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178.e3
CHAPTER 22
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Diabetic Retinopathy
KEY TEACHING POINTS
• Three-quarters of patients with diabetic retinopathy have normal visual acuity.
• The findings that best predict subsequent proliferative retinopathy are venous beading,
intraretinal microvascular abnormalities, and the extent of microaneurysms and
hemorrhages. Soft and hard exudates are less predictive.
• Specialists using direct ophthalmoscopy are more accurate than are general clinicians,
and examinations through dilated pupils are superior to nondilated ones.
• Nonmydriatic digital images have proven accuracy and are commonly used to screen
large numbers of diabetic patients for retinopathy.
Introduction
I.
Diabetic retinopathy is the leading cause of blindness in adults aged 20 to 74 years.
1
Whether a patient
develops retinopathy depends on the type and duration of diabetes: those with type 1 diabetes have
a 0% risk of proliferative retinopathy at 5 years after diagnosis, 4% at 10 years and 50% at 20 years,
whereas those with type 2 diabetes, especially if taking insulin, the risk is 3% to 4% at the time of
diagnosis, 10% at 10 years and 20% at 15 years.
2
Once retinopathy develops, however, the best predictor of progression to sight-threatening retinopathy is the extent of retinopathy during the baseline
examination: the higher the grade of retinopathy during the initial examination, the greater the risk
of progression (Table 22.1). In type 1 diabetics, pregnancy increases the risk of progression 2.3-fold.
2
In large cross-sectional surveys of diabetic patients seen by general practitioners, sightthreatening retinopathy (i.e., proliferative retinopathy and more severe forms of nonproliferative
retinopathy) is found in 5% to 15% of patients.
II.
The Findings
e findings of diabetic retinopathy are divided into nonproliferative changes, which occur within
the retina, and proliferative changes, which are located on the inner surface of the retina or in the
11
vitreous.
e terms background retinopathy and preproliferative retinopathy are outdated and no
longer recommended, having been replaced by the grades of retinopathy shown in Table 22.1.
6–10
Diabetic retinopathy progresses in an orderly fashion through these grades.
A. NONPROLIFERATIVE CHANGES (FIG. 22.1)
3
e earliest changes to appear in diabetic retinopathy are microaneurysms, which are distinct
red, round spots less than one-twelfth the diameter of an average optic disc, or 125 μm in its
179
180
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5—HEAD AND NECK
TABLE 22.1 ■ Progression to High-Risk Proliferative Diabetic Retinopathy*
Cumulative Risk (%) of
High-Risk Proliferative
Grade of Baseline
Retinopathy Principal Clinical Findings
Nonproliferative retinopathy
Mild Microaneurysms
Moderate Extensive microaneurysms and hemorrhages
Severe Same as moderate
Very severe Same as moderate
Proliferative retinopathy
*High-risk proliferative retinopathy is NVD >0.25 of disc area, NVD <0.25 of disc area and vitreous or preretinal
hemorrhage, OR NVE >0.5 disc area and vitreous or preretinal hemorrhage. These figures assume that the
patient is untreated.
†
Moderate, severe, and very severe nonproliferative retinopathy share the same fundoscopic findings, although
they differ in severity (based on standardized photographs) and the number of retinal quadrants involved.
‡
Percentages are for patients whose baseline evaluation reveals proliferative retinopathy with less than high-risk
characteristics.
IRMA, Intraretinal microvascular abnormalities; NVD, neovascularization within one disc diameter of the optic
disc; NVE, neovascularization elsewhere, i.e., beyond one disc diameter of the optic disc; see the text.
Dot and blot hemorrhages
Soft exudates
IRMA
Venous beading
‡
Neovascularization
Preretinal/vitreous hemorrhages
Fibrovascular proliferation
†
†
Retinopathy at:
1 year 5 years
1 16
3–8 27–39
15 56
45 71
22–46 64–75
3–5
longest dimension (the average optic disc is about 1500 μm in diameter; 125 μm is approximately
the
width of an average major vein at the disc margin).
with sharp borders; red spots with indistinct borders are blot hemorrhages. Both dot and blot
hemorrhages are located in the inner retinal layers. Hard exudates (deposition of lipids in the
inner retina) are small, white or yellowish-white deposits with sharp margins that often have a
waxy or glistening appearance. Soft exudates (or cotton wool exudates) are ischemic swellings
of the superficial nerve fiber layer, which appear as white, round, or oval patches with ill-defined,
feathery edges. As retinal ischemia progresses, two other abnormalities appear: venous beading
(veins resembling a string of beads) and intraretinal microvascular abnormalities (IRMA), which
are extra tortuous vessels within the retina that may be either new vessels or dilated preexisting
capillaries.
B.
