Vascular Disorders 1231 Diabetic Retinopathy Definition

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Diabetic retinopathy is an ocular microangiopathy.

Epidemiology: Diabetic retinopathy is one of the main causes of acquired blindness in the industrialized countries. Approximately 90% of all diabetic patients have retinopathy after twenty years.

Pathogenesis and individual stages of diabetic retinopathy: Diabetes mel-litus can lead to changes in almost every ocular tissue. These include symptoms of keratoconjunctivitis sicca, xanthelasma, mycotic orbital infections, transitory refractory changes, cataract, glaucoma, neuropathy of the optic nerve, oculomotor palsy. However, 90% of all visual impairments in diabetic patients are caused by diabetic retinopathy. The most common international nomenclature used to describe the various changes in diabetic retinopathy

(Table 12.1) is based on the classification of the Diabetic Retinopathy Study. A distinction is made between nonproliferative stages (1. mild, 2. moderate, 3. severe; Fig. 12.14) and proliferative stages (1. non-high-risk 2. high-risk; Fig. 12.15-12.17).

Table 12.1 Changes in diabetic retinopathy

Stage of retinopathy Retinal changes

Nonproliferative diabetic retinopathy

Proliferative diabetic retinopathy

❖ Microaneurysms.

❖ Intraretinal hemorrhages

❖ Lipid deposits in the retina (hard exudates)

❖ Retinal edema

❖ Venous beading

❖ Excessive hemorrhages

❖ Cotton-wool spots (nerve fiber infarctions with soft exudates)

❖ Intraretinal microvascular anomalies

❖ Preretinal neovascularization

❖ Vitreous hemorrhage

❖ Tractional retinal detachment (due to traction of vitreous scarring)

❖ Rubeosis iridis (neovascularization of the iris that can occlude the angle of the anterior chamber; this entails the risk of acute secondary angle closure glaucoma)

Moderate nonproliferative diabetic retinopathy.

Moderate nonproliferative diabetic retinopathy.

Exudates Eye
Fig. 12.14 Microaneurysms, intraretinal hemorrhages, hard exudates (arrow), and cotton-wool spots (arrowheads).

316 12 Retina Proliferative diabetic retinopathy.

316 12 Retina Proliferative diabetic retinopathy.

Vitreous Exudates

Fig. 12.15 a Preretinal neovascularization (arrows) is a typical sign.

b Corresponding angiographic image. Fluorescein dye leakage is seen in the neovascularized area (arrows).

Fig. 12.15 a Preretinal neovascularization (arrows) is a typical sign.

b Corresponding angiographic image. Fluorescein dye leakage is seen in the neovascularized area (arrows).

Symptoms: Diabetic retinopathy remains asymptomatic for a long time. Only in the late stages with macular involvement or vitreous hemorrhage will the patient notice visual impairment or suddenly go blind.

Diagnostic considerations: Diabetic retinopathy and its various stages (see Table 12.1) are diagnosed by stereoscopic examination of the fundus with the pupil dilated. Ophthalmoscopy and evaluation of stereoscopic fundus photographs represent the gold standard. Fluorescein angiography is used to determine if laser treatment is indicated. The presence of rubeosis iridis is confirmed or excluded in slit-lamp examination with a mobile pupil, i.e., without the use of a mydriatic, and by gonioscopy of the angle of the anterior chamber.

— High-risk proliferative diabetic retinopathy.

— High-risk proliferative diabetic retinopathy.

Determining Patient Acuity

Fig. 12.16 The clearly visible vitreous hemor rhage seen here (arrow) is a typical sign of this stage of diabetic retinopathy. The patient will only notice deterioration of vision in this later stage.

Fig. 12.16 The clearly visible vitreous hemor rhage seen here (arrow) is a typical sign of this stage of diabetic retinopathy. The patient will only notice deterioration of vision in this later stage.

Differential diagnosis: A differential diagnosis must exclude other vascular retinal diseases, primarily hypertonic changes of the fundus (this is done by excluding the underlying disorder).

Treatment: Clinically significant macular edema, i.e., macular edema that threatens vision, is managed with focal laser treatment at the posterior pole. Proliferative diabetic retinopathy is treated with scatter photocoagulation performed in three to five sessions.

Prophylaxis: Failure to perform regular ophthalmologic screening examinations in patients with diabetes mellitus is a negligent omission that exposes patients to the risk of blindness. Therefore, all type II diabetics should undergo ophthalmologic examination upon diagnosis of the disorder, and type I diabetics should undergo ophthalmologic examination within five years of the diagnosis. Thereafter, diabetic patients should undergo ophthalmologic examination once a year, or more often if diabetic retinopathy is present. Pregnant patients should be examined once every trimester.

Clinical course and prognosis: Optimum control of blood glucose can prevent or delay retinopathy. However, diabetic retinopathy can occur despite optimum therapy. Rubeosis iridis (neovascularization in the iris) in proliferative diabetic retinopathy is tantamount to loss of the eye as rubeosis iridis is a relentless and irreversible process.

H The risk of blindness due to diabetic retinopathy can be reduced by optimum control of blood glucose, regular ophthalmologic examination, and timely therapy, but it cannot be completely eliminated.

318 12 Retina Proliferative diabetic retinopathy before and after laser treatment.

318 12 Retina Proliferative diabetic retinopathy before and after laser treatment.

Clinically Significant Macular Edema
Fig. 12.17 a Proliferative diabetic retinopathy with clinically significant macular edema before laser therapy.
Acute Retinal Syndrome
b Findings after successful laser treatment (laser burns appear whitish brown).

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