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Diabetic Retinopathy: Atlas and Text
Amod Gupta, Vishali Gupta, MR Dogra, Ramandeep Singh
1:
Understanding Diabetes Mellitus and Risk Factors for Diabetic Retinopathy
SUMMARY AND CONCLUSIONS
2:
Clinical Characterization and Ancillary Investigations in Diabetic Retinopathy
OCT SCAN PROTOCOLS IN MACULA
SCAN PROTOCOLS SUITABLE FOR MACULA
Line Scan
Cross-hair Scan
Radial Lines
Macular Thickness Map
Fast Macular Thickness Map
Raster Lines
Repeat
Non-mydriatic Fundus Photography
SUMMARY AND CONCLUSIONS
3:
Pathogenesis of Diabetic Retinopathy
BIOCHEMICAL ALTERATIONS
Non-enzymatic Glycosylation and Advanced Glycation End Products (AGEs)
Increased Polyol Pathway or Flux/Sorbitol Pathway
Protein Kinase C Activation
Oxidative Stress
HEMODYNAMIC ALTERATIONS
Altered Blood Flow
Hypercoaguable State
Platelets abnormalities
RBC abnormalities
Leukocyte abnormalities
PARACRINE FACTORS
Diabetic Macular Edema (Fig. 3.5)
Retinal Neovascularization (Fig. 3.6)
SUMMARY AND CONCLUSIONS
4:
Non-proliferative Diabetic Retinopathy
PATHOGENESIS
CLINICAL FEATURES
Microaneurysms
Retinal Hemorrhages
Hard Exudates
Cotton-wool Spots
Intraretinal Microvascular Abnormalities
Venous Changes
FEATURELESS RETINA
CLASSIFICATION
Classification of NPDR
INVESTIGATIONS
Fundus Fluorescein Angiography (FFA)
Systemic Examination
MANAGEMENT
ADVICE TO PATIENT
CASE 4.1
Non-proliferative Diabetic Retinopathy
CASE 4.2
Non-proliferative Diabetic Retinopathy with Clinically Significant Macular Edema
CASE 4.3
Worsening of NPDR on Initiation of Insulin Therapy
CASE 4.4
Severe NPDR
CASE 4.5
Systemic Control in Severe NPDR
SUMMARY AND CONCLUSIONS
5:
Diabetic Macular Edema
CLINICAL FEATURES
CLASSIFICATION
Focal Macular Edema
Diffuse Macular Edema
ANCILLARY INVESTIGATIONS
1. Color Stereo Fundus Photographs
2. Fundus Fluorescein Angiography
3. Optical Coherence Tomography
MANAGEMENT
Prevention and Systemic Control
Treatment
Laser Photocoagulation
The treatable lesions are
Follow-up
Pars Plana Vitrectomy
PHARMACOTHERAPY
Role of Sorbitol Accumulation and Use of Aldose Reductase Inhibitors
Role of AGEs and Use of AGE Inhibitors
Role of the PKC-β Pathway and Use of PKC-β Inhibitors
Role of Oxidative Stress and Use of Antioxidant Compounds
Role of Angiogenic Factors and the Use of Anti-angiogenic Agents
MANAGEMENT GUIDELINES
CASE 5.1
Focal Laser Photocoagulation for Focal Edema
CASE 5.2
Repeat Focal Laser Photocoagulation for CSME
CASE 5.3
Focal Macular Edema Recalcitrant to Focal Laser Photocoagulation: Missed TPHM
CASE 5.4
Focal Laser Induced Subfoveal Serous RD
CASE 5.5
Comprehensive Systemic Control in CSME
CASE 5.6
Subfoveal Migration of Lipids Following Focal Laser Photocoagulation
CASE 5.7
Lipid Lowering Drug Atorvastatin Prior to Laser Photocoagulation
CASE 5.8
Correction of anaemia causes spontaneous microaneurysmal closure
CASE 5.9
Pars Plana Vitrectomy for Taut Posterior Hyloid Membrane (TPHM) in Recalcitrant Macular Edema
CASE 5.10
Regressed NVE Causing Fibrosis and Tractional Macular Edema
CASE 5.11
Regressed NVE Causing Worsening of Macular Edema
CASE 5.12
Intravitreal Triamcinolone Acetonide for Macular Edema
CASE 5.13
Deep Posterior Subtenon Triamcinolone Acetonide for Macular Edema
CASE 5.14
Avastin for Macular Edema
CASE 5.15
Pars Plana Vitrectomy for Subfoveal Hard Exudates
SUMMARY AND CONCLUSIONS
6:
Proliferative Diabetic Retinopathy
CASE 6.1
Regression of NVD Following PRP
CASE 6.2
Supplement PRP for Persistent NVD Following PRP
CASE 6.3
Development of Fresh New Vessels after Successful PRP
CASE 6.4
Nonclearing Vitreous Hemorrhage Despite Full PRP: Indication for PPV
CASE 6.5
Progression of Inadequately Treated PDR
CASE 6.6
PPV for Pre-macular Hemorrhage
CASE 6.7
PPV for Premacular Fibrosis
CASE 6.8
PPV for Peripapillary TRD involving the Fovea
CASE 6.9
PPV for Combined Retinal Detachment
CASE 6.10
PPV for Tractional Retinal Detachment with Macular Edema
CASE 6.11
PPV for Tractional Retinal Detachment Threatening the Fovea
SUMMARY AND CONCLUSIONS
7:
Cataract Surgery in Diabetes Mellitus
CATARACT SURGERY IN DIABETICS
Timing of Surgery
Preoperative Assessment
Patient Counseling
Systemic Control
Procedure of Choice
Postoperative Care
GUIDELINES
CASE 7.1
Irvine-Gass Syndrome Following Cataract Surgery
CASE 7.2
Progression of NPDR to PDR with Worsening of Macular Edema
CASE 7.3
Progression of CSME Following Phacoemulsification with Intraocular Implant
CASE 7.4
Subfoveal Serous Retinal Detachment Responding to Posterior Subtenon Triamcinolone Acetonide
SUMMARY AND CONCLUSIONS
8:
Screening for Diabetic Retinopathy
WHEN TO REFER?
