Diabetic eye disease

Question 1

What is the leading cause of blindness in the UK working population?

1 - diabetic retinopathy
2 - presbyopia
3 - cataract
4 - glaucoma

Answer 1

1 - diabetic retinopathy

Question 2

Diabetic retinopathy is a common microvascular complication of diabetes, characterised by progressive damage to the retina’s blood vessels. Following diagnosis, how long is it before T1DM patients have diabetic retinopathy?

1 - immediately
2 - 3-5 years following diagnosis
3 - 5-10 years
4 - >10 year

Answer 2

2 - 3-5 years following diagnosis

Question 3

What % of patients with T2DM have diabetic retinopathy and how long are they likely to have had it for?

1 - 50-80% of patients for 20 years
2 - 10-20% of patients for 20 years
3 - 50-80% of patients for 10 years
4 - 10-20% of patients for 10 years

Answer 3

1 - 50-80% of patients for 20 years

Question 4

There are 4.9 million people with diabetes in the UK. What number of these have their sight seriously affected by diabetes every year?

1 - 2 million
2 - 1 million
3 - 50,000
4 - 1700

Answer 4

4 - 1700

Question 5

The national diabetic screening process ensures that all T1DM and T2DM patients are seen. But at what age are all diabetic patients entitled to at least one screening every 2 years?

1 - from birth
2 - >5 years old
3 - >12 years old
4 - >16 years old

Answer 5

3 - >12 years old

Question 6

All of the following are forms of diabetic eyes, but which 2 are the most common?

1 - cataracts
2 - retinopathy
3 - maculopathy
4 - vascular occlusions

Answer 6

2 - retinopathy
- damage to the back of the eye as a whole, specifically the blood vessels

3 - maculopathy
- damage/degeneration of the macula specifically
- diabetic macular oedema caused by blood vessels near to the macula that leak fluid or protein onto the macula and typically treated with laser photo coagulation or VEGF medications.

Retina helps with vision, but most visual acuity is in the macula

Question 7

Which of the following is NOT a risk factor for developing diabetic retinopathy?

1 - female gender
2 - disease duration
3 - blood glucose control
4 - hypertension
5 - smoking
6 - pregnancy

Answer 7

1 - female gender

Question 8

When there is hyperglycaemia the sugar in the blood is able to bind with other molecules in the blood, with no enzymatic activity. What is this process called?

1 - enzymatic glycation
2 - non-enzymatic glycation
3 - glycoselation
4 - glucosurinaemia

Answer 8

2 - non-enzymatic glycation

Question 9

When there is hyperglycaemia the sugar in the blood is able to bind with other molecules in the blood, with no enzymatic activity called non-enzymatic glycation. What 2 molecules does sugar typically bind with?

1 - carbohydrates and lipids
2 - lipids and albumin
3 - proteins and lipids
4 - proteins and carbohydrates

Answer 9

3 - proteins and lipids

Question 10

When there is hyperglycaemia the sugar in the blood is able to bind with other molecules in the blood, with no enzymatic activity called non-enzymatic glycation, binding with lipids and proteins. Why is this important?

1 - non-enzymatic glycation molecules are very pro-inflammatory
2 - non-enzymatic glycation increases LDL and atherosclerosis
3 - hyaline atherosclerosis causing stiff blood vessels
4 - a thickening of the basement membrane in blood vessels
5 - all of the above

Answer 10

5 - all of the above

Question 11

When there is hyperglycaemia the sugar in the blood is able to bind with other molecules in the blood, with no enzymatic activity called non-enzymatic glycation, binding with lipids and proteins creating very pro-inflammatory molecules. This can then lead to:

• non-enzymatic glycation molecules are very pro-inflammatory
• non-enzymatic glycation increases LDL and atherosclerosis
• hyaline atherosclerosis causing stiff blood vessels
• a thickening of the basement membrane in blood vessels

At a blood vessel and membrane basis what 2 effects can the 2 above disease processes then cause?

1 - decreased blood flow
2 - increased blood flow
3 - decreased gas exchange due to basement membrane thickening
4 - leaky basemement membrane

Answer 11

1 - decreased blood flow

3 - decreased gas exchange due to basement membrane thickening

Question 12

Pericytes are specialist cells that are embedded in the basement membrane of blood capillaries. They wrap around endothelial cells of capillaries and have a close relationship between endothelial cells, astrocytes and neurons and are crucial for normal blood vessel function. Which of the following is NOT a function of pericytes?

1 - regulate blood vessel formation (angiogenesis)
2 - regulate blood flow
3 - regulates immune cells flow
4 - regulates blood glucose

Answer 12

4 - regulates blood glucose

Question 13

In diabetic retinopathy, non-enzymatic glycation between glucose, lipids and proteins leads to the following:

• non-enzymatic glycation molecules are very pro-inflammatory
• non-enzymatic glycation increases LDL and atherosclerosis
• hyaline atherosclerosis causing stiff blood vessels
• a thickening of the basement membrane in blood vessels

Doe the above increase or decrease the number of pericytes in the endothelial cells of the retina?

Answer 13

• decreases the pericytes number

Typically as endothelial damage increases, pericyte number decreases

Question 14

Diabetic retinopathy, is primarily caused by non-enzymatic glycation between glucose, lipids and proteins leads to the following:

• non-enzymatic glycation molecules are very pro-inflammatory
• non-enzymatic glycation increases LDL and atherosclerosis
• hyaline atherosclerosis causing stiff blood vessels
• a thickening of the basement membrane in blood vessels

This can cause all of the following changes in the capillaires of the retina, EXCEPT which one?

