| Management |
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| Diabetic Retinopathy |
| - Annie Mathai, Nihal Thomas |
Vellore, India
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Recommended eye examination schedule for patients with diabetes |
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Age of onset of diabetes mellitus (years) |
Recommended time of first examination |
Recommended follow-up |
| 0-29 |
5 years after onset |
Yearly |
| 30 and older |
At time of diagnosis
|
Yearly |
| Prior to pregnancy |
Prior to conception or early in first trimester |
No retinopathy
Mild-moderate
NPDR
Other stages :
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Every 3-12 months
Every 1-3 months |
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| Examination of Fundus, Role of Colour Fundus Photography and Fluorescein Angiography in the management of Diabetic Retinopathy. |
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| Examination of Fundus |
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| All fundus examinations should be done with dilated pupils. Pupils can be safely dilated with 1% tropicamide. Undilated fundus examination can overlook potentially treatable disease. |
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| Fundus photography complement the clinical examination and provides “hard-copy” documentation of the disease status. |
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| Fluorescein Angiography is used in the following situations : |
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- As a guide for treating clinically significant macular oedema.
- As a means of evaluating cause of unexplained decrease in visual acuity. Angiography can identify macular ischaemia.
- To identify subtle areas of neovascularisation.
- To differentiate between IRMA and neovascularisation.
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| Treatment strategies of diabetic retinopathy Medical |
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| The WESDR suggests that the impact of tight glycaemic control on retinal disease is greater in type 1 thatn in type 2 diabetes mellitus. Nevertheless, all efforts to maintain tight glycaemic control in such patients are imperative. |
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| Clinically significant Macular Edeme (CSME): This can occur with either NPDR or PDR |
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| Newer interventions like protease kinase inhibitor12, VEGF inhibitors and vitamin E are under evaluation to prevent the progression of diabetic retinopathy. Octreotide may induce improvement of diabetic retinopathy by virtue of growth hormone suppression, however, it is an expensive medication and could induce worsening of hyperglycaemia in a subset of patients. Erythropoietin therapy in patients with chronic renal failure is associated with a regression of hard exudates and improvement in visual acuity that corresponds to arise in haematocrit in these patients13. |
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| Ophthalmologic14 |
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- Macular laser : Helps by clearing macular oedema and maintains or often improves visual acuity.
- Pan retinal photocoagulation (PRP) :This involves giving laser to a large area of the retina except the posterior pole. It works by converting hypoxic retina into anoxic retina and thus eliminates the vasogenic stimuli that promote neovascularisation. Laser often stabilizes vision and prevents further deterioration.
- Vitrectomy : Indications
Non-clearing vitreous haemorrhage.
Tractional retinal detachment involving the macula.
Combined tractional-rhegmatogenous retinal detachment.
Rubeosis irides with vitreous haemorrhage.
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When should a diabetic patient be referred to an opthalmologist? |
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- Decreased visual acuity or presence of any visual symptoms.
- Moderate to severe NPDR.
- Macular oedema.
- Proliferative diabetic retinopathy.
- Presence of any risk factors like nephropathy, pregnancy etc.
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| Conclusion |
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| Diabetic retinopathy has useful and cost-effective screening methods and treatment. Screening detect asymptomatic treatable conditions. It is important to remember that visual acuity may be decreased only in very advanced retinopathy, therefore visual acuity is not an indicator of the severity of the disease. Timely treatment can help preserve visual acuity; thus emphasizing the importance of screening. |
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Management of patients with diabetic retinopathy |
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Level of retinopathy |
Fluorescein angiography
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Macular Laser
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Pan retinal photocoagulation
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Follow up (months)
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Mild NPDR
No macular oedema
Macular oedema
CSME
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No
Occasionally
Yes
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No
No
Yes
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No
No
No
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12
4-6
2-4
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Moderate NPDR
No macular oedema
Macular oedema
CSME
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No
Occasionally
Yes
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No
No
Yes
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No
No
No
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6-8
4-6
2-4
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Severe NPDR
No macular oedema
Macular oedema
CSME
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No
Occasionally
Yes
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No
Occasionally
Yes
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Rarely
Occasionally after focal
Occasionally after focal
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3-4
2-3
2-3
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Very severe NPDR
No macular oedema
Macular oedema
CSME
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No
Occasionally
Yes
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No
Occasionally
Yes
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Occasionally
Occasionally after focal
Occasionally after focal
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2-3
2-3
2-3
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Non high risk PDR
No macular oedema
Macular oedema
CSME
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No
Occasionally
Yes
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No
Occasionally
Yes
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Yes
Yes
Yes
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2-3
2-3
2-3
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High risk PDR
No macular oedema
Macular oedema
CSME
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No
Occasionally
Yes
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No
Occasionally
Yes
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Yes
Yes
Yes
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2-3
1-2
1-2
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| Regular dilated fundus examination and timely referral to the opthalmologist can prevent severe visual loss in diabetic patients. Thus, the primary care physician together with the opthalmologist have a major responsibility in improving the quality of life in diabetics. |
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| References |
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- Klein R, Klein BEK, Moss SE, et al. The Wisconsin Epidemiologic study of Diabetic Retinopathy:III. Prevalence and risk of retinopathy when the age of diagnosis in 20 years or more. Archives Ophthalmol. 1984:102:527-532.
- Klein R, Klein BEK, Moss Se, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy : II. Prevalence and risk of retinopathy when the age of diagnosis is less than 30 years. Archives Opthalmol. 1984; 102:520-526.
- The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N. Engl. J. Med. 1993;329:977-896.
- Klein R, Palta M, Allen C, et al. Incidence of retinopathy and associated risk factors from time of diagnosis of insulin dependent diabetes. Arch. Ophthalmol. 1997;115:351-356.
- Lloyd CE, Klein R, Maser RE, et al. The progression of retinopathy over 2 years: The Pittsburgh Epidemiology of Diabetes Complications (EDC) Study. J. Diabetes Complications 1995;9:140-148.
- Chew EY, Klein ML, Ferris FL II, et al. Association of elevated serum lipid levels with retinal hard exudates in diabetic retinopathy. Early Treatment Diabetic Retinopathy Study (ETDRS) Report 22. Arch. Ophthalmol. 1996;114:1079-1084.
- Parving HH, Hommel E, Mathiesen Em et al. Prevalence of microalbuminuria, arterial hyperternsion, retinopathy and neuropathy in patients with insulin dependent diabetes. Br.Med J. 1998;296:156-160.
- Kikkawa R, Haneda M, Togawa M, et al. Microalbuminuria associated with a rise in blood pressure in non-insulin dependent diabetes. J. Diabetes Complications 1989;3:99-102.
- Klein BE, Moss SE and Klein R. Effect of pregnancy on progression of diabetic retinopathy. Diabetes Care 1988;11:745-746.
- Axer-Seigel R, Hod M and Fink-Cohen S, et al. Diabetic retinopathy during pregnancy. Ophthalmology 1996;103:1815-1819.
- Nelson RG, Wolfe JA, Horton MB, et al. Proliferative retinopathy in NIDDM: Incidence and risk factors in Pima Indians. Diabetes 1989;38:435-440.
- Murphy M, McGinty A and Godson C. Protien Kinase C: Potential targets for intervention in diabetic nephropathy. Curr. Opin. Nephrol. Hypertens. 1998;7:5, 563-570
- Berman DH and Friendman EA. Partial absorption of hard exudates in patients with diabetic end-stage renal disease and severe anemia after treatment with erythroproietin. Retina 1994;14(1):1-5.
- Murphy RP. Management of diabetic retinopathy. Am. Fam. Physician 1995;51:785-796.
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