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Delaying and preventing diabetic retinopathy in primary care For this session you will need to use your phones or the clickers provided. If you choose to use the clickers there will be some questions you will not be able to answer. To

  1. Delaying and preventing diabetic retinopathy in primary care • For this session you will need to use your phones or the clickers provided. • If you choose to use the clickers there will be some questions you will not be able to answer. • To use your phone please download the turning point app from your app store • The session code for this session is dpc2019tuesday • Or please use your web browser and go to: www.ttpoll.eu • The session code for this session is dpc2019tuesday

  2. A chronic progressive, potentially Delaying and preventing sight-threatening diabetic retinopathy in disease primary care of the retinal Dr Rebecca Thomas neuro- Diabetes Research Unit vasculature Cymru associated Swansea University Medical School with diabetes mellitus

  3. Diabetic Eye Health : Global Perspective: Diabetes Pandemic : Diabetes Any DR STDR Year Increase 2017: 7% of world population (Millions) Million (%) Millions (%) 2045: 10% of world population 2017 425 149 (35%) 47 (11%) Population expansion, increased ageing, urbanisation, reduced 2045 629 220 (35%) 69 (11%) +48% physical activity, dietary changes DR = Diabetic Retinopathy; STDR = Sight-threatening DR 629 m Adults with diabetes Year 425 m 2045 Adults with diabetes Year 2017 220 m Have any DR 149 m Have any DR 69 m 47 m Have Vision Threatening Have Vision DR Threatening DR SUMMARY

  4. Diabetic Eye Disease : GLOBAL Prevalence & Risk Factors Pooled analysis of 35 studies (n=22,896) based on retinal images (1980-2008): Overall Prevalence (%): → Any DR ~ 35% → P roliferative DR ~ 7% ; → D iabetic M acular E dema ~ 7% →V ision- T hreatening DR ~ 11% Global estimates (millions) : → Any DR ~ 93 → P roliferative DR ~ 17 Prevalence of DR greater with increasing → D iabetic M acular E dema ~ 21 HbA1c, BP and duration of diabetes → V ision- T hreatening DR ~ 28 Prevalence higher in Type 1 than Type 2DM Yau et al Diabetes Care 2012;35:556-564 2017 Global estimates (millions) : → Any DR ~150 → V ision- T hreatening DR ~ 50

  5. Causes of Blindness: England and Wales Comparison between 1990-91 and 1999-2000 causes of blindness in England and Wales: Increasing problem Major Causes of ALL 1990-1991* 1999-2000** Blindness Certifications (% of Total) (% of Total) Remaining as: Blind Blind 1. A ge related M acular All 16-64 All 16-64 D egeneration (AMD) AMD 48.5 11.3 57.2 7.7 2. Glaucoma 3. Diabetic Retinopathy Glaucoma 11.7 5.3 10.9 5.4 4. Optic atrophy D Retinopathy 3.4 11.9 5.9 17.7 Optic atrophy 3.4 9.4 3.1 10.1 Working age group (16-64 Cataract 3.3 3.4 1.0 N/A years)… DR leading cause Major causes of AVOIDABLE Blindness : * Evans et al Health Trends 1996;28:5-12 with the most marked 1. Diabetic Retinopathy ** Bunce & Wormald 2006; BMC Public Health; 6:58 increase from 11.9 to 17.7% 2. Glaucoma & 3.Cataract ** Bunce & Wormald 2008; Eye;22:905-11 = 85% of potentially avoidable cases of visual impairment……

  6. OUTCOME of Screening for Diabetic Retinopathy in the UK A comparison of the causes of blindness certifications in England and Wales in working age adults (16-64 years): 1999-2000 versus 2009-2010 Design : Analysis of National database of Blindness C ertificates of V ision I mpairment (CVIs) in working age 16-64 years (n=1756) Main cause of blindness 1990-2000 2009-2010 Diabetic Retinopathy/maculopathy 17.7% 14.4% Hereditary Retinal Disorders 15.8% 20.2% Optic atrophy 10.1% 14.1% Conclusions : For the first time in at least five decades, diabetic retinopathy/maculopathy is NO longer the leading cause of certifiable blindness among working age adults in England & Wales. “This change may be related to factors which include introducing a Nationwide Diabetic Retinopathy Screening in England & Wales…” Liew et al bmjopn.bmj.com 4 th August, 2014

  7. OUTCOME of Screening for Diabetic Retinopathy Wales Retrospective analysis of newly recorded certifications of visual impairment due to diabetic retinopathy in Wales during 2007-2015 Prediction: Blindness & Visual “A National program impairment due to DR delivered in Wales 2007-2015 to a high quality (across all age can reduce groups) new blindness CVIs down by half due to diabetic retinopathy by A 49.4% reduction in 40% serious sight loss within 5 years” (blindness) after 8 National Screening years of screening. Committee, 2001 Thomas et al BMJ Open 2017;7:e015024.