MANAGEMENT GUIDELINES
1. No Retinopathy or Minimal NPDR
2. Mild to Moderate NPDR
3. Severe to very Severe NPDR
4. Non-high-risk PDR
4. High-risk PDR
9:
Vitreous Surgery in Diabetic Retinopathy
INDICATIONS
Vitreous Hemorrhage
Progressive Neovascularization Despite Full Pan Retinal Photocoagulation
Dense Premacular Hemorrhage
Macular Detachment
Pre-macular fibrosis
Tractional Retinal Detachment Threatening or Involving the Fovea
Combined Retinal Detachment
Media Opacities
Iris Neovascularization (INV)
Anterior Hyaloidal Proliferation
Recalcitrant Macular Edema
PREOPERATIVE COUNSELING
APPLIED PATHOANATOMY
SURGICAL PROCEDURE
Informed Consent
Systemic Control
Procedure
Vitreous Hemorrhage
Tractional Retinal Detachment
Combined Retinal Detachments
Diabetic Macular Edema
INTRAOPERATIVE COMPLICATIONS
POSTOPERATIVE CARE
APPROACH TO PATIENT WITH CATARACT AND RETINOPATHY
Prognosis
SUMMARY AND CONCLUSION
10:
Pharmacotherapy in Diabetic Retinopathy
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) AND ITS INHIBITORS
PROTEIN KINASE C INHIBITORS
SOMATOSTATIN
CYCLOOXYGENASE (COX)–2 INHIBITORS
ANGIOTENSIN CONVERTING ENZYME INHIBITORS/ANGIOTENSIN II RECEPTOR BLOCKERS
ANTIOXIDANTS
ADVANCED GLYCATION END PRODUCT INHIBITORS
ASPIRIN
MATRIX METALLOPROTEINASE (MMP) INHIBITORS
STATINS
ALDOSE REDUCTASE INHIBITORS
OXYGEN
ENZYMATIC VITREOLYSIS
CASE 10.1
Avastin in CSME
CASE 10.2
Avastin in CSME - Recurrence of Macular Edema
CASE 10.3
Avastin in PDR
CASE 10.4
Avastin Used as an Adjunct with PPV in PDR (Vitreous Hemorrhage and TRD)
CASE 10.5
Avastin in PDR and Vitreous Hemorrhage
CASE 10.6
Avastin for Iris Neovascularization
CASE 10.7
Posterior Subtenon Injection of Triamcinolone Acetonide (Kenacort) for CSME
CASE 10.8
Posterior Subtenon Injection of Triamcinolone Acetonide (Kenacort) for CSME
SUMMARY AND CONCLUSION
11:
Systemic Control in Diabetic Retinopathy Management
HYPERGLYCEMIA
BLOOD PRESSURE CONTROL
Angiotensin Converting Enzyme (ACE) Inhibitors or Angiotensin Receptor II Blockers (ARB)
HYPERLIPIDEMIA
ANEMIA
NEPHROPATHY
CASE 11.1
Multimodal Intervention for Diabetic Macular Edema
CASE 11.2
Decrease in Microaneurysmal Leak After Control of Anemia
SUMMARY AND CONCLUSION
12:
Comments on Video Films
VIDEO 1
Focal Laser Photocoagulation
VIDEOS 2-4
Modified Grid Laser Photocoagulation
VIDEOS 5-7
Pan Retinal Photocoagulation
VIDEO 8
Intravitreal Injection of Avastin (bevacizumab)
VIDEO 9A
Posterior SubTenon Injection of Triamcinolone Acetonide
VIDEO 9B
Deep Posterior SubTenon Injection of Triamcinolone
VIDEO 10
20 G Three Port Pars Plana Vitrectomy: Conjunctival Peritomy
VIDEO 11
Cautery Application
VIDEO 12
Insertion of Infusion Cannula
VIDEO 13
Sclerotomy Formation
VIDEO 14
Insertion of Instruments
VIDEOS 15 AND 16
Core Vitrectomy to Remove Vitreous with/without Hemorrhage
VIDEOS 17 AND 18
Aspiration of Blood Using Flute/Soft Tip Aspiration
VIDEO 19
Posterior Hyaloid Separation Using Barbed MVR
VIDEO 20
Posterior Hyaloid Separation with Active Suction
VIDEO 21
Posterior Hyaloid Separation Using End-gripping Forceps
VIDEOS 22 AND 23
Segmentation
VIDEOS 24 AND 25
Delamination
VIDEOS 26-30
Segmentation and Delamination
VIDEO 31
Membrane Peeler Cutter (MPC)
VIDEOS 32 AND 33
Aspiration and Endocautery
VIDEOS 34 AND 35
Endolaser
VIDEO 36
Closure of Sclerotomies
VIDEO 37
Removal of Infusion Cannula
VIDEO 38
Conjunctival Closure
Suggested Reading
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