糖尿病视网膜病（全英）课件

DIABETIC RETINOPATHY Prof. Raj Vardhan Azad Diabetes: Global Perspective Diabetes Challenges Total no of people with diabetes is projected to rise 171 million 2000 to 366 million in 2030 DR is the 3rd leading cause of visual impairment among inner city Adults 40 yrs of age. Biochemical mechanisms Capillaropathy Haematological changes Microvascular occlusion PATHOGENESIS DR 糖尿病视网膜病的发病机理 ANGIOGENIC FACTORS Hypoxia VEGF BRB breakdown And new vessel formation 组织缺氧 血管内皮细胞生长因子数量上升 视网膜屏障与新生血管形成 CLINICAL FEATURES 临床特征 Microaneurysms 微动脉瘤 Hemorrhages 眼底出血 Soft Exudates 血管软性渗出 Venous Caliber Alterations 静脉管径改变 Intraretinal Microvascular abnormalites 视网膜微血管异常 New Vessels 新生血管的出现 Macular Edema 黄斑水肿 Microaneurysms 微动脉瘤的形成 Sorbitol And Free Radical Accumulation Destruction Of Pericytes Microaneurysm 山梨糖醇与游离基的聚集 外膜细胞受到破坏 微动脉瘤形成 Hemorrhages 眼底出血的形成 Dot and Blot They occur in deeper capillary plexus and spread antero- posteriorly like a cylinder New Vessels Budding endothelial tubules from venous end of the capillary bed NVE Neovascularisation elsewhere NVD Neovascularisation of the disc Macular Edema FocalDiffuse ETDRS Classification NPDR Mild Moderate Severe Very Severe PDR Without HRC With HRC Advanced Macular Edema CSME Microaneurysms Mild to moderate Intra-retinal haemorrhages in 4 quads Hard exudates Macular oedema Foveal avascular zone abnormalities Cotton-wool spots Intraretinal haemorrhages in 4 quadrant Venous beading IRMA Severe intraretinal hemorrhages in 4 quadrants Venous beading in 2 quadrants Moderately severe IRMA in 1 quadrant “4-2-1 Rule” Severe NPDR: Any 1 of the above Very Severe NPDR: Any 2 of the above NVD NVE Preretinal hemorrhages Vitreous hemorrhages Tractional retinal detachment NVI / NVA /or both NVD atleast -1/3 disc area in extent NVD with preretinal or vitreous hemorrhage NVE atleast disc areas in extent & associated with pre- retinal or vitreous hemorrhage. Investigations Visual Acuity and Refraction Slit Lamp Slit Lamp Biomicroscopy with +90D lens Indirect Ophthalmoscopy Fundus Flourescein Angiography(FFA) Optical Coherence Tomography FFA in DR Always on first visit Clinical Suspicion Confirm and document Type/ Location etc Treatment And on Follow-up: For activity To confirm resolution Disease worsening/ complications FFA in DR No DR Diffuse Diabetic Macular Edema FFA in DR Ischemic ME NVE suspicion in IRMA OCT Types SPONGY THICK HYALOID CYSTOID VMT Current treatment approach Medical treatment Tight control of blood sugar/ blood pressure Controlling hyperlipidaemia/ renal status/ anaemia Laser treatment Conventional laser Laser indirect ophthalmoscope delivery Pascal Intravitreal injections Intravitreal steroid injection Posterior sub-tenon steroid injection Intravitreal anti-VEGF agents Surgical intervention Intravitreal steroid implants Pars plana vitreous surgery Current Treatment Protocol Systemic Control Screening Non Proliferative Diabetic Retinopathy Follow-up Treatment consideration for severe NPDR especially with other risk factors with PRP Macular Oedema Identify CSME FFA/ OCT (R/O Ischemia) Laser (Focal/ Grid) Pharmacological (Steroid/ AntiVEGF) Proliferative Diabetic Retinopathy Identify HRC Laser (Pan retinal photocoagulation) Identify indications for Surgery Pars Plana Vitrectomy Surgical Approach Posterior Hyaloid Separation Complete Partial Significant separation Narrow s