The new vessels damage sight by bleeding (Figure 5) or forming sheets of fibrovascular membranes that may cause traction retinal detachments. The early treatment of diabetic retinopathy study (ETDRS) defined clinically significant macular oedema (CSMO)1 as the stage at which the eye needs to be treated in order to prevent loss of vision. The blood vessels in the central part of the retina may also become blocked (capillary closure), leading to macular ischaemia. The two main treatment options for proliferative DR are pan-retinal laser photocoagulation and diabetic vitrectomy. Pan-retinal photocoagulation (PRP), or scatter laser, is the main form of treatment for proliferative diabetic retinopathy. The aim of the laser is to induce regression of new blood vessels (that is, to make them stop growing and shrink).
The technique is an important part of the treatment of proliferative diabetic retinopathy and leads to improvement or stabilisation of vision in 90% of patients.1 2 Vitreous and blood are cut and aspirated and membranes causing tractional detachment of the retina are removed. In countries without screening, many people present with long-standing tractional retinal detachments of the macula. In a proportion of patients, intravitreal bevacizumab preoperatively may lead to clearing of the vitreous haemorrhage, thus avoiding surgery. In the Diabetic Retinopathy Clinical Research Network trial, intravitreal injections of the steroid triamcinolone acetonide was compared with standard laser treatment.
Anti-vascular endothelial growth factor (anti-VEGF) treatment VEGF levels are increased in the vitreous and retina in patients with diabetic retinopathy. In practice, laser should remain the cornerstone of treating clinically significant macular oedema and the use of intravitreal injections should be tailored to the needs of individual patients. Treat circinate exudates (Figure 6) with focal laser, blanching the retina in the centre of the exudate. Start with a low power setting, around 150 milliwatt, and increase the power until the desired endpoint is reached. In patients with established foveal thickening or who are not responding to laser, consider intravitreal bevacizumab.
We audited a number of patients who had ultimately needed vitrectomy for advanced proliferative disease to find out how we could improve, and arrived at the following recommendations for laser in countries where patients may not come for regular appointments. Warn all diabetes patients to come if they experience floaters or blur, as these symptoms suggest a vitreous haemorrhage.
Give PRP to anyone who has vitreous or sub-hyaloid blood (Figure 5) even if there are no visible new vessels. Diabetic retinopathy (DR) can be diagnosed by clinical examination alone if you are good at examining the retina with a slit lamp microscope. Fluorescein angiography is a technique for examining the fine detail of the retinal circulation. Optical coherence tomography (OCT) is a relatively new technique that uses lasers to scan the retina and build up a very detailed three-dimensional image. This diabetic retinopathy (DR) grading system is based on the International Council of Ophthalmology’s diabetic retinopathy and diabetic macular oedema disease severity scales (see Useful Resources). What you could say to your patients: Diabetes can affect the inside of your eyes at any time. What you could say to your patients: Your diabetes has damaged your eyes quite severely, although your vision is still good. What you could say to your patients: You have probably noticed your eyesight has got worse. If you cannot see the retina due to cataract or vitreous haemorrhage, refer to an ophthalmologist for cataract surgery or a retinal sugeon for vitrectomy. Vitreoretinal consultant, University of Cape Town, Division of Ophthalmology, Faculty of Health Sciences, H53 Old Main Building, Groote Schuur Hospital, Observatory 7925, South Africa. When managing the cataract of a patient with diabetes, you should remember that cataract surgery may make diabetic retinopathy worse.
Ideally, when the cataract does not preclude laser treatment, you should achieve and maintain effective control of retinopathy and maculopathy for at least three months before surgery.
The severity of the cataract sometimes prevents adequate examination or treatment of the retina in patients with diagnosed or suspected severe non-proliferative and proliferative diabetic retinopathy. Consider intravitreal triamcinolone or anti-VEGF at the end of surgery to reduce macular oedema.
If you plan to give laser treatment with a contact lens in the early post-operative period, then you should suture the cataract wound. In summary, diabetes patients with mild to moderate diabetic retinopathy and no maculopathy have a good prognosis following cataract surgery. Diabetic retinopathy results FROM the effects of the diabetes on blood vessels in the retina, the tissue which lines the inner eye.
In proliferative diabetic retinopathy, patients grow new abnormal blood vessels which extend over the surface of the retina. Patients may develop advanced stages of diabetic retinopathy without being aware that the disease is progressing.
