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Pathology-my one > Diabetic Retinopathy Classification > Flashcards

Diabetic Retinopathy Classification Flashcards

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1
Q

What is diabetes?

A

Failure of insulin secretion, insulin action or both

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2
Q

What does insulin do?

A

It lowers blood glucose

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3
Q

What can chronic diabetes affect?

A

Eyes, kidneys, nerves, heart and blood vessels

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4
Q

What are the types of diabetes?

A

Primary: type 1 & 2
Secondary: happens because of something eg. gestational, drugs, pancreatic disease

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5
Q

What is type 1 diabetes?

A

Insulin dependant

loss of insulin production

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6
Q

What is type 2 diabetes?

A

Non-insulin dependant

Ineffective use of insulin (insulin resistance) or insufficient insulin production

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7
Q

Who requires insulin injections?

A

All type 1 and some type 2 diabetic

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8
Q

What are ocular complications of diabetes?

A 
Retinopathy
Retinal detachment
CRVO/CRAO
Anterior ischaemic optic neuropathy (AION)
Maculopathy
Cataract
Rubeosis iridis 
(neovasc glaucoma)
Cranial nerve palsies
Corneal erosions, ulcers, persistent epithelial defects
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9
Q

Which cranial nerves can be affected in diabetic patients?

A

III, IV, VI, VII

Nerves to the extraocular muscles

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10
Q

What is diabetic retinopathy ?

A

It is a microvascular disease which means it affects the small blood vessels i.e capillaries

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11
Q

What is the earliest sign of DR?

A

Micro-aneurysms

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12
Q

What affects the risk of getting DR and progression of DR?

A
  • Duration person has had diabetes
  • Control of DM
  • Type (1 more common to get DR)
  • HTN, high cholesterol
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13
Q

What is the DES programme?

A

Diabetic eye screening offered by the NHS to 12+ type 1 and type 2 diabetics

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14
Q

What happens at the screening?

A

BCVA
Patient dilated
2 images taken for each eye, 1 centred on the macula and 1 centred on the optic disc. Both images merged together

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15
Q

What happens with the images taken

A

The images are graded. Optometrists or ophthalmologists grade the images. You can become a grader-need to be accredited

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16
Q

What does it mean if the image is not gradeable?

A

Patient may have cataract or asteroid hyalosis for example which does not give a clear image. these patients then need to be seen on slit lamp

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17
Q

Which two part of the retina does DR affect?

A

Periphery (R) or macula (M)

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18
Q

What 2 types of DR are there?

A

Non-Proliferative=no new blood vessels

Proliferative= new blood vessels

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19
Q

What are the retinopathy grades?

A 
R0= No DR
R1= Background DR (no referral)
R2= Pre-proliferative (refer)
R3= Proliferative (urgent refer)
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20
Q

What are the features of R1?

A

Background DR

  • Micro-aneurysm
  • Retinal haemorrhage dot/blot
  • Exudates
  • Venous loops
  • Cotton wool spot in presence of other R1 features (meaning a single CWS and no other feature is R0)
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21
Q

What are the features of R2?

A

Pre-proliferative

  • Multiple blot haemorrhages
  • Venous beading
  • Venous reduplication
  • Intra-retinal microvascular abnormality (IRMA)
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22
Q

What are the features of R3?

Study These Flashcards
A

Proliferative

  • NVD: New vessels at disc
  • NVE: New vessels elsewhere
  • Pre-retinal or vitreous haemorrhages
  • Pre-retinal fibrosis ± tractional retinal detachment
23
Q

What are micro-aneurysms caused by and what do they look like?

Study These Flashcards
A

Vessels become weaker causing pouches to be formed in the vessel walls.
Rupture of vessels in the inner nuclear layer

Small dark red dots with sharp border, even 1 diagnoses DR

24
Q

What are dot haemorrhages and what do they look like?

Study These Flashcards
A

Capillaries in the inner plexiform layer ruptured

They look exactly like micro-aneurysm.Smaller than blot haemorrhages but larger than micro-aneurysms.

