Diabetic retinopathy (diagnostics, therapy, classification) C:\Dokumenty\Obrázky\Nemocnice\Nemocnice Bohunice2.jpg Diabetes mellitus- definition •Diabetes mellitus is disease with high glucose level (hyperglycaemia) due to absolute or relative lack of insulin produced in beta cells of Langerhans pancreatic islets Diabetes mellitus- classification ØDiabetes type 1 ØDiabetes type 2 ØGestational diabetes Epidemiology of diabetes (CZ in 2009) •800 000 •8% of population -DM type 1 8% -DM type 2 92% Pathogenesis of diabetes type 1 •The destruction of insulin-producing beta-cells of pancreatic islets of Langerhans • (autoimmune process, a genetic predisposition, external environmental factor, in the second of identical twins diabetes arises only in 50% of cases) Ø Pathogenesis of diabetes type 2 •Failure of insulin secretion in pancreatic beta-cells Reduction of insulin action in target tissues (insulin resistance) Insulin D:\Semináře\Diabetická retinopatie\Obrázky\inzulín.jpg D:\Semináře\Diabetická retinopatie\Obrázky\Langerhansův ostrůvek.jpg discovered 1921 (Banting, Best, Macleod, Collip) §hyperglycaemic ketoacidotic coma hyperglycaemic hyperosmolar coma lactacidotic coma hypoglycaemic coma Diabetes mellitus (acute complications) Diabetes mellitus (late complications) 1.retinopathy 2.nephropathy 3.diabetic foot 4.neuropathy Diabetes mellitus (therapy) •Education •Diet •Oral antidiabetics •Insulin Diabetic retinopathy (definition) •Diabetic retinopathy is microangiopathy, ie. retinal vascular impairment in diabetic patients Diabetic retinopathy (history) •DM first description– Ebers papyrus (1550 before Ch.), Aretaios from Kappadokia (2th century) •DR was first described after Helmholtz ophthalmoscope discovery (1851) •First description of DR – Jäger (1851), Desmarres (1855), von Gräfe (1858) •First classification of DR – Ballantyn a Löwensteine (1943), nonproliferative and proliferative DR •First retinal fotocoagulation– Meyer-Schwickerath (1945), solar photocoagulator (heliostat) •Regression of proliferative DR after postpartual hypophysal necrosis (1953) – Simmonds- Sheehan syndrome •Discovery of fluorescence angiography – Novotny, Alvis (1959) Diabetic retinopathy (history) •First use of laser– Meyer-Schwickerath (1955-1958), xenon lamp •Rubine laser (1960) •Argon laser (1968) •Pars plana vitrectomy – Machemer, Parel (1970) •Fluorophotometry – Cunha-Vaz (1975), preretinopathy Diabetic retinopathy (history) •1976- Diabetic Retinopathy Study (DRS)- laser reduces risk of blidness in proliferative DR •1985- Early Treatment Diabetic Retinopathy Study (ETDRS)- focal laser photocoagulation reduces risc of visual acuity lost in diabetic macular edema Diabetická retinopatie (historie) •Diabetes mellitus- 8% population •25% diabetics - DR •5% diabetics - proliferative DR •DR rare until first 3-5 years of duration of DM •DR in 60- 90% after 15- 20 years of duration of DM •DR in 97% after 30 years of duration of DM Diabetic retinopathy (epidemiology) C:\Dokumenty\Semináře\graf DR.jpg Patophysiology of diabetic retinopathy •Microangiopathy •Lost of endothelial cells and pericites •Thickening of basal membrane of retinal capillaries (glycoproteins) •Failure of outer and inner blood retinal barrier Patophysiology of diabetic retinopathy C:\Dokumenty\Semináře\okluze.jpg Patophysiology of diabetic retinopathy C:\Dokumenty\Semináře\ischemie.jpg Patophysiology of diabetic retinopathy C:\Dokumenty\Semináře\neovaskularizace.jpg Patophysiology of diabetic retinopathy 1.Nonproliferative DR (NPDR) 2.Proliferative DR (PDR) 3.Diabetic maculopathy (M) • (each level of diabetic retinopathy may or may not beaccompanied by diabetic maculopathy) Classification of diabetic retinopathy Nonproliferative DR (NPDR) •Beginning •Intermediate •Advanced C:\Dokumenty\Semináře\NPDR I.JPG Beginning NPDR C:\Dokumenty\Semináře\NPDR II 1.JPG Intermediate NPDR C:\Dokumenty\Semináře\NPDR II 2.JPG Intermediate NPDR C:\Dokumenty\Semináře\NPDR III.JPG Advanced NPDR Proliferative DR (PDR) •Light •Intermediate •Fully advanced VH- vitreous hemorrhage, PRH- preretinal hemorhage, TRD- retinal detachment at center of macula C:\Dokumenty\Semináře\NVE.JPG Light PDR C:\Dokumenty\Semináře\NVD 1.JPG Intermediate PDR C:\Dokumenty\Semináře\Proliferace.JPG Fully advanced PDR C:\Dokumenty\Semináře\Trakční amoce.JPG Fully advanced PDR C:\Dokumenty\Semináře\VH.JPG Vitreous hemorrhage in fully advanced PDR C:\Dokumenty\Semináře\Klasifikace EDTRS.jpg Diabetic maculopathy (M) •affects 33% of diabetic patients after 8-10 years of duration of disease •the most common cause of vision loss in diabetic retinopathy Diabetic makulopathy (M) C:\Dokumenty\Semináře\graf makula.jpg •Macular area is a predilection site for edema formation Microangiopathy leads to ischemia, fluid accumulation, formation of microcysts and cysts Hard exudates (lipid accumulation) occur on the boundary of ischemic and normal retina Diabetic makulopathy (M) C:\Dokumenty\Semináře\makula.jpg Diabetic makulopathy (M) Diabetic makulopathy (classification) •Focal edema •Difuse edema •Ischemic edema (rare)- avascular zone in macula C:\Dokumenty\Semináře\Fokální makulopatie.JPG Focal edema C:\Dokumenty\Semináře\Difuzní makulopatie.JPG Difuse edema C:\Dokumenty\Semináře\Ischemicka makulopatie.JPG Ischemic edema Therapy of diabetic retinopathy and maculopathy •Gold standard is laser photocoagulation of ischemic retinal parts •Laser can‘t be performed in central macular zone Laser therapy (technique) •Laser therapy of DR 1.focal 2. 2. 2.panretinal (scatter) C:\Dokumenty\Semináře\Schéma PAN laseru.jpg C:\Dokumenty\Semináře\Panretinální laser.JPG Laser spots in retina suffered from NPDR •Laser therapy of diabetic maculopathy 1.focal 2.grid Laser therapy (technique) C:\Dokumenty\Semináře\Postup při fokálu.jpg C:\Dokumenty\Semináře\Fokální laser 1.JPG Focal laser C:\Dokumenty\Semináře\Schéma mřížky.jpg C:\Dokumenty\Semináře\Mřížka.JPG Grid laser Laser therapy (positives) •Reducing of risc of visual loss •Reducing of risc of vitreous hemorrhage, neovascular glaucoma and tractional retinal detachment Laser therapy (negatives) •Paliative treatment •Dark adaptation problems Surgical therapy of DR •Pars plana vitrectomy- (Machemer, Parel – 1970) C:\Dokumenty\Semináře\PPV.jpg C:\Dokumenty\Semináře\PPV membrány.jpg