MD Shahid Beheshti University Of Medical Science PREVALENCE OF DIABETIC RETINOPATHY In 198082 the WESDR showed that 71 23 and 11 of those with type 1 diabetes insulindependent diabetes ID: 931821
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Slide1
Diabetic retinopathy
R.Nourinia
MD
Shahid
Beheshti
University Of Medical Science
Slide2PREVALENCE 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.
Slide3it
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%.
Slide4Slide5Slide6INCIDENCE 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.
Slide7In 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).
Slide8GENETIC FACTORS
T
he putative genes
and genetic variants have not been found to be as
strongly or
consistently associated with diabetic
retinopathy.
Slide9DURATION 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).
Slide10Slide11Slide12In 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
Slide13GLYCEMIA
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%
Slide14Slide15Slide16UK 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
%.
Slide17Action 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).
Slide18The 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.
Slide19BLOOD 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.
Slide20UKPDS:(
<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.
Slide21ACCORD
(
<
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).
Slide22The 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.
Slide23Renin-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.
Slide24SERUM 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.
Slide25T
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)
Slide26Pregnancy
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
Slide27Classification of diabetic retinopathy
Slide28Slide29Slide30Slide31Slide32Slide33Slide34Slide35Slide36Slide37Slide38Macular Edema
Slide39Slide40Slide41Slide42Slide43Slide44MANAGEMENT OF NONPROLIFERATIVE
DIABETIC RETINOPATHY AND DIABETIC
MACULAR EDEMA
Modification of systemic risk
factors.
Slide45Focal/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.
Slide46However, 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.
Slide47Pharmacotherapy of DME
Slide48Slide49Slide50Proliferative diabetic retinopathy
Slide51Slide52Slide53Slide54Slide55Slide56Slide57Slide58Slide59Slide60Slide61Slide62Slide63Slide64Slide65Pharmacotherapy
Surgery