PROLIFERATIVE RETINOPATHY
Proliferative retinopathy is new vessel formation (i.e., neovascularization) on the inner surface
of the retina or vitreous, which threatens vision by increasing the risk of retinal detachment or
vitreous hemorrhage. ese new vessels often resemble a small wagon wheel, with individual
vessels radiating like spokes to a circumferential vessel forming the rim.
is subdivided into neovascularization of the disc (within one disc diameter of the optic disc,
abbreviated [NVD]) and neovascularization elsewhere (NVE). Of the two, NVD has a much
worse visual prognosis.
5
Dot hemorrhages are
12
New vessel formation
larger red dots
22—DIABETIC RETINOPATHY
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AB
CD
Dot/blot hemorrhages
Microaneurysms
Hard exudates
Soft exudates
Diameter of major vein
at disc margin
a
a
c
c
181
d
d
b
b
Neovascularization
of the disc (NVD)
Venous beading
Intraretinal microvascular
abnormalities (IRMA)
Fig. 22.1 Types of diabetic retinopathy. The center figure depicting the fundus of a patient with diabetic
retinopathy is surrounded by four enlarged views, each labeled with a letter (A to D) corresponding to specific
locations on the center figure. (A) Microaneurysms and dot/blot hemorrhages. The diameter of microaneurysms is less than the width of a major vein at the disc margin (reproduced in square inset). (B) Hard and soft
exudates. (C) Venous beading and intraretinal microvascular abnormalities (IRMA). (D) Neovascularization,
which may be located within one disc diameter of the optic disc (NVD) or elsewhere (NVE). Although both
IRMA and neovascularization represent the formation of new blood vessels, IRMA is confined to the layers of
the retina, whereas neovascularization is on the inner surface of the retina or vitreous (see the text).
C. MACULAR EDEMA
Macular edema, which may accompany any stage of nonproliferative or proliferative retinopathy,
is very difficult to visualize using the direct ophthalmoscope, although important clues are rings of
hard exudates (often surrounding the edematous area) and diminished visual acuity.
11
III. Clinical Significance
In patients with high-risk proliferative retinopathy or those with clinically significant macular
edema, laser photocoagulation or intravitreal injections of anti–vascular endothelial growth factor
182
LRs
DIABETIC RETINOPATHY
Abnormal nondilated examination
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5—HEAD AND NECK
(anti-VEGF) significantly reduces the risk of subsequent visual loss.1 Retinal examination is the
only way to detect these lesions, thereby making diabetic retinopathy one of the best examples of
a disorder benefiting from an attentive physical examination.
e findings that best predict subsequent proliferative retinopathy are venous beading, intraretinal microvascular abnormalities, and the extent of microaneurysms and hemorrhages. Soft
exudates are less predictive, and the extent of hard exudates correlates poorly with subsequent
proliferative retinopathy.
5
A. VISUAL ACUITY AND DIABETIC RETINOPATHY
Diminished visual acuity per se is a poor screening test for diabetic retinopathy (EBM Box 22.1:
positive likelihood ratio [LR] = 1.5, negative LR not significant [NS]). Indeed, the most common
causes of diminished visual acuity in diabetics are cataracts (49% of diabetics with diminished
acuity) and macular degeneration (29%), not diabetic retinopathy (15%).
14
EBM BOX 22.1 Ophthalmoscopy and Diabetic Retinopathy
Sensitivity
6–10
†
(%)
21–28 82–86 1.5 NS
50 92 6.2 0.5
15
53–69 91–96 9.4 0.4
48–82 90–100 25.5 0.3
Finding (Reference)
Detecting any diabetic retinopathy
Visual acuity 20/40 or
13,14
worse
Detecting sight-threatening retinopathy, using the following technique
Direct ophthalmoscopy,
nondilated pupils
Direct ophthalmoscopy,
dilated pupils,
general
8,9,16–18
providers
Direct ophthalmoscopy,
dilated pupils,
specialists
*Diagnostic standard: for sight-threatening retinopathy, retinal photographs through dilated pupils or slitlamp biomicroscopy reveal proliferative retinopathy, macular edema, or both.
†
Definition of findings: for sight-threatening retinopathy, proliferative retinopathy, macular edema, or both.
‡
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
Specificity
(%)
Likelihood Ratio‡ if Finding Is
Present Absent
*
Probability
Decrease Increase
+45%+30%+15%–15%–30%–45%
0.1 0.2 0.5 12510
LRs
Normal dilated examination
(specialists)
Abnormal dilated
examination (specialists)
Abnormal dilated examination
(nonspecialists)
22—DIABETIC RETINOPATHY
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183
TABLE 22.2 ■ Recommended Ophthalmologic Examination Schedule for Patients With Diabetes
Mellitus
Time of Onset of
Diabetes
Less than 30 years of
age*
30 years of age or older* At time of diagnosis of diabetes Yearly
Pregnancy in preexisting
diabetes
*Less than 30 years and greater than 30 years are operational definitions of type 1 and type 2 diabetes used in
the Wisconsin Epidemiologic Study of Diabetic Retinopathy.
