QuestionSBA
QuestionChoice
This is the treatment for preproliferative/proliferative diabetic retinopathy. Photocoagulation is also done for maculopathy but more locally. Alternatives include intravitreal antivascular endothelial growth factor treatment. This patient has only got background changes on her retinal imaging. The treatment for this is good glycaemic control and maintaining a healthy and active lifestyle. This patient should be advised to stop smoking.
52913
b
Panretinal photocoagulation
QuestionChoice
This is one of the first-line pharmacological treatments for acute angle closure glaucoma (AACG). Diabetic patients have a higher risk of AACG; however, this patient has no symptoms consistent with this, such as pain, loss of vision or vomiting. The patient also has normal optic discs; in glaucoma there is a raised cup:disc ratio. The retinal findings are consistent with background diabetic retinopathy; therefore, first-line treatment is lifestyle advice and good glycaemic control.
52914
c
Acetazolamide
QuestionChoice
This is a patient with type 2 diabetes with background changes (also known as mild preproliferative retinopathy) on her retinal photography (dot/blot/flame haemorrhages, microaneurysms, hard exudates.) There is no evidence of preproliferative change (soft exudates, also known as cotton wool spots, or venous changes) or proliferative changes (new vessels and frank haemorrhage). There are no changes at the macula or within one optic disc space of the macula, which would indicate a diagnosis of maculopathy. The optic disc is normally vertically oval in shape and the central depression is otherwise known as the optic cup. The normal cup:disc ratio is 0.3. For background changes, the mainstay of treatment is lifestyle modifications, such as weight loss, smoking cessation and healthy diet. Glycaemic control is good in this case and it is important to note that rapid tightening of glycaemic control can make retinopathy acutely worse; long-term, gradual control is important for improving long-term outcomes.
52912
a
Lifestyle modifications
QuestionChoice
This is the definitive management for AACG. This patient has no features of glaucoma on clinical presentation or on her retinal photographs. The retinal photography findings describe the normal appearance of the optic discs and of background diabetic retinopathy, the first-line treatment for which is lifestyle advice.
52915
d
Peripheral iridotomy
QuestionChoice
The retinal image findings are consistent with background diabetic retinopathy; therefore, the first-line treatment is lifestyle advice and good glycaemic control. This patient continues to smoke and has a high BMI. Advice to lose weight and quit smoking can improve her long-term outcomes, both in terms of microvascular disease but also macrovascular disease.
52916
e
No treatment required
Concept
Chapter
# Summary

Diabetic retinopathy is a serious complication of diabetes mellitus characterised by vascular occlusion and leakage in the retinal capillaries, leading to potential sight loss if unmanaged. Key signs on fundoscopy include 'dots' (microaneurysms), hard exudates, 'blots' (haemorrhages), engorged tortuous veins, and cotton wool spots. Diagnosis is primarily through fundoscopy, with advanced stages confirmed by fluorescein angiography. Management involves optimal blood glucose control, with advanced cases requiring laser photocoagulation, vitrectomy or intravitreal injections of anti-vascular endothelial growth factor agents.

# Definition

Diabetic retinopathy is a sight-threatening complication of diabetes mellitus, resulting from poor glycaemic control. This leads to vascular occlusion and leakage from the capillaries that supply the retina, causing retinal ischaemia, neovascularisation and, if left untreated, potential loss of sight.

Diabetic retinopathy is a broad term encompassing two primary stages: non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR). NPDR presents in three severity levels:

- **Mild NPDR:** Microaneurysms and dot haemorrhages on fundoscopy.
- **Moderate NPDR:** Microaneurysms, dot and blot haemorrhages, cotton-wool spots, and hard exudates.
- **Severe NPDR:** Beaded veins, intraretinal microvascular abnormalities (IRMA), and extensive retinal hemorrhages.

PDR involves neovascularisation and fibrous proliferation on the retina or vitreous, posing a higher risk of severe vision loss.



# Epidemiology

Diabetes is the leading cause of severe visual impairment among working-age individuals in England, Wales, and Scotland. The risk of diabetic retinopathy increases with the duration of diabetes and poor glycaemic control.

# Pathophysiology

Chronic hyperglycaemia in diabetes mellitus causes structural changes to the retinal capillaries, including thickening of the basement membrane and loss of pericytes. This results in capillary occlusion and leakage, leading to retinal ischaemia and formation of new, fragile vessels.

# Signs and symptoms

Early stages of diabetic retinopathy may be asymptomatic. As the disease progresses, symptoms can include:

- Floaters or dark spots in the vision
- Blurred or distorted vision
- Difficulty seeing at night
- Sudden loss of vision

# Differential diagnosis

Other conditions that can cause similar symptoms include:

- Age-related macular degeneration: Mainly affects central vision. Symptoms include distorted vision and difficulty recognising faces.
- Retinal vein occlusion: Sudden painless loss of vision in one eye, often associated with a history of hypertension, hyperlipidaemia or glaucoma.
- Hypertensive retinopathy: Characterised by arteriolar narrowing, copper or silver wiring, flame haemorrhages, and cotton wool spots.

# Investigations

- Fundoscopy: 
	- Signs of milder disease include:
		- Microaneurysms
		- Hard exudates
		- Blot haemorrhages 
	- Severe disease presents with:
		- Engorged tortuous veins
		- Large blot haemorrhages. 
	- In proliferative diabetic retinopathy (PDR), neovascularisation can be observed on the retina or optic disc.
- Optical Coherence Tomography (OCT): Can be used to detect macular oedema.
- Fluorescein angiography: Used in advanced cases to evaluate the extent of neovascularisation and guide treatment.

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# Management

Management strategies include:

- Optimisation of blood glucose control to slow the progression of retinopathy.
- Laser photocoagulation for proliferative diabetic retinopathy and clinically significant macular oedema.
- Intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents for diabetic macular oedema.
- Vitrectomy surgery for advanced cases with complications such as vitreous haemorrhage or retinal detachment.

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# Complications

* **Vitreous Hemorrhage:** Can cause sudden vision loss.
* **Tractional Retinal Detachment:** May lead to blindness.
* **Macular Oedema:** Causes central vision loss.
* **Neovascular Glaucoma:** Can result in severe pain and vision loss.
* **Blindness:** The ultimate complication in untreated or advanced cases.

# References

[Click here for more information on diabetic retinopathy](https://patient.info/doctor/diabetic-retinopathy-and-diabetic-eye-problems)

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An example of flame haemorrhages and hard exudate deposits on a diabetic retina.
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Diabetic retinopathy that has been treated with laser photocoagulation.
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An example of diabetic retinopathy.
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Fundoscopy of patient with mild non-proliferative retinopathy, Credit: Clare Gilbert
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Topic
16
Ophthalmology
1007
Diabetic retinopathy
Topic
16
Ophthalmology
10643
Lifestyle modifications, including weight loss and smoking cessation, are crucial for managing background diabetic retinopathy in type 2 diabetes patients.
A 45-year-old woman with type 2 diabetes mellitus presents for her routine eye screening appointment. She is on metformin monotherapy and her last HbA1c was 44. She is a current smoker. On examination, she has a body mass index (BMI) of 30. Retinal photography reveals dot and blot haemorrhages and hard exudates. There is no evidence of microvascular growth. The optic discs are vertically oval in shape with a central depression, which has a ratio compared with the disc of 0.3.

What is the most appropriate management for this patient?
a