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Snapshot
  • A 47-year-old man presents with progressive worsening of his symptoms. He reports having increased bluriness that does not improve with frequent blinking or glasses. Medical history is remarkable for type II diabetes, and his last hemoglobin A1c was 11%. He is currently on metformin and insulin; however, he has been nonadherent to his medications. A dilated study was perfomed via slit-lamp examination, which demonstrated multiple dot and blot hemorrhages, microaneurysms, and hard exudates. (Nonproliferative diabetic retinopathy)
Introduction
  • Overview
    • ocular manifestations for chronic hyperglycemia leading to microvascular and retinal dysfunction
      • diabetic retinopathy is classified as
        • nonproliferative
          • absence of neovascularizations
        • proliferative 
          • presence of neovascularizations
  • Epidemiology
    • incidence
      • an important cause of visual loss worldwide
      • most common cause of preventable blindness
    • risk factors
      • poorly controlled diabetes
  • Pathophysiology
    • chronic hyperglycemia impairs autoregulation of retinal blood flow
      • leads to shear stress on the retinal vasculature, resulting in
        • production of vasoactive molecules
        • vascular leakage
        • macular edema
    • retinal microthrombosis
      • occludes retinal capillaries and increases capillary leakage
        • retinal ischemia leads to the release of many growth factors (e.g., VEGF)
    • growth factors
      • leads to the production of new blood vessels (neovascularization)
        • increases the risk of a vitreous hemorrhage 
  • Prognosis
    • if untreated can progress to proliferative diabetic retinopathy
Presentation
  • Symptoms
    • decreased visual acuity
  • Physical exam
    • nonproliferative diabetic retinopathy
      • dot and blot hemorrhages
      • hard exudates
        • reflects leakage of lipids and proteinacenous materal
      • capillary microaneurysms
    • proliferative diabetic retinopathy
      • neovascularization
      • vitreous hemorrhage, if newly formed vessels rupture 
Studies
  • Serum studies
    • hemoglobin A1c
Differential
  • Hypertensive retinopathy
    • differentiating factors
      • arteriovenous nicking
      • silver or copper wiring
Treatment
  • Lifestyle
    • optimizing glycemic, lipid, and blood pressure control
      • indication
        • holistic management
  • Medical
    • intravitreal anti-vascular endothelial growth factor (VEGF)
      • indication
        • significant macular edema
        • proliferative diabetic retinopathy
      • medications
        • bevacizumab
        • ranibizumab
        • aflibercept
  • Surgical
    • panretinal photocoagulation
      • indication
        • significant macular edema
        • proliferative diabetic retinopathy
Complications
  • Blindness

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