Slide 1: DIABETIC RETINOPATHY
Pathogenesis , Classification
Recent Studies
Dr Gyanendra Lamichhane, MD
Lumbini Eye Institute
Bhairahawa, Nepal
REFERENCES : REFERENCES Clinical ophthalmology - jack .j kanski 6th edition
AAO series -- Retina and vitreous ( 2004-2005)
Davidson's principle and practice of medicine 19th edition
Current perspectives of diabetic retinopathy John G Osheha
Websites
www.diabetic retinopathy. Com
6) Vitreo-retinal diseases ,2nd edition
Coverage : Coverage Introduction
Epidemiology and incidence
Risk factors
Etiopathogenesis
Classification
Causes of vision loss in Diabetic Retinopathy
Few recent studies
Introduction : Introduction Refers to involvement of retina in a patient with DIABETES
Q) Why should we know about diabetic retinopathy?
i) leading cause of blindness among patients aged 20- 74 yrs
ii) Ophthalmologist may be the first to diagnose Diabetes mellitus
iii) Early detection and timely management can save the vision
iv) Commonest category attending retina clinic
400 out of 1100 ( 36%)
Incidence : Incidence About 17 million people in USA( 6.2%) have Diabetes
Prevalence of blindness in western countries is (1.6 -1.9 / 100000)
Will affect 239 million people by 2010
Most of them (appox.139 million) will be from ASIA
Risk factors : Risk factors Duration
- Diabetes diagnosed before 30 yrs of age,
incidence of DR after 10 yrs 50%
30 yrs is 90%
- type I rarely develop retinopathy with in 5 yrs of onset
- 5% of type 2 DM have DR at presentation
( KANSKI 6th edition)
Slide 7: After 20 yrs of Diabetes
almost all type I and more than 60% type II have some degree of retinopathy ( www.priory.com)
incidence of proliferative retinopathy is more in type I DM
Slide 8: Poor metabolic control- tight control delay onset and progression
Pregnancy – i) diabetic with no retinopathy incidence increase by 10%
ii) 4% with NPDR progress to PDR
iii) some regression after delivery
Hypertension- systolic mainly
worsening of DR and development of PDR
Slide 9: Nephropathy
-worsening of DR
-protein urea , elevated BUN ,creatinine are excellent predictor of DR
-treatment of renal disease improves DR and better response to LASER
Hyperlipidemia
Smoking & obesity
Cataract surgery- may leads progression of macular edema
Pathogenesis : Pathogenesis exact mechanism is unknown.
Exposure to hyperglycemia over an extended period :
biochemical & physiologic changes in vascular endothelium
microangiopathy affecting the retinal precapillary arterioles, capillaries and venules
features of –
micro vascular occlusion micro vascular leakage
due to due to
i) capillary changes i) capillary changes
ii) hematological changes
Micro vascular occlusion : Micro vascular occlusion A. Capillary changes- loss of pericytes,
thickening of BM damage &proliferation of endothelial cells
B. Hematological changes-
rouleaux formation of RBC, increased platelets adhesiveness, abnormal serum lipids,
increased VEGF,
abnormalities in serum and whole blood viscosity.
Slide 13: Micro vascular occlusion
Retinal ischemia and hypoxia
VEGF
A-V shunt Neovascularisation
capillary drop out (disc, retina, iris)
( IRMA)
Slide 15: Microvascular Leakage: ( capillary changes mainly)
ed no. of pericytes
loss of vessel wall integrity
distension of capillary wall outpouchings Micro aneurysms leakage
breakdown of blood-retinal barrier leakage of plasma constituents Intraretinal Haemorrhage, Retinal Oedema (Diffuse & Localized) & Exudates
Micro vascular leakage : Micro vascular leakage Micro aneurysms-localized saccular out pouching of vessel wall
Classification : Classification 1 ) Non –proliferative mild
moderate
severe
2) Proliferative
3) Diabetic Maculopathy focal exudative
diffuse exudative
ischemic
mixed
4) Advanced Diabetic eye disease
hemorrhages ( pre retinal ,VH)
retinal detachment
neovascular glaucoma
Terminologies : Terminologies Micro aneurysms - saccular out pouching of retinal capillaries
- inner nuclear layer
-earliest detectable change
-tiny, round red dot initially temporal to fovea
- venous end of capillary
FFA – early hyper fluorescence with late leakage
Microaneurysms in FA : Microaneurysms in FA
Slide 23: Other causes of micro aneurysm
i) retinal vein occlusion
ii) hypertension
How to differentiate?
arterial site
more in periphery
How to differentiate from DOT HAEMORRHAGE?
near blood vessel
sharply defined
leak on FFA ( confirmatory)
Slide 24: Hemorrhages
Intraretinal Nerve fiber layer
( dot blot, venous end) flame shaped arteriolar end
Why dot shaped? Why flame shaped?
