diabetic findings what do they mean?

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diabetic findings what do they mean?

cotton wool spot
These yellow-white spots are called cotton wool spots. They are caused by retinal nerve fiber layer microinfarcts. Exploded retinal ganglion cell axons extrude their axoplasm like toothpaste. Expect to find cotton wool spots arrayed around the optic disc and along the temporal vascular arcades.
Cotton wool spots have a myriad of causes. Any process that occludes small retinal arterioles will do this: hypertension, diabetes, HIV, severe anemia or thrombocytopenia, hypercoagulable states, connective tissue disorders, viruses, lues, Behçet's and many others.

rule out myeloma, purtschers,interferon toxicity,

purtschers peripapillary cws surrounds normal optic disc

Joslin notes
renal cws are larger , closer to disc
DM related -at edge of periphery,smaller ,whiter,well defined in mid periphery

diabetic findings what do they mean?

cotton wool spots
Clinical features:
Symptoms:
Asymptomatic
Various degree of blurry vision
Signs:
Localized, white-yellowish, fluffy areas of nerve fiber layer edema
Focal ischemia that causes axoplasmic flow interruption, results in drainage of axoplasmic content into the retina
Commonly found in many vascular diseases:
AIDS
Diabetic retinopathy
Hypertensive retinopathy
Collagen vascular diseases such as SLE, dermatomyositis and polyarteritis nodosa
INTERFERON toxicity used for LIVER disease

Joslin notes
renal cws are larger , closer to disc
DM related -at edge of periphery,smaller ,whiter,well defined in mid periphery

diabetic findings what do they mean?

cotton wool spots

from clinical features of retina disease
results from ischemia
thickening of gangloin cell layer
histopath cystoid bodies in Ganglion cell layer

rule out myeloma, purtschers,interferon toxicity,

purtschers peripapillary cws surrounds normal optic disc

diabetic findings what do they mean?

venous loops
preproliferative sign

Venous loops and reduplications in diabetic retinopathy. Prevalence, distribution, and pattern of development.

Bek T.


Source

Department of Ophthalmology, Arhus University Hospital, Denmark.


Abstract

PURPOSE:

Venous loops and reduplications are rare manifestations of diabetic retinopathy, and knowledge of their natural history is therefore limited to descriptions from a few casuistic reports. The purpose of the present study was to describe the prevalence and clinical characteristics of venous loops and reduplications based on a large data material from the screening clinic for diabetic retinopathy at the Department of Ophthalmology, Arhus University Hospital.

METHODS:

Fundus photographs of 4418 patients were reassessed for the presence of venous loops or reduplications.

RESULTS:

Venous loops or reduplications occurred in 29 (0.66%) of the examined patients, and in 26 of 338 patients with proliferative diabetic retinopathy (7.7%). The abnormalities were most frequent on the larger retinal veins, and in advanced retinopathy, but were unlinked to the development of the proliferative retinopathy. The development of the venous abnormalities was seen to be preceded by a gradual occlusion of a larger vein with the formation of multiple smaller collateral vessels, one or some of which to become the venous loop or reduplication. The epidemiology, localization, and pattern of development of the occlusion preceding the formation of loops or reduplications was different from that of retinal vein thrombosis.

CONCLUSION:

The findings suggest that retinal venous loops and reduplications secondary to diabetic retinopathy are shunt vessels developed to bypass a nonthrombotic occlusion of a larger retinal vein.

sign of severe ischemia or severe npdr
occurs adjacent to ischemic retina

diabetic findings what do they mean?

PRE-PROLIFERATIVE retinopathy consists of any or all of the changes of background diabetic retinopathy with the addition of significant venous beading, cotton wool spots, extensive formation of IRMA, extensive ischemia.
1. Significant venous beading --Initially, venules may show focal areas of dilation which may progress to significant venous beading and formation of venous loops as the diabetic retinopathy progresses.

diabetic findings what do they mean?

notes
venous caliber changes such as dilation,venous beading, or loop formation indicate severe retinal hypoxia

thus a severe stage of npdr

sign of severe ischemia or severe npdr
occurs adjacent to ischemic retina

diabetic findings what do they mean?

IRMA
notes
irma are preexisting retinal capillaries that have adapted to changes in the distribution of retinal blood flow
they adapt from being constricted
so look for constricted retinal vessels

WHY?
dilation of retinal resistance vessels in order to BYPASS areas of CAPILLARY OCCLUSION

can be seen as shunt vessels that connect arterial and venous part of retinal vascular system

HISTOPATH
normally large vessels are on surface with terminal arterioles branching to supply the deeper retinal layers
BUT IRMA has large caliber vessels deep in the retina

IRMA vs NV
IRMA connects arterioles with venules
usually tortuous with FEW SIDE BRANCHES
develop intraretinally
NEVER crossses feeder vessel

NV originates from larger venule and course back to point of origin
nv usually heavily branched
nv grows preretinallymay cross feeder vessel

diabetic findings what do they mean?
irma vs nv

...IRMA vs NV
IRMA connects arterioles with venules
usually tortuous with FEW SIDE BRANCHES
develop intraretinally
NEVER crossses feeder vessel

NV originates from larger venule and course back to point of origin
nv usually heavily branched
nv grows preretinallymay cross feeder vessel

