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Eye Disease > Diabetic Eye Disease: Clinical Features and Classification > Flashcards

Diabetic Eye Disease: Clinical Features and Classification Flashcards

1
Q

state the four types of diabetes

A

-type 1
-type 2
-maturity onset diabetes of the young (MODY)
-gestational diabetes

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2
Q

what type of diabetes is MODY similar to?

A

type 2- although NOT linked to obesity- occurs before 25 yo and required insulin injections

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3
Q

what is type 1 diabetes mellitus?

A

-body unable to produce insulin
-more common in childhood
- genetic risk prevalence

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4
Q

what is risk (%) to child if mother has DM?

A

2%

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5
Q

what type of cells are destroyed in type 1 DM?

A

pancreatic beta cells

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6
Q

what is risk (%) to child if father has DM?

A

8%

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7
Q

what is Type 2 DM?

A

Insulin resistance OR bodys inability to produce enough insulin

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8
Q

how can DM T2 be controlled?

A

-diet
-excercise
-tablets
-insulin

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9
Q

what are risk factors of Type 2 DM?

A

-Age
-smoking
-obesity
-lack of physical activity

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10
Q

can race be a risk factor of Type 2 DM?

A

yes
around ~6x in South Asian & ~3x in Afro-Caribbean people compared to Caucasian.

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11
Q

risk if 1 PARENT has T2 DM?

A

Risk ~15% if 1 parent has type II

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12
Q

does risk of T2 DM increase if both parents have it?

A

yes ~75% if both have.

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13
Q

list the 7 eye conditions associated with diabetes

A

-rubeoses iridis
-cataract-PSC
-OM-diplopia- can be underlying cause of 3rd, 4th or 6th nerve palsies
-corneal erosions- ulcers ,persistent epithelial defets
-diab retinopathy
-AION
-CRVO/CRAO

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14
Q

What are the two types of diabetic eye disease and where do they occur on the fundus?

A

can be diabetic retinopathy (peripheral) or maculopathy (macula)

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15
Q

the presence of what molecule in the blood gives an indication of how well controlled diabetes is?

A

HbA1C- higher levels mean diabetes is less well controlled

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16
Q

what other vascular condition can also be a risk factor for DR?

A

hypertension

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17
Q

name two sight threatening forms of DR?

A

-Proliferative DR
-Macula oedema

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18
Q

What is non-proleferative DR

A

no formation of new blood vessels

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19
Q

what is proliferative DR?

A

Formation of new blood vessels

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20
Q

list 5 signs of DR that can cause sight loss

A

-macula oedema and exudates
-macular ischaemia
-fibrous tissue formation= new bvs
–vitreous haemorrhages as result of new bvs
-ret detachment

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21
Q

how are exudates formed in DR?

A

due to leakage of fluid and lipoproteins from bvs

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22
Q

what 5 factors affect the risk of getting DR and the risk of its progression?

A
  • how long px has had DM- longer means higher risk
  • Control of DM-poor control= high risk
  • Type of diab-type 1 has higher risk
  • HTN
  • high cholesterol- covered in another flashcard
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23
Q

why does having high levels of cholesterol link to risk of DR?

A

as this can cause exudates

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24
Q

what is the screening programme for DR called?

A

NHS diab eye screening programme

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25
Q

how old should a diabetic patient be to be registered on the NHS diab screening programme?

A

12 years old

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26
Q

is DR graded based off the appearance of the fundus or vision?

A

appearance of fundus

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27
Q

what are the 4 grading classifications of DR and what are they called and how do we refer them?

A

-R0- no retinopathy present
-R1-background DR (no referral required)
-R2- pre prolif - refer to Ophthalmology
-R3-proliferative retinopathy (urgent referral)

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28
Q

what are the features of R1 DR?

A

-Microaneurysms
-ret haemmorhages - not within definition of R2
-exudates- in absence of r2 feautures
-venous loops- in absence of R2 features
-cotton wool spots- in presence of other R1 Features

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29
Q

What are features of R2 DR?

A

-multiple blot haem
-venous beading
-venous reduplication (?)
-Intra-retinal microvascular abnormality (IRMA)

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30
Q

What are feautures of R3 DR?

A
  • NVD- new vessels on disc
    -NVE- new vessels elsewhere
    -pre-retinal/vitreous haem
    -pre retinal fibrosis and tractional ret detachment
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31
Q

would a single Cotton wool spot be a feature of DR?

A

No- it would be classed as no retinopathy R0

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32
Q

Would other eye conditions such as CRVO be a feature of DR?

A

No- would be classed as no retinopath R0

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33
Q

Would a single microaneurysm be a feature of DR?

A

YES- characteristic of R1 DR

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34
Q

What are microanuerysms described as, their size and where are they usually found?