†
In some patients with normal eye examinations, eye specialists may advise less frequent examinations (every 2
to 3 years).
1
Recommended First
Examination Minimal Routine Follow-Up
Within 5 years after diagnosis of
diabetes
Prior to conception and during
first trimester
†
Yearly
†
Physician discretion pending results
of first trimester examination
B. DIAGNOSTIC ACCURACY OF OPHTHALMOSCOPY
EBM Box 22.1 displays the accuracy of various methods in detecting sight-threatening retino-
pathy (i.e., proliferative changes and macular edema), using multiview dilated pupil retinal photographs or slit-lamp biomicroscopy as the diagnostic standard. Not surprisingly, specialists using
direct ophthalmoscopy perform better than general clinicians, and dilated examinations are superior to nondilated ones (LRs 6.2 to 25.5; EBM Box 22.1). In comparison, many diabetic centers
now routinely screen their patients for retinopathy using nonmydriatic photography, a test with
excellent diagnostic accuracy (positive LR = 24.5, negative LR = 0.1).19*
Macular edema is rarely detected by general providers using direct ophthalmoscopy (sensitivity
is close to 0%).20 Because many patients with macular edema have normal visual acuity (i.e., the
sensitivity of “visual acuity worse than 20/30” for macular edema is only 38%),20 clinicians who
screen for macular edema using just visual acuity are missing many patients who would benefit
from treatment.
C. SCREENING RECOMMENDATIONS
Diabetic retinopathy is common, treatable, and detectable using simple tools. Consequently, it is
the prototype of a disease that would benefit from organized screening. Table 22.2 reviews the
screening schedule recommended by the American Diabetes Association.1 Given the stakes of
missing serious retinopathy and the suboptimal performance of general clinicians using direct
ophthalmoscopy, only clinicians with training and experience—in most cases, optometrists and
ophthalmologists—should screen patients. Any patient with macular edema, more than moderate
nonproliferative retinopathy, or proliferative retinopathy should be seen by eye care providers with
experience in the management of diabetic retinopathy.
References may be accessed online at Elsevier eBooks for Practicing Clinicians.
*e LRs of 24.5 and 0.1 (from reference 19) refer to >2 field nonmydriatic photographs in detecting “any
diabetic retinopathy” compared to retinal photographs through dilated pupils or slit-lamp biomicroscopy.
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23
The Red Eye
KEY TEACHING POINTS
• In patients with red eye, the finding of anisocoria or painful pupillary constriction increases
the probability of serious eye disease.
• The presence of significant eye pain or visual blurring in the patient with red eye should
prompt referral to a specialist.
• Bacterial conjunctivitis is more likely than viral or allergic conjunctivitis if there is
bilateral matting of the eyes, conjunctival redness obscuring tarsal vessels, or purulent
discharge.
Introduction
I.
e term red eye refers to several acute inflammatory disorders of the eye, all of which produce prominent ocular erythema. For clinicians evaluating patients with the red eye, the most important decision
is to distinguish serious disorders (e.g., iritis, keratitis, corneal abrasion, scleritis, or acute glaucoma)
from more benign disorders of the conjunctiva (e.g., conjunctivitis, episcleritis, or subconjunctival hemorrhage). All patients with serious disorders require urgent referral to an eye specialist. In patients
with suspected conjunctivitis, distinguishing bacterial conjunctivitis from nonbacterial (viral, allergic)
conjunctivitis is important because only bacterial conjunctivitis benefits from administration of topical
antimicrobial eye drops.
with identifying serious disease and on those distinguishing bacterial from nonbacterial conjunctivitis.
Descriptions of the red eye are as old as ophthalmologic records, figuring prominently in
descriptions from ancient Egypt and classical Greece and Rome.
descriptions likely suffered from trachoma or other contagious diseases of the eye.
ophthalmologist Charles Saint Yves (1667–1736) is credited with the first clear description of
iritis, including its characteristic redness, photophobia, pain, and decreased pupillary diameter.
II.
The Findings
A. DISTINGUISHING SERIOUS FROM BENIGN DISEASE
e traditional signs of serious causes of the red eye are significant eye pain, visual blurring, photophobia, and abnormalities of the pupil.
1. Visual Acuity
Benign causes of the red eye do not affect visual acuity, except for the temporary effects of purulent
exudate in bacterial conjunctivitis, a blurriness that resolves when secretions are wiped away. In
1
is chapter therefore focuses on those bedside findings that assist clinicians
2
Many patients in these ancient
3
e French
2
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