25
What are blot haemorrhages and what do they look like?
Deeper capillaries between IPL and INL. Sign of local ischaemia Larger and darker than dot
26
How do you know if it's R1 or R2 when blot haemorrhages are present?
If only a few then R1 If multiple and in all 4 quadrants then R2
27
What are flame shaped haemorrhages?
Occurs in the nerve fibre layer so feathery appearance as they follow pattern of nerve fibre axons
28
What are conditions are flame shaped haemorrhages seen in?
HTN Glaucoma Vein occlusion
29
What are exudates and what do they look like?
Lipid and lipoprotein deposits leaking from capillaries in the outer or inner plexiform layer (fat leaking out of blood vessels). Can reabsorb spontaneously or after treatment. Bright yellow appearance
30
How can you differentiate exudates from drusen?
Drusen are hazier in colour whereas exudates appear yellowish white OCT: Drusen is under the RPE which you can differentiate from exudate which are in inner retinal layer
31
What is oedema and what does it look like?
Accumulation of fluid within retina. Exudate and oedema shows the same thing – leakage from blood vessels, oedema is a leakage of fluid from blood vessels whereas exudate is leakage of fat, hard to see, best to see on OCT-black pockets of fluid in inner retinal layers May see cysts and greying on fundus
32
What are CWS and what do they look like?
Fluffy white lesions in RNFL Caused by focal or diffuse inner retinal ischaemia, disrupting RNFL axonal transport. Basically arterial blood supply is reduced. They can reabsorb but can take 6+ months They look fluffy white and obscure blood vessels underneath
33
What are venous loops and what do they look like?
Abrupt curving away from normal path of vessel
34
How can you remember R1 features?
``` H O M E +CWS and venous loops ```
35
What is IRMA?
Intraretinal Microvascular Anomaly - IRMA are little capillaries that have dilates to bring extra blood in areas that have become hypoxia - Odd branching patterns - Doesn't leak and doesn't cross major vessels - Indicates ischameia - They look like new vessels but they are not
36
How can you tell it's IRMA and not new vessels?
They don’t cross major vessels, run from arteriole to venule and they don’t leak-when u do FA the flurocene doesn’t leak
37
What venous changes can occur in R2?
Beading=looks like sausages Occluded vessels, sign of severe ischaemia
38
Why do new vessels grow in R3?
In response to growth factors (VEGF) due to ischaemia. Retina in under nourished so to compensate for this they eye grows new vessels
39
What do the new vessels look like
Fragile, thin, leak and bleed, loop back on themselves Crosses major vessels Obscures underlying lesions therefore on top of retina Eventually grows into vitreous
40
Why does R3 require urgent referral?
High risk of vitreous haemorrhage. Associated with fibrous traction on retina. NVD= 50% risk blindness in 5y if untreated. NVE=30% risk blindness in 5 years if left untreated
41
How does Pre-retinal / vitreous haemorrhage occur?
When new vessels grow forward from the retina, cross pre retinal space and enter vitreous
42
What are the symptoms of vitreous haemorrhage?
Sudden visual loss or sudden onset of dark floaters.
43
What does vitreous haemorrhage look like?
Appears dark, may completely block view of the retina. Flat top due to red blood cells settling down due to gravity (boat shape or D shape)
44
Is a vitreous haemorrhage reversible?
It can reabsorb but takes months or years for the blood to reabsorb. If it doesn't in 6 months then vitrectomy is done
45
What is a Pre-Retinal Fibrous Traction?
Retinal detachment= retina is pulled off from the underlying choroid due to the fibrous tissue contracting May have sudden loss of vision
46
What does a Pre-Retinal Fibrous Traction look like?
Retina may appear wrinkled (traction lines), bumped and folded, or tears may be visible.
47
What is Rubeosis Iridis?
Severe retinal hypoxia can cause new vessels to grow on the iris
48
What can Rubeosis Iridis cause?
Neovascular glaucoma due to fibrovascular tissue blocking angle of drainage. Very painful
49
What is M0?
No maculopathy Non-referable maculopathy (MAs or haems within 1DD of fovea but vision better than 0.3 LogMAR/ Snellen 6/12)
50
What is M1?
Exudate within 1 disc diameter of the centre of the fovea Circinate or group of exudates within the macula Retinal thickening within 1 DD of the centre of the fovea (fluid pockets on OCT) Any microaneurysm or haemorrhage within 1 DD of the centre of the fovea ONLY if associated with VA worse than Snellen 6/12 or 0.3 logMAR Requires treatment: Clinically Significant Macular Oedema (CSMO)
51
What is P0?
No photocoagulation (laser scars)
52
What is P1?
Presence of photocoagulation scars: - Evidence of focal/ grid laser to macula - Evidence of peripheral scatter laser
53
Why is laser treatment used for proliferative retinopathy?
Laser burns reduces the oxygen demands so less hypoxia
54
What are the referral guidelines for DR?
R1=annual review R2=Routine referral to HES R3 new vessels=urgent referral to HES R3 sudden loss of VA, ret detachment, vitreous haem, rubeosis iridis= emergency referral M1= routine referral P1=refer to HES if not recorded before

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