INL NFL
Slide 27: Soft Exudates (Cotton-wool Spots)
- indistinct fuzzy margin
- focal infraction of retinal nerve fiber layer
-small, whitish, fluffy superficial lesions
-axoplasmic stasis
- post equatorial retina due to more NFL
Cotton wool spots : Cotton wool spots
FFA of Cotton wool spot : FFA of Cotton wool spot
Slide 32: Hard exudates
- outer plexiform layer
- waxy yellow distinct margin
-clumps or circinate pattern
Intra Retinal Micro vascular Abnormalities ( IRMA) : Intra Retinal Micro vascular Abnormalities ( IRMA) -arterio- venous shunt by- passing capillaries
-fine redline from arteriole to venule
-Histology- dilated vascular channel with newly formed endothelial cell and immature tight junction ( leakage on FFA )
tight junction mature ( no leakage on FFA )
-distinguishing features
i) intra-retinal location
ii) failure to cross major retinal vessels
iii) absence of leakage on FFA
Slide 38: Retinal edema- initially between OPL and INL
-later IPL and NFL
-retinal thickening
FFA hyper fluorescence due to leakage
Slide 41: Venous changes - looping , beading -dilatation
Arteriolar change - narrowing
-silver wiring
-obliteration resembling BRAO
Slide 43: Cotton-wool spots
Venous irregularities Dark blot haemorrhages
Intraretinal microvascular
abnormalities (IRMA)
Classification of NPDR : Classification of NPDR No Retinopathy no retinal lesion
Very mild NPDR few Micro aneurysm only
Mild NPDR -micro aneurysm+ retinal hemorrhage+ hard exudates
Moderate NPDR -mild NPDR 2-3Q+ cotton wool spots
Severe NPDR- (4:2:1) 1 of the below
H/Ma in all 4 quadrant
VB in 2 or more quadrant
IRMA in1 quadrant
Very Severe NPDR: 2 or more of above 4:2:1
Risk of progressing to PDR with in 1 yr is 15% in severe NPDR and 45% in very severe NPDR ( ETDRS study)
MILD NPDR : MILD NPDR
Moderate NPDR : Moderate NPDR
Severe NPDR : Severe NPDR
Proliferative Diabetic Retinopathy ( PDR) : Proliferative Diabetic Retinopathy ( PDR) affects 5-10% of the diabetic population
IDDM are at increased risk
Features:
Neovascularization -hallmark
New Vessels at Disc (NVD)
New Vessels Elsewhere (NVE)
New Vessels at Iris (NVI)-rubeosis iridis
Vitreous Detachment with fibro vascular proliferation
Vitreous Haemorrhage
Preretinal Haemorrhage
Pathogenesis of New Vessels : Pathogenesis of New Vessels micro vascular occlusion
retinal ischemia and hypoxia
release of vasoproliferative substances ( VEGF )
endothelial proliferation esp. from vein
passes through defect in ILM
between retina and post. Vitreous face ( scaffold)
Slide 51: Stages of evolvement of new vessel
i) fine new vessel with minimal fibrosis
ii) increasement in both new vessel and fibrosis
iii) regression of new vessel , leaving residual fibro vascular proliferation in posterior hyaloids
TRACTIONAL RD HAEMORRHAGE
( SUDHYALOID,VITREOUS)
one fourth of the retina has to non perfused before PDR develop
Clinical assessment of Neovascularisation : Clinical assessment of Neovascularisation NVD
new vessel in the disc or with in 1DD around disc
Mild – less than 1/3rd disc area
Severe - if > 1/3rd
NVE
arise from retinal vein at arterio-venous crossing
superotemporal, inferotemporal
superonasal , inferonasal
Mild - <1/2 disc area in extent
Severe- >1/2 area in extent.
