Ocular Disease III: Exam 2: Lecture 5: Diabetic Retinopathy

Question 1

Diabetes

1. Type 1
2. Type 2

Answer 1

1. Immune system Ab that attacks the insulin producing BETA CELLS of the pancreas. (lack of Insulin Production, B-Cells of PANCREASES)
2. Due to Insulin Resistance; GLUT4 RECEPTORS

Question 2

Blood Glucose Ranges

1. Fasting Blood Glucose: Normal?
   a. Over what?
2. Random Blood Glucose > what?
3. A1c > than what?
   a. LATEST Recommendation is to keep it BELOW what?
   b. It’s a measurement of what?
   c. REPRESENTS what?
4. Normal Glucose Values?
   a. Consistent Range over what = HYPERGLYCEMIA?
   b. Consistent Range BELOW what = HYPOGLYCEMIA?
5. TWO MOST IMPORTANT THINGS ABOUT DIABETES?

Answer 2

1. 200
2. • > 6.5
     a. Latest Recommendation is TO KEEP IT BELOW 6

b. of Glycated Hemoglobin
c. the AVG Blood Glucose over the LAST 2-3 MONTHS. MOST IMPORTANT NUMBER!
4. 80-110 mg/dL
a. over 126 mg/dL
b. below 70 mg/dL
5. HOW LONG THEY HAVE HAD IT, and the A1C Number!!!

Question 3

Diabetes

1. Type 1
   a. Onset when?
   b. Causes?
2. Type 2
   a. Onset
   b. % of DM?
   c. Causes?

Answer 3

1. a. 30 Years
   b. 90-95% of DM cases
   c. Genetics, OBESITY, Poor Diet, Inactive Lifestyle, UNKNOWN?

*if Idiopathic is an answer, circle it, 90% of the time, that’s the CORRECT ANSWER!

Question 4

Epidemiology: USA

1. What is the LEADING cause of NEW-ONSET BLINDNESS in WORKING-AGE POPULATION (20-74 yrs)
2. Less than what % of diabetics receive annual retinal Examinations?

Answer 4

1. DIABETES (17 million americans w/DM…probably a lot more than that)
2. <50%
   * EVERY diabetic needs to receive an Annual Dilated Blood Exam.

Question 5

Prevalence of DM by race/Ethnicity in USA an %

1. Whites?
2. Blacks?
3. Hispanic/Latino?

Answer 5

1. 11.4 million (7.5%)
2. 2.8 million (15%)
3. 2 million (13%)
   * Diabetic…Pretty much an everybody disease…it doesn’t discriminate

Question 6

DIABETIC EPIDEMIC: What % of Pts with Type 2 are OVERWEIGHT?

Answer 6

1. About 80%

Question 7

Diabetic Epidemic

1. About how many NEW CASES of DIABETES is there each year in the US?
2. ALARMING INCREASE of INCIDENCE IN TYPE 2 DM among whom?

Answer 7

1. 800,000 NEW CASES/YEAR in US

2. Among KIDS and YOUNG ADULTS!

Question 8

Risk Factors For Development of Diabetic Retinopathy

1. IDDM
   a. 95% over how many years after being Diagnosed? (*YEARS BEFORE PUBERTY DO NOT COUNT!!) By puberty he means 14 yrs old.

b. 10 Years?
e. >30 years?

2. What is the NUMBER 1 REASON that CAUSES the RISK FACTOR FOR DIABETES?
3. NIDDM
   a. 11-13 years?

b. >15 Years?
c. >10 years?

Answer 8

1. a. >30 YEARS w/the Disease, about 95% have Diabetic Retinopathy
   b. VERY Rare
   c. 27%
   d. 71%
   e. 30% have PDR
2. It’s simply the NUMBER OF YEARS YOU HAVE HAD the DISEASE! (regardless of treatment and blood sugar control)
3. a. 23%
   b. 60%
   c. 3% have PDR

Question 9

Risk Factors for Development of Diabetic Retinopathy

1. 4 things?