A

dark red spots, sharp border, < 125μm in diameter,
-usually temporal to macula

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35
Q

where are microaneurysms located in the retina?

A

found in inner nuclear layer

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36
Q

where are dot haemmorhages found in the retina?

A

inner plexiform layer

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37
Q

are dot haemmorhages larger or smaller than microaneurysms ?

A

larger

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38
Q

are dot haemmorhages larger or smaller than blot haemorrhages?

A

smaller

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39
Q

are microaneurysms easy to differentiate from dot haem?

A

not using ophthalmoscpy or fundus - easier with oct?

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40
Q

where are blot haem located?

A

deeper between IPL and INL

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41
Q

what can the appearance of blot haem be an indication of?

A

local ischaemia

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42
Q

are blot haem a feature of R1 or R2?

A

BOTH- if only a few R1 if multiple (8-10) can be R2

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43
Q

Where are flame shaped haem found?

A

in nerve fibre layer

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44
Q

why are flame shaped haem flame shaped?

A

as they follow the path of the retinal nerve fibres

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45
Q

what 3 other eye conditions are flame shaped haem found in?

A

-systemic HT
-glauc
-vein occlusion

46
Q

where do the exudates leak out from?

A

capillaries in the outer plexiform and inner plexiform layer usualy oedema

47
Q

what is oedema and how does it present on the fundus ?

A

accumulation of fluid in the retina- can appear as cysts or greyish

48
Q

how is oedema best detected?

A

oct

49
Q

what are cotton wool spot and where are they found

A

fluffy white lesions found in RNFL

50
Q

why do cotton wool spots occur?

A

focal or diffuse inner retinal ischaemia disrupting RNFL axonal transport

51
Q

are cotton wool spots commonly found in the thickets or thinnest part of retina?

A

thickest- eg posterior pole

52
Q

is venous looping a feature of R2?

A

NO- has recently been moved to R1- but do check for other identifiable R2 features as then would be classed as R2

53
Q

what does Acronym HOME stand for in R1 DR?

A

Haemmorhages
Oedema
Microaneurysms
Exudates

54
Q

what are the 3 distinct feautures of R2?

A

-IRMA
-multiple blot haem
-venous beading

55
Q

do we refer pxs with suspect R2 DR?

A

yes

56
Q

what is IRMA an indication of?

A

Retinal ischaemia

57
Q

what is IRMA

A

Dilated capillaries that ‘mimic’ new bvs- IRMA vessels DON’T leak

58
Q

do IRMA vessles cross over major vessels?

A

NO- cross over each other

59
Q

what is another possible mechanism for formation of IRMA?

A

variant of colalteral formation - can be seen with localised arteriolar occlusion and cotton wool spots

60
Q

MOST RELIABLE SIGN OF SEVERE ISCHAEMIA?

A

venous changes

61
Q

what are some (4) features of venous changes?

A

segmented, beading and dilated vessels- can have vessel occlusion also, variable calibre

62
Q

What are the 4 main fratures of R3- Prolif Retinopathy?

A

New vessels on disc (NVD)
New vessels elsewhere (NVE)
Pre-retinal or vitreous haemorrhages
Pre-retinal fibrosis ± tractional retinal detachment

63
Q

what does fibrosis look like on a fundus?

A

appears white sort of like myelination

64
Q

what stimulates the activation of growth of new vessels

A

VEGF

65
Q

Why is the growth of new vessels an important indication in R3?

A

new vessels (growth looks blossom like on fundus) tend to be very fragile and can leak and bleed as they grow ON and not IN retina.
-Can also loop back on themselves and widen in diameter

66
Q

do new vessels cross over major arteries and veins?

A

YES- differentiation between these and IRMA (which don’t)

67
Q

name another differentiation of new vessles vs IRMA

A

Obscure underlying lesions therefore on top of retina, not within it (unlike IRMA)

68
Q

What can be the result when new vessels eventually grow in vitreous and why might this require an urgent referral?

A

vitreous haemmorhages THAT CAN CAUSE TRACTION (PULLING) and eventually result in ret detachment

69
Q

as R3 DR has inner retinal growth of new vessles, which other main eye condition has CHOROIDAL neovasc?

A

Wet AMD

70
Q

how do we characterise Neovasc at the Disc?

A

new vessels on or within 1DD from the optic nerve head

71
Q

what is the percentage risk of sight loss if NVD is left untreated for 5 years?

A

50 %

72
Q

what can also be accompanied with NVD?

A

Neovasc elsewhere on fundus (NVE)

73
Q

How can we differentiate between NVE and IRMA?

A

NVE appears more wispy and is often temporal to macula but can also be nasal

74
Q

what is the risk of blindess if NVE is left untreated for 5 years?

A

30%

75
Q

wat can be a symptom patient may complain of in pre-retinal/vitreous haem?

