up. • PDR : Treat with PRP. Anti-VEGF injections.
Treatment for diabetic macular oedema • Optimize medical treatment • DME without central involvement : Observation • Central-involved DME and good visual acuity (better than 6/9) › careful follow-up with anti-VEGF treatment only for worsening DME; › Intravitreal anti- VEGF injections › laser photocoagulation with anti-VEGF, if necessary. • Central-involved DME and associated vision loss (6/9 or worse) :Intravitreal anti-VEGF treatment. • DME associated with PDR : Monotherapy with anti-VEGF, re-evaluation for need of PRP. • VM traction or ERM on OCT : PPV.
Treatment for diabetic macular oedema anti-VEGF • With 8-10 in the first year • 2 or 3 during the second year • 1 to 2 during the third year • and 0 to 1 in the fourth and fifth years of treatment • Persistent retinal thickening despite anti-VEGF therapy, consider laser treatment after 24 weeks.
Panretinal Photocoagulation (PRP) • Fully dilated pupil & topical anaesthesia. • Initial settings on the Argon laser would be 500 μm spot size, a 0.1 second exposure and 250-270 mw power. 1 burn apart. • 1600-3000 burns are placed in 1 or more sittings. • Burns are placed 2 to 3 disc diameters away from the center of the macula and 1 disc diameter away from the disc extending upto the equator & beyond. • Should not be applied over major retinal veins, preretinal hemorrhages, darkly pigmented chorioretinal scars, or within 1 DD of center of macula. • Favor quadrants with active new vessels or areas with intraretinal microvascular abnormalities.
Lenses for PRP Lens Field of Vision Axial magnification Spot magnification Spot Size Setting for ~500 um Mainster Wide-Field 125° 0.46 1.50x 300µm Volk TransEquator 120-125° 0.49 1.43x 300µm Volk Quad/Aspheric 130-135° 0.27 1.92x 200 to 300µm Mainster PRP 165 160° 0.27 1.96x 200 to 300 µm
Burn characteristics of PRP Size (on retina): 500 µm Exposure 0.05 to 0.1 seconds recommended. 0.02 or 0.03 seconds can be considered for use in High Resource Settings (in certain laser machines, where applicable). Intensity mild white (i.e. 2+ to 3+ burns) Distribution Mild and moderate PDR: Edges 1 burn width apart Severe PDR: Edges 0.5 to 0.75 burn width apart Number of sessions/sittings 1 to 3 Nasal proximity to disk No closer than 500 µm Temporal proximity to center No closer than 3000 µm Superior/inferior limit No further posterior than 1 burn within the temporal arcades Extent Arcades (~3000 µm from the macular center) to at least the equator
Burn characteristics of PRP Total number of burns 1200 – 1600 Guide for 20ms PRP and 100ms PRP: Mild PDR: 20ms PRP ETDRS laser 100ms 2400-3500 burns 1200-1800 burns Moderate PDR: 20ms PRP ETDRS laser 100ms 4000-5000 burns 2000-2500 burns Severe PDR: 20ms PRP ETDRS laser 100ms 5500-6000 burns 2000-2500 Wavelength Green or yellow (red can be used if vitreous hemorrhage is present)
PRP TECHNIQUE
Complications of PRP
Lasers in DME Focal direct laser treatment Directly treat all leaking microaneurysms in areas of retinal thickening between 500 and 3000 µm from the center of the macula (but not within 500 µm of disc). Change in microaneurysms color with direct treatment is not required, but at least a mild gray-white burn should be evident beneath all microaneurysms. Burn size 50-100 µm Burn duration 0.05 to 0.1 sec Wavelength Green to yellow wavelengths Grid laser treatment Applied to all areas with diffuse leakage or non-perfusion area. Treat the area 500 to 3000 µm superiorly, nasally and inferiorly from the center of the macula, and 500 to 3500 µm temporally from macular center. No burns are placed within 500 µm of disc. Aim barely visible (light gray) laser burn and each burn should be at least two visible burn widths apart. Burn size 50-100 µm Burn duration 0.05 to 0.1 sec Wavelength Green to yellow wavelengths
Indications for Vitrectomy • Severe vitreous hemorrhage of 1–3 months duration or longer that does not clear spontaneously. • Advanced active proliferative DR that persists despite extensive PRP. • Traction macular detachment of recent onset. Fovea-threatening or progressive macula-involving traction detachments benefit from surgical management. • Combined traction-rhegmatogenous retinal detachment. • Tractional macular edema or epiretinal membrane involving the macula.
Complications of Vitrectomy
Management of Diabetic Retinopathy in Special Circumstances Pregnancy • Informed on the need for assessment of DR before and during pregnancy. • Retinal assessment : First antenatal clinic appointment and again at 28 weeks if the first assessment is normal. • If any DR is present, additional retinal assessment should be performed at 16-20 weeks. • Should not be considered a contraindication to vaginal birth.
Management of Diabetic Retinopathy in Special Circumstances • Management of Cataract • Mild cataract - carefully assess DR status. Patients without vision loss with clear fundus view may not require cataract surgery. • Moderate cataract - carefully assess DR status. Attempt to treat any severe NPDR with laser PRP, and/or DME with focal/grid laser or anti-VEGF therapy, before cataract surgery. Once DR/DME is stable, consider cataract surgery to improve vision. • Severe to advanced cataract with poor fundus view - consider early cataract surgery followed by assessment and treatment as necessary. If DME is present, consider anti- VEGF before surgery, at the time of surgery, or after surgery if DME is discovered when the media is cleared.
Bibliography 1. Jack J Kanski, Brad Bowling, Clinical Ophthalmology, A Systemic Approach. 8th Edition. 2. International council of Ophthalmology . Guidelines for Diabetic eye care. Updated 2017. 3. Internet Sources.
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