Answer 9

1. Quality of Glucose Control
   a. Elevated Glycated Hemoglobin levels
   b. Hyperglycemia may cause DR (With High glucose levels, glucose binds to Amino Groups of Proteins and this leads to Tissue Damage)
2. Hypertension
3. Serum Lipid Levels
4. Pregnancy
   a. 10% progression to NPDR
   b. 4% progression to PDR

Question 10

Diabetes: Causes

1. Know that Hyperglycemia causes what?
   a. Know that PKC and Angiontensin System will do what?

Answer 10

1. Oxidative Stress.
   a. Vascular Endothelial Dysfunction
   * Know that diabetes issues is a MESS. It’s overwhelming.

Question 11

Pathophysiology of DR

1. Glucose Toxicity from Hyperglycemia will AFFECT WHAT?
2. Possible Culprits
   a. Aldose Reductase (Converts Sugars to Alcohol): So Aldose Reductase Inhibitors Do what?
   b. PKC
   c. Increased RBC Aggregation
   * b, and c, he won’t ask questions about it.
3. Other possible Culprits?

Answer 11

1. CAPILLARY ENDOTHELIUM
   a. It has tight junctions, so blood doesn’t perforate, but if it breaks, that’s what causes the Leakage of Blood.
2. a. reduce cataract formation, PERMEABILITY of SMALL VESSELS, and PERICYTE LOSS (KEY thing is Pericyte Loss)
3. Platelets and Elevated Prostaglandin (this is inflammation!)
   * Causes Adhesion, Secretion, Aggregation

Question 12

Diabetic Retinopathy: Pathophysiology

1. Is Cause of DIABETIC RETINOPATHY Single or Multi Factorial?
   a. But it all leads to what?

Answer 12

1. MULTI FACTORIAL (multiple things cause it)

a. VASCULAR ENDOTHELIAL DYSFUNCTION is CENTRAL to ALL of the MECHANISMS of DAMAGE!

Question 13

**KNOW THIS

Decreased Tissue Oxygenation

1. CHRONIC VASODILATION does 3 things: what?

Answer 13

1. BASEMENT Membrane THICKENING
2. Pericyte DEGENERATION
3. Endothelial CELL PROLIFERATION

Question 14

Diabetes is the Disease of the Capillaries (1)

1. What happens to the CAPILLARY BM?
   a. What does this prevent?
2. What happens to Pericytes?
3. The first HEME in DR is due to what?

Answer 14

1. THICKENING (may lead to closure)
   a. Prevents Pericytes from being in Contact w/Endothelial Cells (They form the Tight Junction) which may increase LEAKAGE Potential
2. PERICYTE DROPOUT (lining capillaries)
   a. Increases leakage potential and leads to breakdown of BLOOD-RETINA BARRIER.

b. FOCAL Loss leads to Bulging of Capillaries and MICROANEURYSM FORMATION
3. Due to Capillary leakage from Pericyte loss.

Question 15

Diabetes is the Disease of the Capillaries (2)

1. Weakened Capillaries!
   a. 1st CHANGE that OCCURS in RETINOPATHY?
   b. Dot and Blot Hemes
   c. Flame Shaped Hemes
   d. MACULAR EDEMA: what is it?

e. THIS IS THE MOST COMMON CAUSE of WHAT in DR?
f. What is Fluid leakage & Lipid Accumulation?
g. What happens with Capillary Closure?

Answer 15

1. a. Aneurysm formation and LEAKAGE from WEAKENED CAPILLARIES
   b. INL and OPL (Deep)
   c. NFL (superficial)
   d. LEAKING ANEURYSMS & CAPILLARIES in MACULAR AREA
   e. of VISUAL REDUCTION! (but, it’s not the Most common cause of severe, Irreversible Visual Reduction: That would be NEO, NVG and Tractional RD)! KNOW THIS!
   f. Exudate!
   g. Hypoxia and Progression
   * Macular Edema will NEVER Cause Comprehensive Drastic Vision loss.

