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0V2022 Introduction to eye diseases > Diabetic retinopathy > Flashcards

Diabetic retinopathy Flashcards

1
Q

What is diabetes?

A

disease of the small blood vessels I,e microvascular disease

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2
Q

Where does the earliest change of diabetic retinopathy occur ?

A

in capillaries

-whereby we have capillary close and pericyte loss and capillary drop out

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3
Q

What are the signs we can see of diabetic retinopathy when looking at the fundus ?

A

microaneurysms - dot and blot

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4
Q

What are the complications that arise ?

A

through ischaemia

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5
Q

How is diabetic retinopathy classified ?

A

according to where the changes are seen at the back of the eye

  • they can be at the macula or beyond macula
  • at the macula: maculopathy
  • beyond the macula: diabetic retinopathy
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6
Q

What is diabetic retinopathy given ?

A

given R grade depending on severity

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7
Q

What are the features of diabetic maculopathy ?

A
  • Are any microaneurysm or haemorrhage within 1DD (DISC DIAMETER) of centre of fovea BUT only if associated with VA worse than ≤ 6/12
  • look at fundus , focus on macula- will see several dot haemorrhages

-Exudate (yellow specks) within 1DD of fovea
Circinate or group of exudates within macula

-Retinal thickening within 1DD of centre of fovea- elevation in the centre of the back of the eye

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8
Q

What grade is diabetic maculopathy given ?

A

given grade M1

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9
Q

What do you grade the diabetic eye If none of the changes are present ?

A

M0 = absence of any M1 features

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10
Q

IF you see the exudate sitting within the retina - where is that location called ?

A

intra retinal

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11
Q

What can macular oedema (Retinal thickening )be picked up by ?

A

OCT

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12
Q

What do you see in OCT of macular oedema ?

A
  • fovea lost the foveal dip

- see cystic spaces sitting within the retina

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13
Q

What causes macular oedema ?

A

Capillary closure (ischaemia) leads to accumulation of:

  • extracellular oedema: fluid from damaged outer blood-retina barrier
  • intracellular oedema: fluid accumulating within individual retinal cells as a result of hypoxia
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14
Q

What does macular oedema cause ?

A

VA will be reduced

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15
Q

What are the different features of diabetic retinopathy ?

A

-which affects the fundus outside or beyond the area of macula

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16
Q

What grade do we give if there are no changes at the back of the eye?

A

R0= No DR ( diabetic retinopathy)

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17
Q

What do we give background diabetic retinopathy grade?

A

R1
-HAVE MICROANEURYSMS
and small retinal haemorrhages

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18
Q

What is the management of R0 AND R1?

A
  • Routine Diabetes care

- annual screening

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19
Q

How do you differentiate between different types of haemorrhages ?

A

dot and blot- tend to be intra retinal- small and round in shape
-flame haemorrhages occur in the retinal nerve fibre layer- take shape of a flame as they follow the pattern of the RFNL

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20
Q

What are the 2 ways to distinguish haemorrhages ?

A
  1. look at the actual shape of haemorrage

2. consider where it is occurring within the retinal layers

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21
Q

What are pre proliferative changes classified as in diabetic retinopathy ?

A

R2

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22
Q

What are the clinical features you see in the fundus for R2 ?

A
  • Venous looping, beading or reduplication- blood vessel take different shape
  • Intra Retinal Microvascular Abnormality (IRMA) - small changes occurring between connections of different blood vessels
  • Multiple deep, round/blot haemorrhages-
  • Cotton Wool Spots (CWS)
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23
Q

What is the management of this type of diabetes (R2) ?

A
  • Management of diabetes

- Opthalmogocal monitoring

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24
Q

What does Venous looping represent?

A
  • foci of venous endothelial cell proliferation that have failed to develop into new vessels
25
Q

Where does venous beading occur in ?

A
  • sausaging
  • occurs in areas of extensive capillary closure
  • venous length appears segmented- looks like a little chain of beads
26
Q

What is IRMA caused by ?

A
  • Extensive closure of capillaries between arteriole and venule which leads to dilated capillary remnants.
  • poor capillary perfusion results in A-V shunts
27
Q

What is a CWS - cotton wool spot ?

A

=swollen ends of interrupted axons, where build-up of axoplasmic flow occurs at the edge of the infarct

  • most frequently where the nerve fibre is densest such as the nasal side of the optic nerve
  • not just in diabetic retinopathy
28
Q

What is the proliferative phase of diabetic retinopathy ?

A

R3

29
Q

How do we reach the R3 proliferative phase ?

A
  • if the previous phase goes unmanaged,

- the diabetes get worse with diabetic retinopathy

30
Q

What is R3 characterised by

A
  • Ischaemia
  • leading to VEGF released which promotes the growth of new blood vessels
  • New vessels- neovascularisation
31
Q

What is VEGF?

A

Vascular endothelial growth factor

32
Q

Where doe these new blood vessels occur ?

A

may occur at disc -

33
Q

What are the new vessels at the optic disc referred to as ?

A

NVD

34
Q

What are the new vessels anywhere else referred to as?

