Diabetic retinopathy R.Nourinia - PowerPoint Presentation

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Diabetic retinopathy

R.Nourinia

MD

Shahid

Beheshti

University Of Medical Science

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PREVALENCE OF DIABETIC RETINOPATHY

In 1980–82, the WESDR showed that 71%, 23%, and 11%

of those

with type 1 diabetes (insulin-dependent diabetes

mellitus, IDDM

) and 47%, 6%, and 8% of those with type 2

diabetes (noninsulin-dependent

diabetes mellitus, NIDDM) had

retinopathy, proliferative

retinopathy, and macular edema,

respectively.

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it

was estimated

that among persons with diabetes,

the prevalence of

diabetic retinopathy was 40% and

the prevalence of

severe vision-threatening retinopathy (pre-proliferative

and proliferative

retinopathy or macular edema) was 8%.

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INCIDENCE AND PROGRESSION OF

DIABETIC RETINOPATHY

The incidence of retinopathy in a

4-year interval

in the entire WESDR population was 40.3

%.

In that

study, the

cumulative incidence of proliferative diabetic

retinopathy and

macular edema after 20 years of diabetes declined

from 31

% and 19%, respectively, in those diagnosed from 1965

to 1969

, to 13% and 7%, respectively, in those diagnosed

from 1979

to

1984.

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In the WESDR, the annualized estimates for the

progression of

diabetic retinopathy (4.5

vs

2.5%) and the

incidence of

proliferative diabetic retinopathy (3.4

vs

1.5%),

clinically significant

macular edema (1.0

vs

0.4%), and visual

impairment (0.7

vs

0.3%) were higher in the first 12 years of the

study (1980–92

) than in the latest 13 years of the study (1994–2007).

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GENETIC FACTORS

T

he putative genes

and genetic variants have not been found to be as

strongly or

consistently associated with diabetic

retinopathy.

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DURATION OF DIABETES

The prevalence of retinopathy 3–4 years after

diagnosis of

diabetes in the WESDR younger-onset group with type

1 diabetes

was 14% in men and 24% in women.

In the first 3 years after diagnosis of diabetes, 23%

of the

type 2 diabetic group not taking insulin had retinopathy,

and 2

% had proliferative retinopathy (PDR).

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In 2008 and 2009, Klein

et al

.

reported on the

25‑year cumulative

progression and regression of DR and

cumulative incidence

of ME and CSME in type 1 patients in the

Wisconsin Epidemiologic

Study of Diabetic Retinopathy.

The 25‑year cumulative

rate of progression of DR was 83%,

progression to

PDR was 42%, and improvement of DR was 18% and

the 25‑year

cumulative incidence was 29% for ME

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GLYCEMIA

Diabetes Control and Complications Trial (DCCT

):

In

addition, when both

cohorts were

combined, the intensive therapy group also had a

reduction in

risk for development of severe

nonproliferative

retinopathy or

proliferative retinopathy by 47% and of treatment

with photocoagulation

by 51%

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UK Prospective Diabetes Study (UKPDS

):

After 12 years of follow-up, there was a

reduction in

rate of progression of diabetic retinopathy of 21% and

reduction in

need for laser photocoagulation of 29% in the

intensive versus

the conventional treatment

group.

A1c level from 8.4% to 6.9

%.

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Action to Control Cardiovascular Risk in

Diabetes (ACCORD

):

A1c level (<6.0

%).

They reported a

33% reduction in the relative risk of progression from

7.3% with

intensive

glycemia

treatment, versus 10.4% with

standard therapy

(adjusted OR 0.67; 95% CI 0.51–0.87;

P

=

0.003

) in a

relatively short

period (4 years).

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The data from

the DCCT

and UKPDS provided further support for the ADA

guidelines of

a target goal of A1c level of 7.0% for persons with

diabetes, and

suggest that this level of control, when

achieved earlier

after diagnosis of diabetes, may have greater

long-term benefit

in terms of reducing the incidence and progression

of Retinopathy.