Question 16

Step By Step

1. What happens to Tight junctions?
   a. This splits apart what cells?
   b. Capillaries will then do what?
   c. What happens to the Lumen
   d. What happens to the Capillaries?
   e. Then you GET what?
   f. This leads to the RELEASE of what?
   g. This starts what?
   h. What happens then

Answer 16

1. They BREAK APART
   a. Pericytes
   b. Bulge and Balloon OUTWARDS
   c. It gets SMALL
   d. You lose them and they Dropout.
   e. HYPOXIA
   f. release of VEGF
   g. Starts formation of New vessels: NEOVASCULARIZATION!
   h. BVs here are FENESTRATED and they LEAK/BLEED…End of story…

Question 17

Diabetic Retinopathy Classification: Old One

1. Background Diabetic Retinopathy (BDR)
2. Pre-Proliferative Diabetic Retionpathy
3. Proliferative Diabetic Retinopathy
4. *WE CLASSIFY BASED ON WHAT?

Answer 17

2. Eye is becoming Hypoxic

4. on “EDTRS” (Early treatment of Diabetic Retinopathy Study)

Question 18

ETDRS Classification

1. Non-Proliferative Diabetic Retinopathy (NPDR) (4)
2. Proliferative Diabetic Retinopathy (PDR) (2)

Answer 18

1. a. Mild NPDR
   b. Moderate NPDR
   c. Severe NPDR
   d. Very Severe NPDR
2. a. Early/Mild PDR
   b. High Risk PDR
   * Diabetic Bill: 250.00 (Medical bill…can bill their medical insurance and not their Vision insurance)

Question 19

Mild NPDR

1. AT LEAST what is seen?
   a. Plus one or more of the following (3 things)
2. Progression to PDR (1 YEAR?)
3. HR-PDR (5 Years)?

Answer 19

1. At Least ONE MICROANEURYSMS plus one or more of the following
   a. Intra-Retinal Hemorrhage
   b. Hard Exudates Away from the Macula
   c. CWS
2. 5% !
3. 15% !

Question 20

Moderate NPDR

1. What is seen?
   a. Plus 1 or more of the following (3)
2. PDR (1 year)
3. HR-PDR (5 Years)

Answer 20

1. Microaneuryms/Hemorrhages in AT LEAST 1-3 QUADRANTS Plus one or more of the following
   a. NFL Infarcts
   b. Venous Beading in 1 Quadrant
   c. CWS
2. 12-27%
3. 33%

Question 21

Severe NPDR

1. ANY one of the following (4-2-1 RULE)
2. PDR (1 year)
3. HR-PDR (5 years)

**This will be a TEST QUESTION on the TEST. YOU jUST NEED ONE OF THE 3! to call it this!

Answer 21

1. Intra-retinal Hemorrhages/Dot Blot Hemes: in ALL 4 QUADRANTS
2. Venous Beading in 2 QUADRANTS
3. IRMA in 1 QUADRANT
4. 52%
5. 60%
   * A lot of doctors refer at this point. He doesn’t.

Question 22

Very Severe NPDR

1. And two of the FOLLOWING (4-2-1 RULE)
2. PDR (1 year)
3. HR-PDR (5 Years)

Answer 22

1. a. Intra-retinal Hemorrhages/Dot Blot Hemes in ALL 4 Quadrants
   b. Venous Beading in 2 QUADRANTS
   c. IRMA in 1 Quadrants
2. 75%
3. 75%
   * This is his LIMIT…