  8. Can you identify the optic disc? www.ttpoll.eu 10 dpc2019tuesday

  9. Can you identify the fovea/macula? www.ttpoll.eu 10 dpc2019tuesday

  10. Which eye (Right or Left) is this? A. Right eye B. Left eye www.ttpoll.eu 10 dpc2019tuesday

  11. Early Diabetic Retinopathy : Retinal Vasculature HYPERGLYCAEMIA loss of pericytes Polyol pathway overactivity endothelial cell proliferation Growth factors white cell migration, ‘plugging’ increased adhesion molecules pro-coagulant status increased intra-luminal pressure 1 Micro-aneurysms

  12. Early Diabetic Retinopathy : Retinal Vasculature

  13. Early Diabetic Retinopathy : Retinal Vasculature Disruption of endothelial cells - Oxidative ‘stress’ - free radical damage Advanced glycation end products (AGEs) Vascular permeability factor (VPF) Release of kinins, PGs, adhesion molecules Disruption of endothelial ‘tight’ junctions ‘fenestrations’ 2 Excessive capillary permeability

  14. Early Diabetic Retinopathy : Exudates (maculopathy)

  15. Diabetic Retinopathy (DR) : Pathogenesis Intra-vascular coagulation - Increased platelet ‘ stickiness’ Adherance of white blood cells to endothelium Exposed basement membrane Pro-coagulant status 3 Capillary closure

  16. Diabetic Retinopathy (DR) : Pre-Proliferative DR

  17. Diabetic Retinopathy (DR) : Pre-Proliferative DR

  18. Diabetic Retinopathy (DR) : Pathogenesis Endolthelial cell proliferation - ‘growth - promotion’ - loss of inhibitors of endothelial cell proliferation Angiogenic factors Local: VEGF / VPF Fibroblastic growth factor (FGF) Transforming growth factor  (TGF  ) General : circulating, IGF 1 , PDGF. 4 Proliferation of new vessels

  19. Diabetic Retinopathy (DR) : Proliferative DR

  20. Diabetic Retinopathy (DR) : Proliferative DR

  21. What lesions of Diabetic retinopathy can you see in this image? A. A. None B. Microaneurysm(s) C. Haemorrhage(s) D. Microaneurysm(s) and Haemorrhage(s) E. Microaneurysm(s), Haemorrhage(s), and exudate(s) www.ttpoll.eu 10 dpc2019tuesday

  22. Can you find the microaneurysm? www.ttpoll.eu 10 dpc2019tuesday

  23. What lesions of Diabetic retinopathy can you see in this image? A. A. Haemorrhages B. Cotton Wool Spots C. Exudates D. Microaneurysms E. All of the above www.ttpoll.eu 10 dpc2019tuesday

  24. What lesions of Diabetic retinopathy can you see in this image? A. Haemorrhages, Microaneurysms, exudates B. Haemorrhages, Microaneurysms, exudates, New Vessels C. Haemorrhages, Microaneurysms, exudates, New Vessels, Pre-retinal Haemorrhages D. Haemorrhages, Microaneurysms, exudates, New Vessels, Pre-retinal Haemorrhages, Vitreous Haemorrhages www.ttpoll.eu 10 dpc2019tuesday

  25. What do you think is happening in this eye? www.ttpoll.eu 20 dpc2019tuesday

  26. Diabetic Retinopathy (DR) : Classification NO apparent Diabetic Retinopathy NO abnormalities 0 Mild non-proliferative DR Microaneurysms only 1 More than just microaneurysms, Moderate non-proliferative DR 2 less than severe non-proliferative DR Any of the following: Severe non-proliferative DR • Intra- retinal haemorrhages (≥20 in each quadrant), or or • Venous beading (≥2 quadrants), or 3 • Intra- retinal microvascular abnormalities (≥1 Pre-proliferative DR (PPDR) quadrant), with • No signs of proliferative DR One or more of the following: Proliferative DR (Active) • Neo-vascularisation and/or 4 • Vitreous or pre-retinal haemorrhage ICDR: International Clinical Diabetic Retinopathy Severity Level ICO: International Council of Ophthalmology Guidelines for Diabetic Eye Care

  27. Diabetic Retinopathy (DR) : Classification: Maculopathy No retinal thickness* or hard DME absent (M0) exudates in posterior pole Retinal thickness* or hard DME present (M1) exudates in posterior pole Retinal thickness* or hard *Retinal thickness exudates in posterior pole, but Mild DME requires three- outside central subfield of macula (diameter 1000 μ m) dimensional assessment (Optical Retinal thickness* or hard Coherance exudates within central subfield Moderate DME of macula, but not involving Tomography) centre point (‘centre - threatening’ DME) Retinal thickness* or hard exudates involving centre of Severe DME macula (‘centre - involved’ DME) ICO: International Council of Ophthalmology Guidelines for Diabetic Eye Care

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