High risks characters : High risks characters High risk for visual loss within 2 years.
i) Mild NVD with hemorrhage
26% risk of vision loss, treatment 4%
ii) Severe NVD without hemorrhages
Loss 26% , treatment 9%
iii) Severe NVD with hemorrhage
loss 37% ,treatment -20%
iv) Severe NVE with hemorrhage
loss 30% treatment 7%
Diabetic Maculopathy : Diabetic Maculopathy involvement of the fovea by
oedema and/or hard exudates
ischemia
most common cause of visual impairment in diabetic pts
edema is due to-
1) dilatation of the capillaries
2)Destruction of capillary walls
ischemia Closure of capillaries->hypoxia and micro infarct
CLASSIFICATION
Focal Maculopathy
Diffuse Maculopathy -
with cystoid macular oedema
Ischaemic Maculopathy
Mixed Maculopathy
Clinically Significant Macular Oedema (CSMO)
Focal exudative : Focal exudative Circumscribed retinal thickening Associated complete or incomplete
circinate hard exudates Focal leakage on FA
Diffuse exudative : Diffuse exudative Diffuse retinal thickening
Obliteration of landmark leads to localization of FOVEA difficult Generalized leakage on FA
Ischaemic : Ischaemic Macula appears relatively normal
dark blot hemorrhage Capillary non-perfusion on FA
Enlargement of the FAZ
Slide 62: Clinically significant macular edema Hard exudates
within 500 m
of centre of
fovea with adjacent
edema which may
be outside 500 m
limit Retinal edema one disc area or larger any
part of which is within one disc diameter
(1500 m) of centre of fovea Retinal edema
within 500 m
of centre of fovea
Advanced diabetic eye disease : Advanced diabetic eye disease Uncontrolled proliferative diabetic retinopathy causes:
hemorrhage preretinal
intragel
retinal detachment
Non rhegmatogenous /rhegmatogenous
neovascular glaucoma
Causes of vision loss in Diabetic Retinopathy : Causes of vision loss in Diabetic Retinopathy 1) macular edema
2) macular ischemia
3) vitreous and pre retinal hemorrhage
4) tractional or combined detachment
Management of Diabetic Retinopathy : Management of Diabetic Retinopathy
Presentation Layout: : Presentation Layout: Introduction
Diagnosis
Clinical Trials in Diabetic Retinopathy
Classification
Management : Medical / Surgical
General Management Recommendation
Introduction : Introduction Diabetic Retinopathy leading cause of blindness of 20-64yrs in world mainly in urban population.
Early detection and management can save the eyes
Commonest disease attending our retina clinic 400 out of 1100 (36%)
Introduction cont… : Introduction cont… Successful management of diabetic retinopathy depends upon-
early, aggressive & consistent control of blood glucose level
regular dilated fundus evaluation
timely & appropriate management
Risk Factors : Risk Factors Diabetes diagnosed <30yrs of age have incidence of Retinopathy in 50% after 10yrs of onset and 90% after 30yrs of onset.
Type 1 rarely develops in DR with in 5yrs onset
5% of type 2 Diabetes have Retinopathy at presentation.
Slide 71: CLINICAL TRIALS IN DIABETIC RETINOPATHY
Clinical Trials in Diabetic Retinopathy: : Clinical Trials in Diabetic Retinopathy: Diabetic Retinopathy Study (DRS) – 1976-1989
Early Treatment Diabetic Retinopathy Study (ETDRS) – 1985-1996
Diabetic Retinopathy Vitrectomy Study (DRVS) – 1985-1990
Diabetes Control and Complication Trial (DCCT) – 1993-1995
United Kingdom Prospective Diabetes Study (UKPDS) – 1977-1999
Diabetic Retinopathy Study (DRS): : Diabetic Retinopathy Study (DRS): Randomized, prospective clinical trial
PDR or bilateral severe NPDR with VA 20/100 or better
1742 participants.One eye assigned to photocoagulation and one no PRP
Outcome variable :visual acuity of 5/200 (2/60) on two consecutive follow up examination 4 m apart
demonstrated ≥ 50 % reduction in the rate of SVL in eyes treated with PRP compared to untreated control group during a follow-up up to 5 years
DRS recommended prompt treatment of eyes with High-risk PDR
High-Risk PDR: : High-Risk PDR: any one of the following:
mild (1/4 to 1/3 disc area) NVD with Vitreous Hemorrhage
moderate to severe NVD with/without Vitreous Hemorrhage
moderate (1/2 disc area) NVE with Vitreous Hemorrhage
any combination of three of the four Retinopathy Risk Factors:
the presence of Vitreous or Preretinal Hemorrhage
the presence of new vessels
location of new vessels on or near the optic disc
moderate to severe extent of new vessels
Slide 75: NVD > 1/3 disc in area NVE > 1/2 disc in area
+ haemorrhage
Early Treatment Diabetic Retinopathy Study (ETDRS): : Early Treatment Diabetic Retinopathy Study (ETDRS): randomized, prospective study
