diabetic retinopathy steven sanislo, m.d. assistant professor stanford university department of...
TRANSCRIPT
![Page 1: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/1.jpg)
Diabetic Diabetic RetinopathyRetinopathy
Steven Sanislo, M.D.Steven Sanislo, M.D.Assistant ProfessorAssistant Professor
Stanford University Department of Stanford University Department of OphthalmologyOphthalmology
![Page 2: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/2.jpg)
Diabetic RetinopathyDiabetic Retinopathy
Diabetic retinopathy is a leading Diabetic retinopathy is a leading cause of new cases of blindness in cause of new cases of blindness in people aged 20 to 74 years in the people aged 20 to 74 years in the USAUSA
Many of the complications of diabetic Many of the complications of diabetic retinopathy can be prevented or retinopathy can be prevented or delayed by blood glucose control and delayed by blood glucose control and timely intervention.timely intervention.
![Page 3: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/3.jpg)
Ocular AnatomyOcular Anatomy
![Page 4: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/4.jpg)
Retinal AnatomyRetinal Anatomy
![Page 5: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/5.jpg)
Retinal HistologyRetinal Histology
Sclera
Choroid
RPE
Photoreceptorouter segments
Photoreceptorinner segment
Outer Plexiform layer
Bipolar cells
Inner plexiform layer
Ganglion cells
Nerve fiberlayer
![Page 6: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/6.jpg)
Retinal Diagnostic TestsRetinal Diagnostic Tests
Fundus PhotographyFundus Photography Fluorescein Angiography (FA)Fluorescein Angiography (FA) Optical Coherence Tomography Optical Coherence Tomography
(OCT)(OCT) Ocular UltrasonographyOcular Ultrasonography Electroretinography (ERG)Electroretinography (ERG)
![Page 7: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/7.jpg)
Fundus Photos and FAFundus Photos and FA
![Page 8: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/8.jpg)
Fundus PhotographyFundus Photography
![Page 9: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/9.jpg)
Normal FANormal FA
![Page 10: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/10.jpg)
Optical Coherence Optical Coherence Tomography (OCT)Tomography (OCT)
![Page 11: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/11.jpg)
Normal OCTNormal OCT
![Page 12: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/12.jpg)
B-scan UltrasoundB-scan Ultrasound
![Page 13: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/13.jpg)
Normal UltrasoundNormal Ultrasound
![Page 14: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/14.jpg)
Pathogenesis of DRPathogenesis of DR
Prolonged hyperglycemia is the Prolonged hyperglycemia is the major etiologic agent in all of the major etiologic agent in all of the microvascular complications of microvascular complications of diabetes, including diabetic diabetes, including diabetic retinopathy. retinopathy.
The cellular mechanisms through The cellular mechanisms through which hyperglycemia acts currently which hyperglycemia acts currently remain unclearremain unclear
![Page 15: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/15.jpg)
Pathogenesis of DRPathogenesis of DR
Mechanisms that have been proposed are:Mechanisms that have been proposed are: 1. hyperglycemia may alter the expression of one 1. hyperglycemia may alter the expression of one
or more genes, leading to increased (or or more genes, leading to increased (or decreased) amounts of certain gene products that decreased) amounts of certain gene products that can alter cellular functions.can alter cellular functions.
2. Glycosylated proteins can undergo a series of 2. Glycosylated proteins can undergo a series of reactions, leading to considerable alteration of reactions, leading to considerable alteration of proteins.proteins.
3. Chronic hyperglycemia may produce oxidative 3. Chronic hyperglycemia may produce oxidative stress in cells, leading to the formation of an stress in cells, leading to the formation of an excess of "toxic end products of oxidation" excess of "toxic end products of oxidation" including peroxides, superoxides, nitric oxide, and including peroxides, superoxides, nitric oxide, and oxygen free radicals.oxygen free radicals.
