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Risk Factors
- Duration of diabetes mellitus
- Poorly controlled diabetes: target HbA1c approx. 7%.
- Arterial hypertension: rigorous blood pressure control recommended
- Renal insufficiency
- Dyslipidaemia
- Pregnancy
Classification
- Mild non-proliferative diabetic retinopathy (NPDR): microaneurysms
- Moderate NPDR: additional retinal haemorrhages, cotton wool foci
- Severe NPDR: any of the following findings (= 4-2-1 rule)
- major haemorrhages and microaneurysms in 4 quadrants
- venous beading in at least 2 quadrants
- intraretinal microvascular abnormalities (IRMAs = dilated, tortuous capillaries or intraretinal neovascularisations) in at least 1 quadrant
- Proliferative diabetic retinopathy (PDR): Neovascularisations (optic disc 1, iris 2, chamber angle, retina (NVE=elsewhere)) or vitreous haemorrhage.
- with/without macular oedema:
- Clinically significant macular oedema according to ETDRS 3
- Oedema within 500µm of fovea
- Hard exudates within 500µm of fovea if associated with oedema
- Retinal thickening of ≥1 optic disc diameter within 1 optic disc diameter to centre of macula
- OCT findings and visual acuity are decisive for anti-VEGF injections
- OCT: fluid within 500µm of fovea
- Visual acuity: initial visual acuity? stable/getting worse?
- Clinically significant macular oedema according to ETDRS 3
Follow-up
- No diabetic retinopathy: annually
- Mild: 6-12 monthly
- Moderate: 6-monthly
- Severe: at least 2-4 monthly
- Proliferative 1-3-monthly
- Macular oedema: initially monthly
Workup and Management
- OCT, Fluorescein angiography if proliferative diabetic retinopathy is suspected, otherwise funduscopic diagnosis
- Severe NPDR: Consider panretinal laser
- in case of proliferative retinopathy of the fellow eye
- in patients with poor adherence to treatment
- Proliferative (PDR): panretinal laser coagulation recommended
- Macular oedema: anti-VEGF therapy
- Consider switching to steroid (e.g. Ozurdex=Dexamethasone) if there is no sufficient response after 6-12 months
- CAVE: May induce cataract and IOP elevations
- Consider switching to steroid (e.g. Ozurdex=Dexamethasone) if there is no sufficient response after 6-12 months
- In vitreous haemorrhage: consider Pars Plana Vitrectomy (PPV)
Sources
- EyeWiki Diabetic Retinopathy
- The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
- Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)
- 1, 2, 3 von Eyerounds.org, © The University of Iowa; Licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.