evaluation of photocoagulation and aspirin treatment of diabetic patients with Clinically Significant Macular Oedema (CSME) and severe NPDR with VA 20/200 or better
Slide 77: Hard exudates at or within 500 m
of centre of fovea with adjacent oedema which may
be outside 500 m limit Retinal oedema one disc area or larger, any
part of which is within one disc diameter
(1500 m) of centre of fovea Retinal oedema at or within 500 m of centre of fovea Clinically Significant Macular Oedema:
Severe NPDR : Severe NPDR Any one of following(4:2:1rule)
Diffuse intraretinal haemorrhage and microaneurysms in 4 quadrants
Venous beading in 2 quadrants
Intraretinal microvascular abnormalities (IRMA) in 1 quadrant
Early Treatment Diabetic Retinopathy Study (ETDRS):… : Results:
Macular Edema
Focal photocoagulation decreased risk of moderate visual loss and reduced retinal thickening.
Early scatter photocoagulation
scatter PRP - not recommended for eyes with mild or moderate NPDR
≥ severe NPDR – consider scatter PRP
Aspirin use
No role Early Treatment Diabetic Retinopathy Study (ETDRS):…
Diabetic Retinopathy Vitrectomy Study (DRVS): : Diabetic Retinopathy Vitrectomy Study (DRVS): randomized, prospective clinical trial
the role of VITRECTOMY in managing eyes with very severe PDR and vitreous haemorrhage from PDR
Diabetic Retinopathy Vitrectomy Study (DRVS):… : Diabetic Retinopathy Vitrectomy Study (DRVS):… Results:
In type I DM patients with severe vitreous haemorrhage - significant benefit of early vitrectomy (35.6%)
In type II DM - no advantage of early vitrectomy (15.9%)
In eyes with very severe PDR - showed advantage of early vitrectomy .
Diabetes Control and Complications Trial (DCCT): : Diabetes Control and Complications Trial (DCCT): randomized, prospective clinical trial
study of control of blood glucose slow in progression of Diabetic Retinopathy
Type 1 Diabetes Mellitus
Results: intensive insulin therapy reduced risk of developing retinopathy by 76% and slow progression of retinopathy by 54%.
United Kingdom Prospective Diabetes Study (UKPDS): : United Kingdom Prospective Diabetes Study (UKPDS): randomized, prospective clinical trial
evaluation of the effect of intensive blood glucose control and intensive control of blood pressure in type 2 diabetes reduce microvascular complication and progression of retinopathy.
Result:
intensive glucose control slowed progression of retinopathy
control of HTN with a beta blocker or an ACE inhibitor proved beneficial for both macrovascular and microvascular complications.
MANAGEMENT : MANAGEMENT
Management of Diabetic Retinopathy : Management of Diabetic Retinopathy Medical Management
Surgical Management
Medical Management: : Medical Management: Hypertension: associated with higher risk of progression of Diabetic Macular Edema and Diabetic Retinopathy
Advanced diabetic renal disease and Anaemia: adverse influence on DR
Pregnancy: associated with worsening of DR
Good glycemic control reduce progression to severe NPDR and PDR
Surgical Management: : Surgical Management: Panretinal Photocoagulation (PRP)
Peripheral retinal cryotherapy
Sub-Tenon / intravitreal Triamcinolone acetonide
Intravitreal Anti VEGF, Bevacizumab (Avastin)
Vitrectomy
Laser Photocoagulation: : Laser Photocoagulation: recommended for eyes with High-risk PDR and CSME
mechanism by which laser photocoagulation works-
exact mechanism - unknown
decreases the production of vasoproliferative factors by eliminating some of the hypoxic retina
stimulates the release of antiangiogenic factors (vasoinhibitors) from the RPE
by thinning the retina, PRP increases oxygenation of the remaining retina and so decreases vasodilation & endothelial cell proliferation
Laser Photocoagulation:… : Scatter Laser Treatment (PRP)
High risk PDR also for severe and very severe NPDR
Scatter Laser Treatment (PRP):
Goal- to cause regression of existing neovascular tissue and to prevent progressive neovascularization in future
Laser Used: Argon, Diode,Red, Green
Amount of therapy- determined by clinical response
Full PRP- 1200 burns of 500 m size, separated from each other by ½ burn width, at 0.1 second duration, in two or more sessions Laser Photocoagulation:…
Laser Photocoagulation:… : Laser Photocoagulation:… Scatter Laser Treatment (PRP):…
avoided in areas of prominent fibrovascular membranes, vitreoretinal traction, and tractional RD
Scatter Laser Treatment : Scatter Laser Treatment Side effects: decrease night vision , color vision and peripheral vision, loss of 1 or 2 lines of visual acuity , macular edema.