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BLOOD PRESSURE

In the WESDR, a 10 mmHg rise in

diastolic blood

pressure was found to be associated with a

330% increased

4-year risk of developing macular edema in those

with type

1 diabetes and a 210% increased risk in those with type

2 Diabetes.

The UKPDS did find that the incidence of retinopathy was

associated with

systolic blood pressure. For each 10 mmHg

decrease in

mean systolic blood pressure, a 13% reduction was found

for

microvascular

complications.

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UKPDS:(

<150/<

85,

<180/<

105)

Tight blood pressure control

resulted in

a 35% reduction in retinal photocoagulation compared to

conventional control

, presumably due to a lower incidence

of macular

edema. After 7.5 years of follow-up, there was a

34% reduction

in the rate of progression of

retinopathy.

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ACCORD

(

<

120,

<

140)

The rates

of progression of diabetic retinopathy were 10% in

the group

undergoing intensive blood pressure control compared

to 9

% in the group undergoing standard blood pressure

control (adjusted

OR 1.23; 95% CI 0.84–1.79;

P

= 0.29).

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The Epidemiology and

Prevention of

Diabetes (EURODIAB) Controlled Trial of

Lisinopril

:

This

study showed a

statistically significant

50% reduction in the progression of retinopathy

in those

taking

lisinopril

over a two-year period after

adjustment for

glycemic control.

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Renin-Angiotensin System Study (RASS

):

It showed that,

as compared

with placebo, the odds of retinopathy progression

by two

or more steps was reduced by 65% with

enalapril

(OR

0.35; 95

% CI 0.14–0.85) and by 70% with losartan (OR 0.30; 95%

CI 0.12–0.73

), independently of changes in blood

pressure.

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SERUM LIPIDS AND LIPID LOWERING

In the WESDR, higher serum total cholesterol was

associated with

higher prevalence of retinal hard exudates in both

the younger-

and the older-onset groups taking insulin but not

in those

with type 2 diabetes using oral hypoglycemic agents

.

In the

ETDRS, higher levels of serum lipids (triglycerides,

low density lipoproteins

, and very-low-density lipoproteins) at

baseline were

associated with increased risk of developing

hard exudates

in the macula and decreased visual

acuity.

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T

here

are few large clinical trials showing the efficacy of

statins of

other lipid-lowering agents in reducing the progression

of retinopathy

, the incidence of macular edema or the loss

of vision.

ACCORD:

The rate of progression of diabetic retinopathy at 4

years was

6.5% in the

fenofibrate

treatment group compared to

10.2% in

the placebo group (adjusted OR 0.60; 95% CI

0.42–0.87;

P

= 0.006)

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Pregnancy

M

ore

rapid progression of

retinopathy.

It has been suggested that laser treatment before pregnancy

for women

with moderate to severe retinopathy be considered

to protect

against progression during

pregnancy.

IGF-1,

ET-1

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Classification of diabetic retinopathy

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Macular Edema

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MANAGEMENT OF NONPROLIFERATIVE

DIABETIC RETINOPATHY AND DIABETIC

MACULAR EDEMA

Modification of systemic risk

factors.

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Focal/grid laser photocoagulation

At 3 years, eyes with mild or moderate

NPDR plus

macular edema at baseline treated with immediate

focal/ grid

laser photocoagulation showed an approximately

50% decrease

in the rate of moderate vision

loss.

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However, in an ETDRS subgroup of 114 eyes

with thickening

of the

foveal

center, visual acuity worse than

20/32, and

mild or moderate NPDR treated with immediate

focal/ grid

laser photocoagulation in the ETDRS, change in

mean visual

acuity from baseline at two years was +4 letters,

with 29

% of eyes improving 10 letters or

more.

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Pharmacotherapy of DME

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Proliferative diabetic retinopathy

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Pharmacotherapy

Surgery