Question 23

Other Signs that Suggest SEVERE NPDR: Featureless Retina

1. Lacks of what?
2. What’s reduced?
3. “PRUNING” of what?
4. Opaque what?
5. What else?

Answer 23

1. Lack of Hemes/Microaneurisms and IRMA
2. Reduced Small Arteriole Branches
3. Pruning of Capillaries
4. Opaque Retinal Appearance
   * Hypoxic Retina (Slide 33!) *Quiet before the STORM
   * CWS happens in INFARCTS (quick death).
5. “OMEGA” Venous Loops AND Sausage-Like Segmentation (Severe venous changes suggestive of Long term Venous Dilation and Tortuosity: SIGN of PROLONGED HYPOXIA)

Question 24

Diabetic Maculopathy

1. At what stage of Diabetic Retinopathy can it occur?
2. MOST COMMON CAUSE of wHAT?
3. Types of DME
   a. FOCAL: Includes what 2 things?

b. Diffuse: What?

Answer 24

1. At ANY STAGE in NPDR or PDR
2. of DR-Related Vision Loss
3. a. Localized to MICROANEURISMS and HARD EXUDATES in the FOVEA (really, you can just say Exudates)
   b. Generalized Breakdown of tight junctions: (Retinal Vessels, RPE, and Sub-Optimal Medical Treatment)

Question 25

Diabetic Maculopathy (2): Prognosis 1. Poor Prognosis when you see what 4 things? 2. Good Prognosis: 4 things? 3. Who is Responsible for catching this?

Answer 25

1. a. Hard Exudates in the Fovea b. Poor INITIAL ACUITY c. Longstanding Duration d. Broken Peri-Foveal Capillary Net 2. a. Exudates Are AWAY from the FOVEAL AVASCULAR Zone b. Good Acuity c. Short Duration d. Intact Perifoveal Net 3. WE, as Optometrist's, ARE!

Question 26

Clinically Significant Macular Edema (CSME) as Defined by EDTRS* MEMORIZE THIS WORD FOR WORD! 1. What are the 3?

Answer 26

1. Any RETINAL THICKNENING within 500 (1/3 DD) microns of the Center of the Macula 2. HARD EXUDATES within 500 (1/3 DD) microns of the center of the macula with Adjacent retinal thickening 3. Retinal Thickening at least 1 Disc Area (DA) in size, any part of which is within 1 disc diameter (DD) of the center of the macula

Question 27

CSME 1. Pattern 1 (Slide 45) 2. Pattern 2 (Slide 46) 3. Pattern 3 (Slide 47)

Answer 27

1. Sponge-like Retinal Thickening 2. Partial Thickness Cystoid Spaces 3. Full Thickness Cystoid Spaces

Question 28

CSME (3) 1. CSME is the Term ONLY USED in what Disease? a. At what stages can we treat CSME? b. Treatment is done in Many cases even if VISION is what?

Answer 28

1. DIABETIC Retinopathy | a. It can happen at ANY STAGE of NPDR or PDR! (it's an urgent referral, not an Emergency referral)

Question 29

1. If there is a P in front of any word (by P: Proliferative), should you manage any of these?

Answer 29

1. NO! Refer Out. SHOULD NOT be managing NEO!!!!

Question 30

1. IF you get Ocular Ischemia, what does your Body do?

Answer 30

1. the body releases VEGF which can lead to VASCULAR PERMEABILITY or NEO!

Question 31

Proliferative DR (PDR): Step by Step (Ischemia) 1. Break apart what? 2. Split apart what? 3. Bulging of what? 4. What happens to the LUMEN? 5. What about Capillaries? 6. What do we get? 7. Then there's a Release of what? a. What does this signal? b. What does this LEAD TO? 8. New Blood vessels are WHAT? 9. What is the PRIMARY FEATURE of PDR?

Answer 31

1. Tight Junctions 2. Pericytes 3. of Capillaries, and Ballooning Outwards 4. It gets SMALL 5. Loss of Capillaries and you get Dropout 6. Hypoxia 7. of VEGF a. VEGF Signals start formation of New Vessels b. NEOVASCULARIZATION! 8. they're FENESTRATED: So they LEAK/BLEED 9. NEOVASCULARIZATION which is caused by Angiogenic Growth Factors Elaborated by HYPOXIC Retinal Tissue, in an Attempt to Re-VASCULARIZE HYPOXIC RETINA!