Please call your local eye care professional for more information regarding diabetic retinopathy. Panretinal photocoagulation (PRP) a€” a laser treatment that inhibits blood vessel growth in the eye a€” is the standard treatment. There are clinical signs which can be seen with an ophthalmoscope or a slit lamp and 90- or 78-dioptre lens. Treatment usually maintains vision, but does not restore vision that has already been lost. The commonest error is undertreatment, and laser should be applied until there is regression of the new vessels or there is no room for further treatment.
The advantage of the slit lamp is that it allows you to visualise the retina with both eyes.
However, the key characteristic of proliferative DR is new vessels growing onto the posterior vitreous surface from the retina or optic disc (Figure 4).
Traction retinal detachment occurs when the fibrovascular tissue contracts and pulls the retina away from the underlying choroid. I hail from a remote rural village in Prakasham District and I joined the vision technician programme at LVPEI in 2007. I also record any history of blurred vision for distance or near vision, flashes, floaters in the field of view, and any fluctuations in vision. During a slit lamp examination (before dilation) I look mainly for neovascularisation of the iris and record intraocular pressure.
Eye care workers would do well to check their patients’ blood pressure and advise those with high blood pressure on the importance of control, referring them to a physician if they needed help.
So, for practical clinical purposes, look for other easily visible markers for macular oedema such as exudates within a disk diameter of the fovea.
It must be given early enough and cover enough retina to induce regression of the vessels that cause the complications of vitreous haemorrhage and tractional detachment of the retina. Treatment includes steroids, anti-vascular endothelial growth factor (anti-VEGF), and laser. Although there were short-term improvements in visual acuity with intravitreal triamcinolone acetonide (IVTA), this improvement was not sustained. The most recent anti-VEGF drugs to be evaluated in the treatment of diabetic maculopathy are ranibizumab2 (Lucentis) and bevacizumab5 (Avastin).
There was a 50% reduction in moderate visual loss in the group that received laser (from 24% to 12%).
Burns should be one burn width apart, using a spot size of 75 to 125 microns, duration 20–50 milliseconds.
It is wise to avoid treating perifoveal microaneurysms as this is likely to increase perifoveal capillary dropout (consider intravitreal bevacizumab instead). The treatment plan followed the textbook recommendation of doing focal laser for the maculopathy first. Using the slit lamp, you will be able to detect haemorrhages, new vessels, exudates, and retinal thickening due to oedema.
The cost of fundus cameras is still high, but they are becoming more affordable and the quality of pictures is improving all the time.
It will show the leaks that cause exudative maculopathy and the areas of blocked capillaries that cause ischaemic maculopathy and proliferative retinopathy. This will not only detect any oedema or swelling of the retina, but also measure it and draw a map that shows the areas where the swelling is greatest.
Predictive clinical features and outcomes of vitrectomy for proliferative diabetic retinopathy.
Intravitreal bevacizumab for prevention of early postvitrectomy hemorrhage in diabetic patients: a randomized clinical trial.
Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Randomized trial of intravitreal bevacizumab alone or combined with triamcinolone versus macular photocoagulation in diabetic macular edema.
Unless otherwise stated, all content is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. At whatever level you work, you must encourage everyone with diabetes to manage their blood sugar and blood pressure. At the moment your vision is good, but we must check your eyes in 12 months’ time to see if these changes are getting worse. At the moment your vision is good, but we must check your eyes in six months’ time as it is likely that these changes will get worse. You are likely to need treatment soon to ensure that you don’t lose vision or go blind.
Although your vision may be good, you are at great risk of losing your sight over the next year. Although your vision may be good at present, it is likely to get worse over the next year or two.
Eyes with mild to moderate non-proliferative diabetic retinopathy at the time of surgery are considered less at risk. In this case, you should deliver pan-retinal photocoagulation either during the procedure or in the early post-operative period. If it is still considered hazardous to use a contact lens then effective slit lamp laser can still be applied through a non-contact 78D or 90D lens. You should treat more advanced retinopathy or maculopathy at least three months prior to surgery if possible.
Factors affecting visual outcomes after small-incision phacoemulsification in diabetic patients.
Role of combined cataract surgery and intravitreal bevacizumab injection in preventing progression of diabetic retinopathy: prospective randomized study.
Efficacy of bromfenac sodium ophthalmic solution in preventing cystoid macular oedema after cataract surgery in patients with diabetes. Type I diabetics should undergo a screening retinal examination by an ophthalmologist within the five years of the diagnosis of their diabetes. Strict control of blood sugar levels slows the development and progression of diabetic retinopathy. An eye physician may refer a patient to a subspecialty ophthalmologist if the problem is severe.
Notice the frond-like vessels coming FROM the optic disk which represent neovascular vessels.
