Epidemiology and Risk Factors Diabetic
Retinopathy
Dr. Putu Budhiastra SpM
Dept Ophthalmology Medical Faculty Udayana University
Sanglah Hospital Denpasar
Definition
Diabetic retinopathy is a condition occurring in persons with diabetes, with causes progressive damage to retina . *
DR may be defined as the presence and characteristic evolution of typical
retinal microvascular lesions in an individual with diabetes. **
DR is a chronic progressive , potentially sight treathening disease of the retina microvasculature associated with the prolonged hyperglycemia and other conditions linked to diabetes such as hypertension ***
Diabetic retinopathy (DR) is the leading causes of new blindness in
persons aged 25-74 years in the United States. A recent estimate of the prevalence of DR in the United States showed a high prevalence of 28.5 % among those with diabetes aged 40 years and older . 1
.
1. Abdish R Bhavsar MD et all : Diabetic Retinopathy : Emedicine Medscape . April 2015
2.. Jim Foran Dr : Guidelines for Management of Diabetic Retinopathy, 2008
*** Royal College
Epidemiology
The Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) *
> 20 years of diabetes , nearly 99% of diabetes type 1 and 60% of diabetes type 2 have DR.
3.6 % of younger onset patient and 1.6 % of older onset patients were found to be legally blind.
Pedoman Penangganan Retinopati Diabetika **
RD occurred 75 % at patients suffering diabetes for 20 years.
The DiaCare Asia Study , Jakarta : ***
1785 diabetes patients has 42 % DR and 6,4 % was Proliferatif DR ***
Multicenter study of 11 Indonesia Hospitals:
1723 diabetes patients at hospital based > 63 % has Diabetic retinopathy. ****
Academy
• * American Academy of Ophth.
• ** Pedoman Penangganan Retinopaty Diabetika 2013
Global Prevalence estimate at 35 study with 20.000 partisipant with diabetes the overall prevalence any DR was 35 % , PDR was 7,0 % and DME was 7 %. *
the prevalence DR at diabetic patients is estimated at approximately 8% at 3 years, 25% at 5 years, 60% at 10 years, and 80% at 15 years **
The most recent Australian DR prevalence data derive from the AusDiab Study which found an overall DR prevalence of 25,4 % with PDR in 2,1 %. **
The prevalence of DR in rural India population among patients with diabetes was 10,3 % ****
The prevalence of DR in a high-risk for diabetes Chinese population was 14,9 %. *****
Beulens (2009) reported that retinopathy of 1602 patients with type 2 diabetes in ADVANCE study was 40,1 % indicating of he early features of microvascular damage. ******
• *joanne Y.W. et all :Global Prevalence and Major Risk Factors of DR Diabetes Care. 2012
• ** institut-vision.org/index.php?option=com_content April 13, 2011
• *** Guideline of the Management Diabetic Retinopathy ,Cwealth Australia,2008
• **** Prevalence and risk factors for DR in rural India.BMJ Open Diabetes Research & Care 2014
• ***** Wang et .al , BMC Public Health 2013 . 13.633
Risk Factors of diabetic retinopathy
1. Modification risk factors classification *
a. Non modification : genetic , sex and diabetes duration. b. Modification : blood glucose, blood pressure and lipid.