1 - microaneurysms = bulge in blood vessels due to weak blood vessel wall
2 - weak blood vessel walls, increasing risk of rupture
3 - angiogenesis of new health blood vessels
4 - rupture can lead to blood loss into the eye

Answer 14

3 - angiogenesis of new health blood vessels

May get new blood vessels, but the quality is never as good due to the high turnover

Question 15

Diabetic retinopathy can thicken the basement membrane and reduce number of pericytes leading to dysfunction and increased permeability of the basement membrane. What can be see clinically on a fundoscope due to increased permeability?

1 - hard exudates
2 - microaneurysms
3 - cotton wool spots
4 - neovascuarlisation

Answer 15

1 - hard exudates

• exudates caused by leaking of lipids and proteins from blood vessels
• appear as thick yellow patches on the retina on fundoscopy

Question 16

In diabetic retinopathy, there is a thickening of the basement membrane, leading to dysfunction and increased permeability. This can lead to changes in the blood vessels, which 2 of the following does this present as upon fundoscope examination?

1 - intraretinal haemorrhage
2 - cotton wool spots
3 - microaneurysms
4 - neovascuarlisation

Answer 16

1 - intraretinal haemorrhage
- leads to blood loss into the retina

2 - cotton wool spots
- microinfarcts, which are essentiall small areas of cell death

Question 17

In diabetic retinopathy ischamia occurs due to a lack of blood flow, thickened basement membranes and dysfunctional capillaries. In response vascular endothelial growth factors are released leading to angiogenesis (neovascularisation called proliferative retinopathy). Although this in principle is a good thing as the vessels aim to increase blood flow to the eye, why can this be bad?

Answer 17

• no
• newly formed blood vessels are weak, which then rupture, leading to more blood in the retina

Question 18

In diabetic retinopathy there is too much glucose, called hyperglycaemia. As the glucose cannot be effectively absorbed it is converted into something else, what is that?

1 - fructose
2 - galactose
3 - sorbital
4 - sucrose

Answer 18

3 - sorbital
- converted by aldose reductase

Question 19

In diabetic retinopathy there is too much glucose, but as this cannot be absorbed it is converted into sorbital, another form of sugar by aldose reductase. Although in principle this may be helpful to reduce glucose levels, this can lead to all of the following, EXCEPT which one?

1 - oxidative stress
2 - hypoxia and endothelial dysfunction
3 - osmotically active so draws H2O into cells
4 - osmotically draws H2O out of cells

Answer 19

4 - osmotically draws H2O out of cells

Question 20

In addition to creating oxidative stress in diabetic retinopathy, excessive levels of sorbitol in the retina can cause oedema drawing in water to the retina and leading to oedema through osmosis. Which part of the eye is particuarly susceptible to this?

1 - iris
2 - choroid
3 - macula
4 - optic disc

Answer 20

3 - macula

Question 21

All of the following are common effects in the eyes of people with retinopathy, EXCEPT which one?

1 - floaters (changes in vitreous composition)
2 - blurred vision
3 - double vision
4 - reduced visual acuity
5 - loss of vision

Answer 21

3 - double vision

Question 22

Label the image below of diabetic retiopathic eye using the labels:

• neovascularisation
• haemorrhage
• cotton wool spots (infarcts)
• hard exudate
• microaneurysms

Answer 22

1 - haemorrhage
2 - microaneurysms
3 - hard exudate
4 - cotton wool spots (infarcts)
5 - neovascularisation

Question 23

Diabetic retinopathy can be divided into proliferative and non-proliferative diabetic retinopathy. Proliferative implies that there is formation of new blood vessels. Which 2 of the following are classed as non-proliferative diabetic retinopathy?

1 - Mild diabetic retinopathy
2 - Active, new blood vessels on the disc or elsewhere
3 - Moderate/Severe diabetic retinopathy
4 - Stable usually previously treated with laser

Answer 23

1 - Mild diabetic retinopathy
graded R1 (scale 0-3)

3 - Moderate/Severe diabetic retinopathy
graded R2 (scale 0-3)

The other 2 are forms of proliferative diabetic retinopathy.

Question 24

The scoring system for diabetic retinopathy uses the following:

1 - R = proliferative retinopathy (scored 0-3)
2 - M = macular oedema (scored 0-1, and P means previous photocoagulation)

Match the management of the patient with their scores using the R and M scoring tools:

• R0 and R1
• R2 and M1
• R3
• immediate referral to ophthalmologist
• annual screening
• seen within 4 weeks

Answer 24

• R0 and R1 = annual screening
• R2 and M1 = seen within 4 weeks
• R3 = immediate referral to ophthalmologist

Question 25

Photocoagulation is a laser used to treat proliferative diabetic retinopathy. What is the purpose of photocoagulation?

1 - remove cotton wool spots
2 - destroy floaters in the eye
3 - shrink or burn new blood vessel formation
4 - break hard exudate

Answer 25

3 - shrink or brun new blood vessel formation

Question 26

In addition to photocoagulation to remove new blood vessels in proliferative diabetic retinopathy, we can use all of the following approaches, EXCEPT which one?

1 - intravitreal steroids (reduces macular oedema)
2 - trabeculectomy
3 - vitrectomy (removal of opaque vitreous humour)
4 - growth factor inhibitors
5 - lifestyle advice and diabetes support

Answer 26

2 - trabeculectomy

This is a surgery used in glaucoma

Question 27

What type of scan can be used to help look at the layers of the macula to help guide and monitor the clinical management of patients?

1 - head MRI
2 - fundoscopy
3 - Optical Coherence Tomography (OCT)
4 - any of the above

Answer 27

3 - Optical Coherence Tomography (OCT)

Question 28

What term can be used to describe the image below depicting new blood vessels development on the anterior surface of the iris in response to retinal ischemia?

1 - rubeosis Iridis
2 - coloboma of the iris
3 - glaucoma
4 - iritis

Answer 28

1 - rubeosis Iridis