Laser Photocoagulation:For CSME : Laser Photocoagulation:For CSME Two types of Laser Treatment for CSME
FOCAL Laser Treatment
GRID Laser Treatment
Laser Photocoagulation:… : Laser Photocoagulation:… Focal Laser Treatment:
For local leakage (guided by FFA)
Laser Used: Argon
applied to all leaking microaneurysmsbetween 500 and 3000 m from the centre of the fovea
Parameters:
50-100 m spot size
0.1 second or less duration
attempt to whiten or darken microaneurysms
Focal Laser Treatment: : Focal Laser Treatment: Complications:
Paracentral scotoma
Transient increase edema
Decreased vision
Choroidal neovascularisation
Subretinal fibrosis
Photocoagulation scar expansion.
Laser Photocoagulation:… : Laser Photocoagulation:… Grid Pattern Laser Treatment:
For diffuse leakage or zones of capillary non-perfusion adjacent to the macula
Laser Used: Argon
applied to all areas of diffuse leakage or capillary non-perfusion more than 500 m from the centre of the macula and 500 m from the temporal margin of the optic disc
Parameters:
50-100 m spot size
0.1 second or less duration
spots spaced at least one burn width apart
Peripheral Retinal Cryotherapy: : Peripheral Retinal Cryotherapy: used to treat eyes with High-risk PDR in which the media are too hazy for PRP
benefits- regression of NVD, NVE & NVI
Complication- development of tractional RD in 25-38% of eyes
should be avoided in patients with tractional RD
Pars Plana Vitrectomy in Diabetic Retinopathy : Pars Plana Vitrectomy in Diabetic Retinopathy INDICATIONS:
Dense, non clearing vitreous hemorrhage
Tractional retinal detachment involving macula
Combined tractional and rhegmatogenous retinal detachment
Diffuse diabetic macular edema associated with posterior hyaloidal traction
Recurrent vitreous hemorrhage despite maximal PRP
VITRECTOMY INDICATION CONT…. : VITRECTOMY INDICATION CONT…. Severe progressive fibrovascular proliferation
Dense premacular hemorrhage
Anterior segment neovascularisation with media opacity preventing PRP
Red blood cell induced glaucoma
CURRENT STANDARD : VITRECTOMY TECHNIQUE : CURRENT STANDARD : VITRECTOMY TECHNIQUE Lens removal / IOL elective for view
Vitrectomy—remove as much vitreous as is necessary and safe
Membrane removal or segmentation
Retinal reattachment as needed
Laser burns, one burn width apart from arcades to periphery
Vitrectomy – blood removal : Vitrectomy – blood removal
Mild NPDR : Mild NPDR At least one microaneurysm +few dot hemorrhages
5% risk PDR within 1yr. & 15% risk High Risk-PDR 5yrs
Mild NPDR- Follow up- 12 months
Mild NPDR + Macular edema-FFA, Follow-up in 4-6 months
Mild NPDR + CSME: FFA, Focal laser & 2-4 months follow up
Moderate NPDR : Moderate NPDR Soft exudates , Venous beading, mild NPDR 2-3 quadrant
12-27% -PDR 1yr
No Macular edema: Follow up- 6-8 months
+ Macular edema - FFA, & Follow up- 4-6 months
+ CSME- FFA
& focal laser + Follow up 2-4months.