c. Additional : artery diseases, gravida, nephropathy and smoking
2. Consistenst risk factors classification **
a. duration, hyperglycemic HbA1c , hypertension, hyperlipidemia, gravida and nephropathy
b. obesitas , smoking , alcohol, and physic inactivity
3. Three Major risk factor ***
a . Diabetes duration , HbA1c and blood pressure
three major modifiable risk factors—hyperglycemia, hypertension, and dyslipidemia—on the risk of all DR > Joanne
* Pedoman Penangganan Reinopati Doabetika 2013 ** Gitalisa A. Retina 2014
Risk Factors
There are two type risk factors *
Consistent risk factors :
duration, hyperglycemic HbA1c , hypertension, hyperlipidemia, gravida and nephropathy
Less consistent risk factors :
obesitas , smoking , alcohol, and physic inactivity
three major risk factors for DR—diabetes duration (17,19,28), HbA1c (17,28–32), and blood pressure (17,28,33) Joanne Globa
lHyperglycemia, hypertension, hyperlipidemia, and renal disease are considerable risk factors. Obesity, smoking, alcohol consumption, and physical inactivity are also important risk factors, though
considered less consistent. Pregnant women with diabetes are a higher risk for developing DR. April 13, 2011
* American
* American
1. Glygemia
Poor glygemic control ( HbA1c) strongly associated with DR *
Diabetic Control and Complication Trial (DCCT) Study with intensif
teraphy reducing HbA1c from 9,1 % to 7,3 % for 6.5 years >
significant reduce DR ( increasing 3 step at ETDRS) **
UK Prospectif Diabetes Study (UKPDS) follow up for 10 years
reducing HbA1c from 7,9 % to 7.0% reducing microvascular risk
25% **
WESDR report that with mean HbA1c level over 12% were 3,2
times more likely to have retinopathy after 4 years than subject
with HbA1c level under 12%. ***
• * Joanne WY : Global Prevalence and Major Risk Factor of DR , Diabetic Care 35, 2012
• ** Pedoman Penangganan Retinopati Diabetika, 2013
2. Blood pressure
Fenofibrate, however, acts mostly on triglycerides, and its effects on retinopathy in those trials were independent of lipid levels achieved. Statins, however, did not affect DR severity in the few studies *
UKPDS showed reducing BP from average 154 to 144 mmHg follow
up 4,5 years reducing microaneurysm, excudat and cotton wool spot f.u. until 7,5 years** . Tight control of blood pressure resulted in 34% reduced in progression of retinopathy with 47% reduced risk in
detorioration in visual acuity of three lines ***
ACCORD Eye control BP intensively lower than 120 mmHg from 140
mmHg, but fail to reducing improvement DR.**
EURODIAB/EUCLID Study, a 50% reduction in the progression of DR
over 2 years was observed in normotensive persons taking lisinopril, ACE inhibitor .****
* American
• * Joanne WY : Global Prevalence and Major Risk Factor of DR , Diabetic Care 35, 2012
• ** Pedoman Penangganan Retinopati Diabetika , 2013
• *** Ramandeep Sing et all : Diabetic Retinopathy An Update , Indian J.O 2008 May-Jul
3. Dislipidemia
Fenofibrate, a lipid-altering agent, may slow the development and progression of DR (34). Fenofibrate, however, acts mostly on
triglycerides, and its effects on retinopathy in those trials were independent of lipid levels achieved. *
ETDRS has reported a positive correlation between serum lipids and risk of retinal hard exudates in type 2 DM. Gupta et all reported
reduction in edema, severity of hard exudates and subfoveal lipid migration and dislipidemia, using a lipid lowering drug atorvastatin, as an adjuvanct to macular photocoagulantion. **
Randomised controlled trials suggest that lipid-lowering therapy with statins or fibrates could be useful in managing DR and as an adjunct to laser treatment for maculopathy. Target LDL cholesterol < 2.5
mmol/l and triglycerides < 2.0 mmol/l. ***
• *Joanne WY : Global Prevalence and Major Risk Factor of DR , Diabetic Care 35, 2012
• ** Ramandeep Sing et all : Diabetic Retinopathy An Update , Indian J.O 2008 May-Jul
4. Smoking
L
UKPDS surprisingly reported that smoking was associated with a
reduced 6-year incidence of DR. Compared with never smokers, current smokers had around one third lower incidence. DR
progression was also lower in current than in never smokers. This is the first major study to demonstrate any relationship between
smoking and DR . Earlier WESDR data did not confirm this relationship.*
5. Gravida
• * Ramandeep Sing et all : Diabetic Retinopathy An Update , Indian J.O 2008 May-Jul
• ** Guidelines of the Management Diabetic Retinopathy, Cwealth Australia 2008
Gen
Pregnant women with diabetes twice the risk of developing PDR
than non-pregnant women. The cause of DR maybe factors both metabolic and hormonal *.