This stereoscopic vision provides a sense of depth which aids diagnosis, particularly of macular oedema. During this programme, we were trained to look for diabetic retinopathy (DR) by direct ophthalmoscope. If the media are not clear or if the patient has signs of DR, I will refer the patient to a secondary centre ophthalmologist for dilated fundus examination, which will give them the information they need to manage the patient’s DR.
The optimum time for a preoperative injection would seem to be 5–7 days before the operation. These trials showed a benefit with intravitreal ranibizumab and bevacizumab in patients with foveal thickening. The chorioretinal atrophy caused by burns, especially intense burns, within 300 to 500 microns of the fovea can years later extend into the fovea and cause vision loss, particularly in myopes. In the interim, every residency programme must provide training in the skills needed to manage DR, including interpreting investigations and delivering laser and other treatments.
The patient then missed two appointments and pan-retinal photocoagulation (PRP) was delayed by about two months. This is particularly important if there are large neovascular (NV) formations which have an increased risk of bleeding, or if the patient is unlikely to return. However, injections of fluorescein carry a small risk (about 1:20,000) of a severe allergic response, which can be fatal. Refer them to available services for help if they are not sure how to do this, or if their control is poor. If the damage becomes severe, we will need to treat your eyes to stop the diabetes affecting your sight.
Those with severe non-proliferative and proliferative diabetic retinopathy have a higher risk of progressive disease.1 Clinically significant macular oedema (CSMO) present at the time of surgery is likely to progress and eyes with previously treated CSMO are at increased risk of recurrence. When performing intraoperative pan-retinal photocoagulation with an indirect ophthalmoscope, you should fill the anterior chamber with viscoelastic and place a corneal suture.
Anti-VEGFs also reduce retinal swelling and may improve visual outcomes.2 Intravitreal steroids may cause raised intraocular pressure and anti-VEGF agents increase the risk of tractional complications in eyes with fibrovascular proliferation. Whereas laser is the most recognised form of treatment, pharmacological agents play an important role in the management of these patients. The proliferating blood vessels frequently break, causing vitreous bleeding that may significantly decrease vision. Pre-proliferative and proliferative diabetic retinopathy may be treated with laser photocoagulation. Other aids to DR diagnosis are fundus photography, fluorescein angiography, and optical coherence tomography (see box on page 7). However, intravitreal ranibizumab injections cost around US $1,200 each and the patients in this study received eight or nine injections in the first year (a cost of around US $10,000 per patient per year.) Intravitreal bevacizumab is much cheaper. Refresher courses can be arranged for those not adequately trained or who have been without the necessary equipment for some time. When PRP was finally given, the intention was to give it in the recommended multiple sessions.
If patients come from far away, consider admitting them to complete the laser before they are discharged. If bleeding occurs after laser, re-treat until NV formations have gone or maximal treatment has been given.
The most valuable use of photography is in patients with diabetic maculopathy or new vessels who have laser treatment. However, if you think you may not be able to come then, we may treat your eyes now, so we can be sure you don’t lose vision later. The treatment may not improve your eyesight, but if you are not treated, your vision will get worse and you may even become blind. The risk of progression is increased if the operation is complicated by excessive manipulation, vitreous loss, or severe post-operative inflammation. Fat and protein particles may leak FROM these vessels and become deposited in the retina in patches known as retinal exudates. Occasionally, a doctor may choose to perform an additional test called a fluorescein angiogram to view the retinal blood vessels. This helps me to identify patients with DR, who I would then send to a secondary centre for further management. We are able to offer patients an intravitreal bevacizumab injection for as little as US $25. We must also advocate for lasers and other necessary equipment wherever there is a trained ophthalmologist. However, due to further missed appointments, the interval between laser sessions was over a month. A pan-retinal pattern of excessively intense burns can lead to choroidal effusion and angle-closure glaucoma with blindness. In high-income countries, OCT and photos, in combination, are the usual means of documenting and investigating DR. This will provide a stable anterior chamber and optimal view, particularly if you anticipate indentation of the periphery.
Occasionally, the tissue may contract and pull the retina off the inner surface of the eye, causing a tractional retinal detachment.
As cameras and OCT machines become more affordable, they will also become more widely used in low- and middle income countries. If any of the leaky fluid accumulates in the central part of the retina (called the macula), the vision is affected. If you only examine the patient occasionally, it is difficult to remember exactly what the retina looked like before you treated it.
By then, tractional retinal detachment involving the macula had developed and vitrectomy was required. When you can still see retinopathy months after laser treatment, you may be unsure if it is better, worse, or much the same.
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