![Page 16: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/16.jpg)
VEGF and DRVEGF and DR
Vascular Endothelial Growth FactorVascular Endothelial Growth Factor Promotes vascular growth and Promotes vascular growth and
permeability permeability Elevated levels of circulating VEGF Elevated levels of circulating VEGF
in conditions with retinal ischemiain conditions with retinal ischemia
![Page 17: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/17.jpg)
Anatomic ChangesAnatomic Changes
MicroanerysmsMicroanerysms Damage to Damage to
endothelial cells endothelial cells leads to dilated leads to dilated capillaries and capillaries and venules venules
These altered These altered vessels allow vessels allow serum and blood to serum and blood to leak into the retinaleak into the retina
![Page 18: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/18.jpg)
NPDRNPDR
![Page 19: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/19.jpg)
NPDR FANPDR FA
![Page 20: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/20.jpg)
NPDR OCTNPDR OCT
![Page 21: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/21.jpg)
Retinal IschemiaRetinal Ischemia
![Page 22: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/22.jpg)
PDRPDR
![Page 23: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/23.jpg)
PDRPDR
![Page 24: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/24.jpg)
PDR FAPDR FA
![Page 25: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/25.jpg)
Vitreous Hemorrhage Vitreous Hemorrhage (VH)(VH)
![Page 26: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/26.jpg)
VH ultrasoundVH ultrasound
![Page 27: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/27.jpg)
TRD ultrasoundTRD ultrasound
![Page 28: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/28.jpg)
Epiretinal MembraneEpiretinal Membrane
![Page 29: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/29.jpg)
PDR Retinal DetachmentPDR Retinal Detachment
![Page 30: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/30.jpg)
Iris NeovascularizationIris Neovascularization
![Page 31: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/31.jpg)
Mechanisms of Vision Mechanisms of Vision LossLoss
Retinal ischemiaRetinal ischemia Macular edemaMacular edema Vitreous hemorrhageVitreous hemorrhage Epiretinal membrane formationEpiretinal membrane formation Retinal detachmentRetinal detachment Neovascular glaucomaNeovascular glaucoma
![Page 32: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/32.jpg)
PreventionPrevention
Prospective controlled interventional Prospective controlled interventional studies have shown that strict studies have shown that strict control of blood glucose and blood control of blood glucose and blood pressure significantly reduces and pressure significantly reduces and delays the onset and severity of delays the onset and severity of diabetic retinopathy.diabetic retinopathy.
![Page 33: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/33.jpg)
ScreeningScreening
Type 1 diabetics:Type 1 diabetics:First screen 5 years after onset, then First screen 5 years after onset, then annually.annually.
Type 2 diabetics:Type 2 diabetics:First screen upon diagnosis and then First screen upon diagnosis and then annually.annually.
![Page 34: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/34.jpg)
TreatmentTreatment NPDR without macular edema -NPDR without macular edema -
ObserveObserve
Macular edema -Macular edema - 1. Focal/Grid laser photocoagulation1. Focal/Grid laser photocoagulation 2. Vitrectomy with membrane peeling2. Vitrectomy with membrane peeling 3. Intraocular Steroid*3. Intraocular Steroid* 4. Intraocular VEGF inhibitor*4. Intraocular VEGF inhibitor*
* Off-label use, contraversial
![Page 35: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/35.jpg)
DME laser treatmentDME laser treatment
![Page 36: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/36.jpg)
DME laser treatmentDME laser treatment
*
*
**
* * *
**
*
* *
![Page 37: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/37.jpg)
TreatmentTreatment Vitreous Hemorrhage -Vitreous Hemorrhage -
1. Pan-retinal photocoagulation1. Pan-retinal photocoagulation 2. Vitrectomy with laser photocoagulation2. Vitrectomy with laser photocoagulation 3. Intraocular VEGF inhibitor*3. Intraocular VEGF inhibitor*
Traction Retinal Detachment - Traction Retinal Detachment - 1. Observation if not involving the macula1. Observation if not involving the macula 2. Vitrectomy with membrane dissection2. Vitrectomy with membrane dissection
* Off-label use, contraversial
![Page 38: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/38.jpg)
Pan-retinal Pan-retinal PhotocoagulationPhotocoagulation
![Page 39: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/39.jpg)
VitrectomyVitrectomy
![Page 40: Diabetic Retinopathy Steven Sanislo, M.D. Assistant Professor Stanford University Department of Ophthalmology](https://reader035.vdocuments.site/reader035/viewer/2022062715/56649db15503460f94aa0719/html5/thumbnails/40.jpg)
http://www.youtube.com/watch?v=iOwpEa4KB5chttp://www.youtube.com/watch?v=iOwpEa4KB5c