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Diabetic retinopathy (Risk factors (Both
T1DM>T2DM
Long duration DM
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Diabetic retinopathy
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Diagnosis
Examination
Fundoscopy
Aneurysms, exudate, haemorrhages, cotton wool spots, neovascularisation, retinal fibrosis
CN examination
Acuity (may be reduced), visual fields (may be reduced),
eye movements intact
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Investigations
Bloods
FBC, U+E, LFTs, clotting, glucose, lipids
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History
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PMH
CVD, DM, hyperlipidemia
DH
Current meds, allergies
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SH
Occupation, living arrangements,
driving, smoking, alcohol
Management
Medical
Steroids
Indication: macular oedema, intraocular inflammation
E.g. triamcinolone injection, dexamethasone implant
MOA: reduce inflammation within the eye
Complications: glaucoma, endophthalmitis,
haemorrhage, cataract, retinal detachment
Intravitreal anti-VEGF
Indication: exudative maculopathy and oedema;
pre-surgery/laser therapy
E.g. bevacizumab
MOA: blocks VEGF, reducing angiogenesis
Complications: endophthalmitis, haemorrhage,
cataract, retinal detachment
Surgical
Laser therapy
Indication: proliferative retinopathy, exudative maculopathy
E.g. panretinal (sacrifice peripheral retina), focal macular (reducing leakage from a specific aneurysm), macular grid (no obvious point of leakage)
MOA: laser light absorbed by retina, heat destroys photoreceptors, reduced O2 demand, reduces ischemia and angiogenic factor release
Complications: discomfort, reduced visual field/
night vision (panretinal), blind spots (macular)
Vitrectomy
Indication: vision-treatening retina detachment,
persistent vitreous haemorrhage
MOA: remove vitreous, divide fibrous bands of scar tissue,
laser to prevent further bleeds, replace vitreous
Conservative
Referral to HES
Regular: R2 (pre-prolif), M1 (maculopathy)
Urgent: R3 (prolif retinopathy, maintain vision)
Information, advice, support
Information on cause, prognosis, treatment
Advice on optomising DM control
Monitoring
R0, R1 - annual screen
Screening
Mechanism
NHS Diabetic Eye Screening Programme
Aim to detect eye disease while still asymptomatic
Annual visual acuity and retinal photographs (digital fundus photography), may measure IOP if needed
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Grading
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2) Maculopathy
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B) Maculopathy (M1)
Central retina involved
Exudate <1DD fovea centre or group exudate <2DD fovea centre
Microaneurysms/haemorrhages <1DD and poor acuity <6/12
3) Photocoagulation
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b) Present (P1)
Macular/scatter scars
Epidemiology
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All T1DM <20y diagnosis,
20% T2DM at diagnosis
Pathophysiology
Microangiopathy
Prolonged hyperglycaemia causes death of pericytes, thickened basement membrane and hypoxia
Leukostasis and occlusion of blood vessels, wall damage
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Definition
Diabetic microangiopathy affecting
the retinal blood vessels leading
to retinal damage and visual loss