Severe NPDR : Severe NPDR Any one of following: haemorrhage or microaneurysm in 4 Q venous beading in 2 Q,IRMA in 1Q
15% -High Risk PDR-1yr
No Macular Edema - PRP- Follow up 3-4 months
+Macular Edema- FFA, oc. PRP after focal
+ CSME – FFA , Focal laser + oc. PRP,Follow up 2-3 months
Very Severe NPDR: : Very Severe NPDR: 2 or more lesions of severe NPDR with no sign of neovascularisation
75% develops into PDR in 1 year
FFA
PRP
If CSME – Focal Laser
Close Follow up 2-3 months
Intravitreal injection of Triamcinolone acetonide for Diabetic Macular Edema : Intravitreal injection of Triamcinolone acetonide for Diabetic Macular Edema Action: inhibition of VEGF and other cytokines and growth factors and regulating endothelial cell tight junctions.
Anti-inflammatory effect contribute to reduction of edema.
Increase diffusion by modulation of ca channels also account for efficacy of corticosteroid in decreasing Macular edema.
Intravitreal injection of Triamcinolone acetonide for DME cont…. : Intravitreal injection of Triamcinolone acetonide for DME cont…. Injection site : Inferotemporal quadrant to avoid drug deposition in front of visual axis
Dose : 0.1ml (4mg)
Disadvantage : short duration of action
Complications :
Cataract
Glaucoma
Endopthalmitis
Intravitreal bevacizumab(Avastin) therapy for persistent diffuse diabetic macular edema:Haritoqloc c et al 2006 Germany : Intravitreal bevacizumab(Avastin) therapy for persistent diffuse diabetic macular edema:Haritoqloc c et al 2006 Germany Purpose:To evaluate efficacy of bevacizumab (Avastin) for treatment of diabetic macular edema
Method:Prospective study included 51 pts with diffuse diabetic macular edema.All pt were treated with 0.05ml injection containing 1.25mg of bevacizumab.70% received 2 doses of intravitreal injection.
Intravitral bevacizumab cont…. : Intravitral bevacizumab cont…. Results: All pts completed 6 wks followup.All pt had undergone previous treatment as focal laser therapy 35% ,PRP 37% , vitrectomy 12% intravitreal injection of triamcinolone 33%
Conclusion:Improvement of visual acuity and decrease in retinal thickness.Mean retinal thickness by OCT 501micrometer reduced to 377micrometer.
Intravitreal bevacizumab (Avastin) treatment of diffuse diabetic macular edema.Kumar Atul et al AIIMS,India Jan2007 : Intravitreal bevacizumab (Avastin) treatment of diffuse diabetic macular edema.Kumar Atul et al AIIMS,India Jan2007 Method:19 pts with diffuse diabetic macular edema were given 2 intravitreal injection of bevacizumab 1.25mg in 0.05ml in 6 wks apart
Results: All eyes received PRP before but had no improvement in vision.Visual acuity improved from 20/494 to 20/295 in 3 months.Mean central macular thickness was 492micrometer reduced to 369micrometer at end of 6 months.
Intravitral bevacizumab cont… : Intravitral bevacizumab cont… Conclusions: Intravitreal bevacizumab resulted in significant decrease in macular thickness and improvement in vision .
Timetable based on Age Of Patient or Pregnancy: : Age of Onset of DM First Eye Exam Follow up minimum:
0-30 yrs within 5 yrs of diagnosis annually
31 yrs upon diagnosis annually
pregnancy before conception or early in first trimester every 3 months or at discretion of ophthalmologist Timetable based on Age Of Patient or Pregnancy:
Suggested Follow-up: : Suggested Follow-up: Normal or Rare Microaneuyrsms - Annually
Mild NPDR - Every 9 months
Moderate NPDR - Every 6 months
Severe NPDR - Every 4 months
CSME - Every 2 - 4 months
PDR - Every 2 - 3 months
Slide 113: GENERAL MANAGERAL RECOMMENDATATION
Slide 114: PRP for -
High-risk PDR
occasionally for -
non-high-risk PDR
severe or very severe NPDR
Focal/Grid Laser for -
CSME
usually for High-risk PDR with macular oedema
occasionally for -
Non-high-risk PDR with macular oedema
very severe / severe NPDR with macular oedema
Diabetic Retinopathy cont…. : Diabetic Retinopathy cont…. Intravitreal administration of corticosteroids
Peripheral Retinal Cryotherapy
Vitrectomy
Diabetic Retinopathy cont….. : Diabetic Retinopathy cont….. Good Control Of Blood Sugar Level.
Regular Follow up as sugested by Ophthalmologist
All above prevents the occurance and progression of Diabetic Retinopathy.
Thank You : Thank You THANK YOU