Question 32

PERTINENT NEGATIVES on EVERY DM Patient. 1. What are they? a. Diabetic...Need to look at what?

Answer 32

1. NVI: Neo of the iris a. Look at the IRIS! 2. NVD: Neo of the DISK 3. NVE: Neo Elsewhere (or blood anywhere) 4. CSME: Clinically Significant Macula Edema

Question 33

Vitreous Hemorrhage 1. It's due to a Break in what? a. It tends to show up in 1 of 2 places...? 2. What 2 things tend to happen to the pt? a. This Results from 1 of 6 things?

Answer 33

1. in the ILM a. In Vitreous Body or Retrovitreous 2. Subjective Floaters and Potentially Severe Vision Loss a. NVD, NVE, PVD w/Retinal Break, Macroaneurysm, ARMD

Question 34

Fibrous Proliferation w/Fibrotic Connective Tissue Formation 1. As the Fibrovascular Membranes and Vitreous Contract, their Attachments to the retina can cause what to the retina? a. This can result in WHAT?! 2. If you see fibrosis with a Diabetic patient, what do you assume?

Answer 34

1. Can Cause Focal ELEVATIONS of the Retina a. in a TRACTIONAL RETINAL DETACHMENT (This is the TYPE of RETINAL DETACHMENT that HAPPENS with DIABETIC PTS.) 2. Assume Tractional Retinal Detachment.

Question 35

Pars Plana Vitrectomy (PPV) 1. This is indicated in what 2 things? 2. Procedure a. Enter the eye w/microsurgical instruments thru what? b. What 3 Devices do we need? 3. GOAL?

Answer 35

1. Non-Clearing Vit HEME and in TRACTIONAL RETINAL DETACHMENTS 2. a. 3 Ports in the PARS PLANA b. Illumination Device, Infusion Device, and Vitrectomy Instruments 3. CHOP up the VITREOUS, SUCK IT OUT and REPLACE it w/SALINE and SOME GLUCOSE

Question 36

Pars-Plana Vitrectomy 1. What are the 3 Goals?

Answer 36

1. RELEASE Traction: Both Anterior-Posterior & Tangential 2. Remove Opaque Vitreous 3. Close ALL retinal Breaks

Question 37

Severity of PDR: NVD 1. Mild: when LESS than what? 2. High Risk: When MORE than what? 3. Mild: if NVE is what? 4. High risk: If NVE is what?

Answer 37

1. Less than 1/3 Disc Area is NVD 2. when more than 1/3 Disc Area is NVD 3. NVE is LESS than Half of the DISC AREA 4. NVE is More than Half of Disc Area

Question 38

Very High Risk PDR 1. If Fibrosis is Associated with what? a. Why?

Answer 38

1. with NEO | a. Because this can LEAD to TRACTIONAL RETINAL DETACHMENT

Question 39

Proliferative Diabetic Retinopathy 1. PDR may have what? 2. High Risk PDR a. Neo on or w/in what? b. NVD when there is new what? c. NVE of what? 3. Management: Refer WITHIN what time frame? a. What Also Indicates the NEED FOR Tx?

Answer 39

1. NVE/NVD/Vit Heme/Subhyaloid/Pre-Retinal Heme 2. a. 1 DD of the disc (NVD) which is more than or EQUAL to 1/4-1/3 Disc Area. This is equal to or greater than Standard Photo 10A b. when there's New Vitreous Hemorrhage (VH) or Preretinal Hemorrhage (PRH) c. greater than or equal to 1/2 DA with Fresh VH/PRH present 3. w/in 24-48 hrs to a Retina Specialist a. N.b. Rubeosis/NVI also indicates need for Tx.