Non-Proliferative Diabetic Retinopathy (NPDR)

Non-Proliferative Diabetic Retinopathy (NPDR)
SYMPTOMS Typically asymptomatic
May report Central vision loss and Metamorphopsia in the presence of diabetic macular edema, Central vision loss in the presence of macular ischemia, Central vision loss and Peripheral vision loss in the presence of diabetic papillopathy
SIGNS Typically bilateral
Microaneurysms, Dot hemorrhages, Blot hemorrhages, Flame hemorrhages, Roth spots, Cotton wool spots, Venous beading, Vascular loops, Intraretinal microvascular abnormalities (IRMA), Capillary nonperfusion, Exudates, Diabetic macular edema, Macular ischemia, Diabetic papillopathy
Stages
Minimal non-proliferative diabetic retinopathy: Microaneurysms only
Mild non-proliferative diabetic retinopathy: Microaneurysms, Dot/blot hemorrhages, Flame hemorrhages, Roth spots, Capillary nonperfusion
Moderate non-proliferative diabetic retinopathy: Microaneurysms, Moderate amount of dot/blot/flame hemorrhages in all 4 quadrants or 1 quadrant with a severe amount of dot/blot/flame hemorrhages, Cotton wool spots, Exudates, Roth spots, Small or mild IRMA in 1-3 quadrants, Capillary nonperfusion, Venous beading, Vascular loops
Moderately severe non-proliferative diabetic retinopathy: Microaneurysms, Severe amount of dot/blot/flame hemorrhages in 2-3 quadrants, Cotton wool spots, Small or mild IRMA in 4 quadrants, Venous beading in 1 quadrant, Roth spots, Exudates, Capillary nonperfusion, Vascular loops
Severe non-proliferative diabetic retinopathy: Includes all signs seen with non-proliferative diabetic retinopathy AND 2 or more of the following (Severe amount of dot/blot/flame hemorrhages in 2-3 quadrants, Small or mild IRMA in 4 quadrants, Venous beading in 1 quadrant) AND at least 1 of the following which involves the 4-2-1 Rule (Severe amount of dot/blot/flame hemorrhages in 4 quadrants, Moderate to severe IRMA in 1 or more quadrants, Venous beading in 2 or more quadrants)
Very severe non-proliferative diabetic retinopathy: Includes all signs seen with non-proliferative diabetic retinopathy AND 2 or more of the following (Severe amount of dot/blot/flame hemorrhages in 2-3 quadrants, Small or mild IRMA in 4 quadrants, Venous beading in 1 quadrant) AND at least 2 of the following which involves the 4-2-1 Rule (Severe amount of dot/blot/flame hemorrhages in 4 quadrants, Moderate to severe IRMA in 1 or more quadrants, Venous beading in 2 or more quadrants)
WORK-UP Pupils, EOMs, Color vision, Full eye exam with dilated retinal exam (look closely at the pupillary ruff for NVI especially before dilating), Gonioscopy, OCT analysis of the macula (signs of diabetic macular edema are best seen with an OCT), OCT analysis of the optic nerve, OCT-Angiography, Fluorescein Angiography, Fundus photos, Watzke-Allen test, Macular photostress test, Amsler grid
TREATMENT Give take home Amsler grid in order to monitor for change
Patient needs to follow up with their primary care provider and control blood sugar, blood pressure, and cholesterol
Lisinopril use has been shown to reduce progression of diabetic retinopathy by 50% and progression to proliferative diabetic retinopathy by 80% (needs to be discussed with PCP)
Lifestyle changes need to be discussed with patient (losing weight, exercising, eating a better diet, discontinuing smoking)
If the patient presents with minimal, mild, or moderate non-proliferative diabetic retinopathy, the patient needs to be monitored
If the patient presents with moderately severe, severe, or very severe non-proliferative diabetic retinopathy, consideration should be given in referring the patient to a retinal specialist for Eylea treatment as it has been shown to decrease the rate of conversion to proliferative diabetic retinopathy and developing diabetic macular edema (especially if severe or very severe non-proliferative diabetic retinopathy)
Criteria for monitoring DME: Best corrected vision in the eye with diabetic macular edema is better than or equal to 20/25, Patient has good glycemic control (HbA1c should be less than or equal to 7%), Diabetic macular edema that is non-center involving, Edema that does not meet the criteria for clinically significant macular edema, and The presence of minimal to moderate non-proliferative diabetic retinopathy
The is no significant difference in visual acuity outcome in the eye with diabetic macular edema when seeing 20/25 or better over a 2 year period when comparing patients who had intravitreal anti-VEGF injections, laser, or were only monitored
Criteria for referring patient to a retinal specialist within 1-2 weeks: Best corrected vision in the eye with diabetic macular edema is worse than or equal to 20/30, Patient has poor glycemic control (HbA1c is worse than 7%), Diabetic macular edema that is center involving, Edema that does meet the criteria for clinically significant macular edema, or The presence of diabetic retinopathy that is worse than moderate non-proliferative diabetic retinopathy
FOLLOW-UP Patients with DM Type 1 should have an eye exam within 5 years of initial diagnosis and then every year thereafter (as long as there is no signs of retinopathy)
Patients with DM Type 2 should have an eye exam at the time of diagnosis and then every year thereafter (as long as there is no signs of retinopathy)
Minimal non-proliferative diabetic retinopathy: Patient should be seen back in 12 months
Mild non-proliferative diabetic retinopathy: Patient should be seen back in 6-12 months
Moderate non-proliferative diabetic retinopathy: Patient should be seen back in 6-8 months
Moderately severe non-proliferative diabetic retinopathy: Patient should be seen back in 2-4 months if monitoring (consider referring patient to retinal specialist for Eylea treatment)
Severe non-proliferative diabetic retinopathy: Patient should be seen back in 2-3 months if monitoring (strongly consider referring patient to retinal specialist for Eylea treatment)
Very severe non-proliferative diabetic retinopathy: Patient should be seen back in 1-2 months if monitoring (very strongly consider referring patient to retinal specialist for Eylea treatment)
If monitoring diabetic macular edema, the patient should be seen back in 2-3 months
If retina and macula are stable following treatment by retinal specialist, patient should be seen back in 4-6 months
ADDITIONAL LAB | TESTS The patient needs to follow-up with their PCP for additional testing if not already done which includes the following: Blood pressure, Fasting blood sugar, HbA1c, Lipid panel, CBC with differential, Renal function testing
ETIOLOGY Increase in blood sugar leads to retinal capillary damage/death which causes retinal ischemia and retinal leakage due to breakdown of the inner blood-retina barrier
DIFFERENTIAL DX Hypertensive retinopathy, Anemia retinopathy, Sickle cell retinopathy, HIV retinopathy, Leukemia retinopathy
NOTES Age of onset and duration is the number one risk factor for development of diabetic retinopathy
Dot/blot hemorrhages are more common to be seen in diabetic retinopathy compared to flame hemorrhages and Roth spots
Dot/Blot/Flame hemorrhages typically outnumber cotton wool spots
The best indicator of potential conversion from non-proliferative diabetic retinopathy to proliferative diabetic retinopathy is venous beading and vascular loops
Non-Proliferative Diabetic Retinopathy (NPDR): Fundus photo demonstrating moderately severe non-proliferative diabetic retinopathy https://ijo.in/viewimage.asp?img=IndianJOphthalmol_2008_56_3_179_40355_3.jpg
Posted in Ocular Conditions, Retina-Vascular