A

NVE

35
Q

What can occur to these new vessels in r3?

A

they can break or leak leading to pre retinal or vitreous haemorrhage
-this sits infront of the retina so obscures the retina behind it

36
Q

What is the shape of vitreous haemorrhage and why ?

A
  • Boat shaped haemorrhage
  • because of gravity the blood settles so that the haemorrhage has a flat top and curved bottom.
  • vit
37
Q

What is a pre retinal fibrosis?

A

happens when diabetes is not under control and the eye has been under duress fo a long time

38
Q

What can pre retinal fibrosis lead to ?

A
  • can lead to traction whereby we have pulling on the retina leading to retinal detachment
  • -tractional retinal detachement
39
Q

What is the most serious complication of diabetic retinopathy?

A

Rubeosis irides

  • new blood vessels forming in the in the anterior chamber angle
  • causes painful red eye
  • Very HIGH IOP
40
Q

What is the NHS diabetes screening programme ?

A

National screening programmes for diabetic retinopathy based on digital retinal photo, graphy were developed and implemented in England, Scotland, Wales and Northern Ireland between 2002 and 2007.

Evidence that early identification and treatment of DED can ⬇ sight loss

-T1 and T2 DM aged 12+ yrs
Unless already under ophthalmology care

-Pregnant women with DM offered additional tests

Screening identifies Px at risk of DR
Not the same as diagnosis
False +ive and false -ive

41
Q

What is the aim of screening ?

A
  • Screening identifies Px at risk of DR
  • Not the same as diagnosis
  • False +ive and false -ive
42
Q

What is the DES programmed based on?

A
  • digital screening
  • Only approved software used
  • Tests every 6mths to ensure quality
  • Uniform grading structure
  • Images should be graded within 1 week of being taken
  • All graders grade at least 1000 image sets per year (optometrists/ophthalmologists: 500)
43
Q

What happens when px goes for diabetic screening ?

A

px eye is dialated- given drops
-digital photograph is taken from each eye
- range out to 45 degrees with one centred out on the macula and one on the optic disc for each eye
-have 2 photo per eye
-the photos are combined for each eye
-

44
Q

What do the graders do?

A
  • determine whether its gradable by :
  • the vessels need to be clearly visible from 1DDD of the foveal centre
  • small vessels must be visible at optic disc
45
Q

What happens if the image is ungradeable ?

A

px asked to see in hospital - px should be seen within 6 weeks and have a slit lamp bicormoscopy assessment to have a look at the back of the eye

46
Q

What are the different retinopathy R grades ?

A 
No retinopathy = R0
Background R1
Pre-proliferative= R2
Active Proliferative= R3A
Stable treated Proliferative = R3S
Photocoagulation =P1
Ungradeable= U
47
Q

What happens when px is diagnosed with diabetes (DM) ?

A

PX INVITED TO screening

  • BCVA - their best corrected visual acuity will be taken
  • Dilate with tropicamide and 2-field digital photography
48
Q

What happens if is graded R0 or M0?

A
  • Routine DM care

- Annual screening

49
Q

What happens if is graded R1 or M1, R2 R3?

A

PX will be invited with diabetes team in GP or hospital for advice or care to Control blood glucose, BP and lipids
-Manage Diabetes

50
Q

What happens if we just have R1 AND NOTHING else?

A

after the appointment they go back to :

  • Routine DM care
  • Annual screening
51
Q

What happens if there is M1 and R2?

A

Aim to be seen in HES by ophthalmologist 13wks-18wks

52
Q

What happens if there is R3?

A

Aim to be seen in HES by ophthalmologist in 2wks-4wks

53
Q

What happens if its very urgent such as
Sudden loss of vision
Retinal detachment ???

A

they get emergency referral to ophthalmologist same day

54
Q

What happens when px goes to the HES to see the opthalmologist ?

A

SL-BIO DFE - Given a slit lamp binocular indirect opthalmoscospcy dilated fundus examination

  • given Fluorescein angiography
  • take OCT
55
Q

What is the Ophthalmological Management of Diabetic retinopathy ?

A
  • if there are proliferative changes seen on the back of the eye the main treatment is :
    1. Pan-retinal photocoagulation
    Heat from laser seals or destroys abnormal, leaking BVs in retina

2.Focal photocoagulation
In specific areas

56
Q

What is Pan-retinal photocoagulation?

A

laser beam directed at the area of neovascularisation

  • small laser burns around the periphery of the retina.
  • heat from laser destroys or seals abnormal leaking blood vessels in the retina
57
Q

What is Focal photocoagulation?

A

laser burns in just specific areas but AWAY from macula

58
Q

What is the treatment/ ophthamological management of retinopathy ?

A

pan retinal photocoagulation

59
Q

What is the treatment of maculopathy ?

A

-stop or to regress new blood vessels forming at macula - this is done by Anti-VEGF intravitreal injection
- in px with macula oedema - Corticosteroids
E.g. Dexamethasone implant- injected in the vitreous - releases steroid which helps reduce the oedema in the macula

0V2022 Introduction to eye diseases (22 decks)

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