NV
capillary occlusion releases growth factors
in fetal growth , this proliferation of endothelial cells from larger venules connect arteriolar counterparts to form microcirculation
BUT


in mature retina, newly formed vessels are UNABLE to grow inside the retinal tissue to replace the occluded vessels. Therefore, the new vessels grow into the vitreous body where they branch extensively and never connect with an arteriole to allow circulation of the blood

diabetic findings what do they mean?
VENOUS loops and reduplication

notes on venous loops and reduplications
occur in only 1 % of dm patients in screening
but 7-8% with pdr
all of these patients have developed or WILL develop PDR within a few months

WHY?
Because histopath shows endothelial cells that have proliferated inside the vascular lumen

diabetic findings what do they mean?

venous beading
sits near widespread retinal ischemia

diabetic findings what do they mean?
NVE

NVE
main question is it BIGGER than 1/2 disc area
AND assoc with VH or Preretinal Heme
Figure 11 New vessels elsewhere (NVE)
(arrow); note that new vessels have an
abnormal branching pattern, are very fine
and tend to form closed loops and fronds.

diabetic findings what do they mean?
NVD

NVD
Main question is it bigger than 1/4 disc area

Neovascularization of the disc

Neovascularization of the disc is characterized by the development of variable caliber vessels anterior to the optic nerve or retina. They could cross over normal retinal vessels, because they grow anterior to the plane on the retina. These vessels leak profusely on angiogram. Neovascularization over the nerve or within 1500 microns of the edge of the optic nerve (anything within the peripapillary field), is considered neovascularization of the disc.

diabetic findings what do they mean?

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diabetic findings what do they mean?

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diabetic findings what do they mean?

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diabetic findings what do they mean?

...Hard exudates seen in diabetic retinopathy are located primarily in the outer plexiform layer of the retina.

diabetic findings what do they mean?

...hard exudates
study 2011
treat lipids and yMedical management of diabetic retinopathy: fenofibrate and ACCORD Eye studies.

Wright AD, Dodson PM.


Source

Department of Medical Ophthalmology, Birmingham Heartlands Hospital, and Health and Life Sciences, Aston University, Birmingham, UK. A.Wright.1@bham.ac.uk


Abstract

The approach of all ophthalmologists, diabetologists and general practitioners seeing patients with diabetic retinopathy should be that good control of blood glucose, blood pressure and plasma lipids are all essential components of modern medical management. The more recent data on the use of fenofibrate in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) and The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye studies is reviewed. In FIELD, fenofibrate (200 mg/day) reduced the requirements for laser therapy and prevented disease progression in patients with pre-existing diabetic retinopathy. In ACCORD Eye, fenofibrate (160 mg daily) with simvastatin resulted in a 40% reduction in the odds of retinopathy progressing over 4 years, compared with simvastatin alone. This occurred with an increase in HDL-cholesterol and a decrease in the serum triglyceride level in the fenofibrate group, as compared with the placebo group, and was independent of glycaemic control. We believe fenofibrate is effective in preventing progression of established diabetic retinopathy in type 2 diabetes and should be considered for patients with pre-proliferative diabetic retinopathy and/or diabetic maculopathy, particularly in those with macular oedema requiring laser
ou treat the eye

diabetic findings what do they mean?

...hard exudates

from Harkness web site
--------------------------------------------------------------------------------

Hard exudates can be seen in any conditions that are associated with chronic vascular leakage , such as:
Diabetic retinopathy
Hypertensive retinopathy
Coat's disease
Capillary hemangioma of the retina
Choroidal neovascularization
Retinal arterial macroaneurysm
Mechanism:
Increased vascular permeability allowing the leakage of fluid and lipoprotein into the retina resulting in thickening of the macula
Resorption of the edema commonly results in precipitation of lipid residues within the outer plexiform (Henle's) layer
Clinical features:
Symptoms: various degree of decreased vision if involving the macula
Signs:
Discrete white-yellow lipid deposits in the posterior pole
Commonly seen in a circinate pattern peripheral to the areas of leakage
May present as large, confluent exudation
Macular star and/or circumpapillary hard exudates can be seen in Leber's stellate neuro-retinitis or end-stage hypertensive retinopathy
Management: treat the underlying diseases.

diabetic findings what do they mean?

...hard exudates and lipid levels
Patients with elevated total serum cholesterol levels or serum low-density lipoprotein cholesterol levels at baseline were twice as likely to have retinal hard exudates as patients with normal levels

diabetic findings what do they mean?

...hard exudates
correlate with VA loss from ACCORD study
according to Dr Aiello

retina layers

1. NFL — Nerve Fiber Layer
• Formed by fibers of the optic nerve
• Composed of axons from the ganglion cells below
• High reflectance of OCT beam

2. GCL — Ganglion Cell Layer
• Contains cell bodies of ganglion cells
• Low reflectance of OCT beam

3. IPL — Inner Plexiform Layer
• Contain dendrites of ganglion cells and cells of the inner nuclear layer
• High reflectance of OCT beam

4. INL — Inner Nuclear Layer
• Contains bipolar, horizontal and amacrine cells
• Low reflectance of OCT beam

5. OPL — Outer Plexiform Layer
• Synapses of the photoreceptors and the cells of the inner plexiform layer
• High reflectance of OCT beam

6. ONL — Outer Nuclear Layer
• Contains the cell bodies of the photoreceptors
• Helps in light detection
• Low reflectance of OCT beam

7. RPE — Retinal Pigment Epithelium
• Pigmented cell layer outside the neurosensory retina
• Composed of hexagonal cells that nourish the retinal visual cells
• Provides phagocytosis of photoreceptor cells

8. C — Choroid
• Vascular layer provides oxygen and nutrients to outer layers of the retina
• Located between the retina and sclera
• Bruch's membrane is the innermost layer of the choroid

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