Among women with NPDR at the onset pregnancy , 47 % developed
increased NPDR and 5% developed PDR during pregnancy, of whom 29% regression postpartum and 50% required laser treatment.
Among women with PDR prior to pregnancy ,46% progressed during pregnancy. Therefore, early progressive scatter laser treatment of active neovascularisation is warranted when high-risk
6. Renal Disease (Nephropathy)
DR is a well established risk factor for the development of Diabetic Nephropathy (DN), with a 50% probability that DN will develop within 5 years and a 7% probability that DN will develop within 12 years in patients with existing DR. few report however, show that DN predict to development of progression of DR. In the WESDR , a population based cohort study , either gross proteinuria or microalbuminuria was a marker for PDR. *
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gftssk7. Cataract surgery
Henricksen (1996) reported that progression of retinopathy
occurred in 30 out of the 70 eyes after cataract surgery. Patients who progressed had a significantly higher incidence macular edema than those who did not progress. *
Chris Emery (2009) reported A year after phacoemulcification
surgery, 28,2 % of the eyes that were on operated on developed DR, compared to only 13,8% of nonsurgical eyes. In patients who had the surgery in only one eye, 35,6% of the eyes operated on showed signs of DR progression compared to only 20% of the eyes that
weren’t surgically .**
8. Diabetes duration
Duration
9. Anemia
In ETDRS , low hematocrit levels at baseline were identified as independent risk factor for the development of high risk PDR and severe visual loss. An increased risk of retinopathy in patients with Hb level < 12 g/dl. Anemia-induced retinal hypoxia is speculated as cause of development of microaneurysm and other retinopathy
stage *
Classification
Non Proliferative DR ( NPDR )
Mild : at least 1 microaneurysm
Moderate : microaneurysm, hemorrhages & hard exudates
Severe : microaneurysm,hemorrhages, venous beading & IRMA
Proliferative DR (PDR) :
There are new vessel, preretinal hemorrhage, hemorrhage in to vitreous, fibrovascular tissue, tractional retinal detachment, macular edema.
Early
High risk
Advanced
* American
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Pathogenesis
The exact cause of diabetic microvascular disease is unknown.
The precise role in the pathogenesis of retinopathy is not well defined.
It is believed that exposure to hyperglygemia over an extended period results in a number of biochemical and physiologic changes that ultimately cause vascular endothelial damage.
Specific retinal vascular changes include the loss of pericytes and basement membrane thickening.
* American
* American
Pathogenesis
Several theories have been postulated to explain the typical course and
history of disease :
Growth hormone
Platelets and blood viscosity
Aldose reductase and vasoproliferative factors
Vascular Endothel Growth Factors ( VEGF) 1
Implammatory mediators.. 2
Abdish R Bhavsar MD et all : Diabetic Retinopathy : Emedicine Medscape . April 2015
AAO Retina and Vitrous . 2011-2013
* American
* American
* American
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Sympton and Sign
Sympton include : Sign include :
Asymptomatic Microaneurysms
Floaters Dot & blot hemorrhage
Blurred vision Flame shape hemorrhage
Distortion Hard exudates
Progressive visual loss Cotton –wool spots
Neovascularization
Preretinal hemorrhage
Hemorrhage in to vitreous
Diagnose
History
Eye examination
Direct funduscopy
Indirect funduscopy
Slit Lamp with condensing lens ( +78D, Panretinal lens)
Auxcillary examination
Fundus Photograph
AF (Auto Flouresense) , FFA ( Flouresin Fundal Angiography)
OCT ( Optical Coherence Tomography)
USG if media is opacity
Auxcillary examination
* American
Thank You
