Diabetic Retinopathy

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  • It is a complication of diabetes mellitus in the eyes
  • It is a chronic progressive sight-threatening disease of the retinal blood vessels associated with the prolonged hyperglycemia and other conditions linked to diabetic mellitus such as hypertension

Clinical Presentation 

  • Loss of vision in advanced stages, when there is retinal haemorrhage or cataract
  • In early stages it may be asymptomatic
  • Regular  and  annual  screening  at  Diabetic  or  Eye  Clinic  is  recommended  for  early diagnosis.
  • Diabetic retinopathy is mainly grouped into three stages/presentations: 
  • Background diabetic retinopathy
  • Diabetic maculopathy
  • Proliferative diabetic retinopathy

Investigations 

  • Visual acuity with and without pinhole
  • Tonometry
  • Dilated fundoscopy (Direct or indirect ophthalmoscopy with or without biomicroscopy)

Note: 

Dilate the pupils with combined 

C: Tropicamide 1%/Phenylephrine 2.5% eye drops  OR 

C: tropicamide 1% with   

C: cyclopentolate 1% eye drops to screen 

Table 14.2 below gives a summary of the Stages of Diabetic Retinopathy at Eye Clinic, treatment  options and Follow up schedule. Treatment is done in consultation with Diabetologist and Physician  to ensure a good glycaemic and blood pressure control

Table 14.2: Treatment options for various grades of DR 

Grade

Treatment Options

Follow-up

No retinopathy 

a.Patient counseling
b. Strict control of blood sugar,

pressure and lipids

 9-12 monthly

Mild or Moderate Non-Proliferative 
Diabetic Retinopathy (NPDR) 
  • No active treatment required
  • Patient counseling
  • Control of blood sugar, pressure & lipids
 9-12 monthly

Pre-proliferative DR 

Severe NPDR * 

Close follow up for dilated fundoscopy 

2-3 monthly

Very severe NPDR * 

Partial scatter PRP therapy (maximum 

LASER burns 800 spots) 

3 monthly 
 

Mild Proliferative DR** 

(NVD/ NVE No pre-retinal or vitreous hemorrhage 

No Fibrovascular membrane <FVM>) 

Full scatter PRP minimum 1200 shots in one sitting or/ and 

Anti-VEGF injection*** 

2 monthly 

Moderate PDR ** 

(NVD/NVE, Moderate to severe Vitreous hemorrhage with visible fundus details for PRP, Pre-retinal Hemorrhage No FVM) 

Full scatter PRP up to Ora-serrata sparing the macula and away from the FVM *** 

3 monthly 

NVD/NVE, Severe Vitreous  hemorrhage obscuring fundus  details/not visible for PRP,  Extensive FVM, Tractional Retinal  Detachment <TRD> Macular traction)

  REFER to VR clinic  

*LASER treatment should also be considered in our settings in patients with severe and very severe NPDR with the following situations as it has shown to reduce the rate of vision loss by half:

  • Older type 2 diabeticsDifficult retinal view
  • Prior to cataract surgery
  • Only eye situation where the first eye was lost due to PDR
  • Regular attendance to clinic for follow up is likely to be poor
  • Difficult to examine patient due to other reasons.

** Monthly intra-vitreal anti-VEGF injections has been found to be effective on treatment for PDR 

*** Mild and moderate PDR should be treated with full scatter PRP (minimum 1200 shots in one  sitting) or intravitreal anti-VEGF injection whichever is available, accessible and affordable. If both  are available and affordable then anti-VEGF injection is the treatment of choice provided the patient: 

  • Is able to come for follow up at regular intervals- every month for 3 months and then every 2 months for 3 months and then 3monthly
  • Can afford the injections which may total up to 6 injections in the first year
  • Has no contraindications to the injections?

If any one of the above does not apply, then the patient should have PRP done. 

Treatment options for DMEManagement of DME depends on the clinical stage of DME and treatment options available at the  facility where the patient has been attended. 

Primary tests are required to be performed in order to grade the DME. Macula OCT for all diabetic  patients should be the baseline test to determine presence or absence of DME. Macular thickness of  equal or more than 400 microns should be considered as DME. Those facilities without this tool, the  clinical assessment will be the baseline test where the best corrected visual acuity will be the key  point for grading which will be matched with the clinical findings. Therefore, VA of less than 6/12  should be considered as DME case. It is important to exclude other causes of visual impairment  before concluding the presence of DME. Use of anti-VEGF has been found to be effective in the  treatment of DME.  

Table14.3: Treatment options for various grades of DME 

Grade

Treatment option

Follow up period

No DME 

Close observation 

review after 6 to 12 months 

Non-Centre involving DME 

  Focal or Grid LASER  3-6 months
Centre involving DME

3 intravitreal anti VEGF injections at monthly interval 
followed by 3 more injections at 6 weekly intervals.  

After 6 injections, refer patient to VR clinic if

  1. VA is not improving
  2. There is clinically persistent DME

If anti VEGF injection is not available:

  1. Grid LASER should be given for diffuse, Exudative or edematous macular edema
  2. Focal LASER to areas of focal Exudative edema
 Every 1 month

Pharmacological Treatment  

For glycemic control give antioxidant in non-proliferative diabetic retinopathy 

C: multivitamin +carotenoids (PO) 24hourly to a maximum of 3months 

For intravitreal anti Vascular Endothelial Growth Factor (VEGF) in Proliferative Disease 

S: bevacizumab, 1.25mg per 0.05ml, intravitreal injection, stat. 

OR  

S: ranibizumab, 0.5mg per 0.05ml, intravitreal injection stat. 

Repeat after every month to a maximum of 3 months then 6weekly to complete 6 injections. Re- assess on 3 monthly basis if there are signs of disease progression, restart treatment if any, with  close follow up. 

AND 

S: triamcinolone acetonide, 0.05ml, intravitreal injection, stat. Repeat after 3months if it is necessary. This is indicated in Diabetic Macula Edema. 

Surgical Treatment 

  • This is done in the proliferative stage
  • It  involves  removal  of  vitreous  and  or  blood,  peeling  of  formed  fibrovascular  tissue  and reattachment of retina if the retina is detached
  • It is combined with retinal photocoagulation
  • The vitreous cavity may be filled with tamponade liquid such as silicon oil or expansile gas like sulfur perfluoropropane or sulphur hexafluoride depending on the level of complication
  • It may also be combined with pharmacological treatment (Anti VEGF) mentioned above

Laser Treatment 

Laser photocoagulation: Extent and type of this treatment depending on the stage of the disease 

  • Focal Laser
  • Grid Laser

Note:  

Ophthalmologists should work together with Physicians to holistically treat the diabetic patient.

Poorly controlled diabetes mellitus and diabetic retinopathy can lead to blindness

All  patients  with  diabetes  mellitus  regardless  of  their  eye  conditions,  should  have  a thorough eye examination by available eye care personnel or an eye specialist at least once a year.

Dilated  eye  examination  and  direct  viewing  of  the  retina  by  an  ophthalmologist  or qualified eye care personnel is mandatory at initial diagnosis of Diabetes Mellitus and as per recommended schedule by the attending clinician.

Urgent referral of all diabetic patients with sudden loss of vision to eye specialist