A

px may complain of sudden visual loss or sudden onset of dark floaters - can block or obscure our view of retina

76
Q

does vit haem have a good or poor prognosis?

A

generally poor- may take months or years to resolve if erythrocytes break into vitreous body. Can lead to risk of 30% blindness if left untreated

77
Q

what surgery can be done f itr haem unresolved for longer than 6 months?

A

Vitrectomy carried out if unresolved in 6 months. - t o compeltely remove vitreous

78
Q

what else can cause the vitreous haemmorhages?

A

age- vitreous shrinking leading them to rupture easily

79
Q

why do Pre-retinal haemorrhages have a flat top?
NB not all of them have a flat top

A

because the red cells settle down due to gravity- if px sits upright?

80
Q

how can vit haem lead to a ret detachment?

A

Contraction of fibrous tissue can pull retina to cause tractional retinal detachment (TRD).

81
Q

what surgery can be done to prevent tractional retinal detachment?

A

vitrectomy

82
Q

how does the retina look during tractional ret detachment?

A

The retina may appear wrinkled (traction lines) or thrown into bumps and folds, sometimes with a visible tear. : because the fibrous tissue contracts and pulls on the retina

83
Q

what is rubeoses irides and when can this occur?

A

occurs in prolif DR- new vessel growth on iris or ange in severe ret hypoxia

84
Q

can rubeoses irides result in glauc and if so, why?

A

Can lead to neovascular glaucoma due to fibrovascular tissue blocking angle of drainage. - hence increase in iops

85
Q

signs and symptoms of rubeosis irdes?

A

Vessels and diffuse reddening of the iris may be seen. Patients may complain that the eye is often extremely painful

86
Q

what is R3S?

A

Stable diabetic proliferative retinopathy- evidence of peripheral retinal laser treatment AS WELL AS a fundus photo showing a stable retina at or after a short period of time after the one taken in HES- basically compare the 2 pics

87
Q

what is the DESP classification of Maculopathy?

A

M0-no maculopathy
M1-maculopathy (requires referral)

88
Q

do we classify maculopathy based off appearance of fundus and vision?

A

both

89
Q

what are features of M0?

A

Non-referable maculopathy (MAs or haems within 1DD of fovea but vision better than 0.3 LogMAR/ Snellen 6/12)

90
Q

WHAT ARE FEATURES OF M1?

A
  • Exudate within 1 disc diameter of the centre of the fovea
  • Circinate or group of exudates within the macula
  • Retinal thickening within 1 DD of the centre of the fovea
  • Any microaneurysm or haemorrhage within 1 DD of the centre of the fovea ONLY if associated with VA worse than Snellen 6/12 or 0.3 logMAR
91
Q

do we treat maculopathy?

A

yes, if there’s Clinically Significant Macular Oedema (CSMO)

92
Q

what category of maculopathy do exudates or haemorrhages within 1DD (and vision <6/12) fall into?

A

M1- referable Maculopathy

93
Q

do we find exudates in M1?

A

YES- can have group of exudates larger than ½ disc area in macula
- can be associated with oedema
-May find accompanying aneurysms (source of leak)

94
Q

what happens to the retina in macular oedema?

A

it thickens

95
Q

what is the P classification in DR?

A

Photocoagulation scars- can be P0 or P1

96
Q

What is P0?

A

no photocoagulation (laser scars)

97
Q

what is P1?

A

Presence of photocoagulation scars:
Evidence of focal/ grid laser to macula
Evidence of peripheral scatter laser

98
Q

HOW DE WE MANAGE R1?

A

Annual review by Optometrist / screening service

99
Q

how do we manage R2 OR M1?

A

Refer to HES
To be seen soon (within 4 weeks)

100
Q

How do we manage a px with jnew vessel formation?

A

Refer to HES
To be seen urgently (within 1 week)

101
Q

how do we manage a px with:
Sudden loss of vision
Evidence of retinal detachment
Pre-retinal/ vitreous haemorrhage
Rubeosis iridis

A

EMERGENCY- refer to HES

102
Q

How do we manage P1?

A

Post treatment: annual review
Refer to HES: if not recorded before

103
Q

TRUE OR FALSE-if have M1 then automatically have R1

A

True- as features seen in M1 are in classification of R1 (provided vidion worse than 6/12)

104
Q

TRUE OR FALSE-if have M1 then automatically have R1

A

True- as features seen in M1 are in classification of R1 (provided vidion worse than 6/12)

105
Q

what is this ?

A

NVD

106
Q

what is this?

A

NVE

107
Q

what is this?

A

pre-retinal haem

108
Q

what is this?

A

vitreous haem

109
Q

what is this?

A

IRMA

110
Q

grade this

A

R2 - multiple blot haem in all 4 quads

111
Q

what is this and what grade is it?

A

looping - R1

112
Q

grade this

A

R1M1

Eye Disease (48 decks)

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