Diabetic Retinopathy

Primary Examination of a Diabetic RetinaPhilip Anderton BOptom PhD

Visiting OptometristManilla Health ServiceHNEAHSPrimary Examination of a Diabetic EyeConfirm regular general diabetic program and Blood Glucose monitoring/controlBest corrected visual acuityNeeds refraction to ddx refractive error vs Clinically Significant Macula Edema (CSME)Intraocular pressuresand assess other risk factors for glaucomaDilated fundus examinationNon-Proliferative Diabetic Retinopathy (NPDR)Proliferative Diabetic Retinopathy (PDR)CSMEReport to GP and diabetes team10915 Medicare Schedule Item

NHMRC Guidelines (2008)Direct Ophthalmoscopy vsSlit-lamp biomicroscopy

Fundus Camera

Ophthalmoscopy or Retinal Camera ?OphthalmoscopyPupil Dilation is ESSENTIALMydriacyl 0.5% or 1.0%; Phenylephrine 1.0%

Direct Ophthalmoscopysmall field of vision, high magnification good for macula and optic disc but difficult to explore complete retina and no stereo viewStereoscopic Biomicroscopy (Indirect) slit-lamp microscope and 78D or 90D lens is the GOLD STANDARD (NH&MRC Guidelines, 2008)

Retinal cameraNon-Mydriatic Digital Retinal Cameramuch better than no retinal examination at allreveals overt macula and disc problems (central 45 deg)misses peripheral problems and mild/early macula edemaolder eyes have small pupils and hazy lenses

What are we looking for?Microvascular pathology in the central retinal vesselsNon-Proliferative Diabetic Retinopathy (NPDR)Capillary aneurism microaneurism (Ma)Capillary anomalies - Intraretinal microvascular anomalies (IRMA)Capillary leakDiabetic macular oedema and exudate (Clinically Significant Macula Edema - CSME)Ischemic neuropathy ganglion cell axons (Cotton wool spots - CWS)Intraretinal bleeding haemorrhageVenous beading (VB)Proliferative Diabetic Retinopathy (PDR)NeovascularizationFragile new vessels proliferating over the retinal surfaceEarly PDR is treatable with laser oblationLate PDR is potentially blinding with poor treatment optionsOther ocular signs of diabetes and ischemic pathologyDiabetic cataract

Neovascularisation of the irisIris rubeosisneovascular glaucoma

Normal Retina (Camera)

Case Study(from Quynh Lam, Tamworth Optometrist)20 yo male, Type 1 IDDM 5 years diagnosedMedication-Actrapid penfillCoversylGlucagon and ProtaphaneBest corrected VAR: 6/7.5L: 6/15 **Non-Proliferative Diabetic Retinopathy

High Magnification Ma, CSME

The other eye CSME, Ma, IRMA?

Fluorescein angiogram Ma 22s

Fluorescein angiogram - leakage

Minimal NPDR single dot haem

IRMA

Venous beading, haems, IRMA, CWS, CSME

Progression of Diabetic RetinopathyNo apparent retinopathyMild NPDRMa onlyModerate NPDRMore than just Ma but less than severe NPDRSevere NPDRMore than 20 intraretinal haems in each of 4 quadrants, definite venous beading in 2 or more quadrants, prominent IRMA in one or more quadrant and no sign of PDRPDRNeovascularizationNeovascularization and vitreous preretinal haems

Proliferative Diabetic Retinopathy - PDR

PDR - fibrosis

Vitreal Haemorrhage

End stage PDR a blind eye

NHMRC Guidelines (2008)For every diabeticIf no known retinal pathology, examine every 24 monthsIf mild (background, NPDR) retinal pathology, examine every 12 months, refer as appropriateIf PDR and/or CSME, refer for assessment and treatmentTreatment options Retinal/ macula LaserIntravitreal anti-VEGF injections