Proliferative Diabetic Retinopathy (PDR)

Proliferative Diabetic Retinopathy (PDR)
SYMPTOMS Mild to severe vision loss in the presence of neovascular glaucoma, a tractional retinal detachment, an intravitreal hemorrhage, a subhyaloid hemorrhage, and a preretinal hemorrhage, 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
All signs seen in non-proliferative diabetic retinopathy as well as Neovascularization of the disc (NVD), Neovascularization elsewhere (NVE), Neovascularization of the iris (NVI), Neovascularization of the angle (NVA), Subhyaloid hemorrhages, Preretinal hemorrhages, Intravitreal hemorrhages, Tractional retinal detachment, Neovascular glaucoma, Fibrovascular proliferation
Stages
Mild proliferative diabetic retinopathy: The presence of less than 1/2DD of NVE in 1 or more quadrants
Moderate proliferative diabetic retinopathy: The presence of less than 1/2DD or more of NVE in 1 or more quadrants and/or less than 1/4DD of NVD
High risk proliferative diabetic retinopathy: The presence of 1/4DD or greater of NVD or 1/2DD or greater of NVE with an associated pretinal, subhyaloid, and/or intravitreal hemorrhage or a preretinal, subhyaloid, and/or intravitreal hemorrhage that obscures 1DD or more of the retina
Advanced proliferative diabetic retinopathy: The presence of a tractional retinal detachment involving the macula and/or view of clinician is obscured by a preretinal, subhyaloid, and/or intravitreal hemorrhage
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, B-scan ultrasound (if unable to view the retina), 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)
Patient needs to use caution with any strenuous exercise or activities
Patient should sleep with their head elevated in presence of a preretinal, subhyaloid, and/or intravitreal hemorrhage
Consider discontinuing or lowering the dosage of any blood thinners (needs to be discussed with PCP)
Mild proliferative diabetic retinopathy: Refer to retinal specialist within 1 week for treatment
Moderate proliferative diabetic retinopathy: Refer to retinal specialist within 1 week for treatment
High risk proliferative diabetic retinopathy: Refer to retinal specialist within 48 hours for treatment
Advanced proliferative diabetic retinopathy: Refer to retinal specialist within 24-48 hours for treatment
Treatment for proliferative diabetic retinopathy includes intravitreal anti-VEGF injections, pan retinal photocoagulation, and a vitrectomy
Proliferative diabetic retinopathy with diabetic macular edema: Refer to retinal specialist within 48 hours for treatment
Proliferative diabetic retinopathy with a tractional retinal detachment: Refer to retinal specialist within 24 hours for treatment
NVI and/or NVA with normal IOP and no evidence of glaucomatous optic nerve damage: Refer to retinal specialist within 48 hours for anti-VEGF treatment and/or PRP
NVI and/or NVA with elevated IOPs but no evidence of glaucomatous optic nerve damage or with associated secondary open angle glaucoma: Begin treatment with topical and oral glaucoma medications. Refer to retinal specialist within 48 hours for anti-VEGF treatment and/or PRP
NVI and/or NVA with secondary angle closure with or without glaucoma: The goal is to lower the IOP as quickly as possible in office and then refer to a retinal specialist ASAP for anti-VEGF treatment and/or PRP. A glaucoma specialist will most likely be involved as well as patient will need a trabeculectomy and/or shunt
FOLLOW-UP Once proliferative diabetic retinopathy becomes involutional or quiescent and the retina and macula is stable, patient should be seen back every 4-6 months
Neovascular glaucoma: Patient will most likely continue care with a retinal specialist and/or glaucoma specialist. If condition is stable and patient is no longer seeing a retinal specialist and/or glaucoma specialist, the patient should be seen every 2-4 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 Angiogenesis due to retinal ischemia
DIFFERENTIAL DX Hypertensive retinopathy, Anemia retinopathy, Sickle cell retinopathy, HIV retinopathy, Leukemia retinopathy
NOTES Proliferative diabetic retinopathy, Diabetic Macular Edema, and Neovascular Glaucoma should always be treated before cataract surgery is considered
Proliferative Diabetic Retinopathy (PDR): Fundus photo demonstrating extensive neovascularization of the disc (NVD) https://imagebank.asrs.org/file/27954/severe-nvd
Posted in Ocular Conditions, Retina-Vascular