Table of Contents

Cover

Title Page

List of contributors

Prologue

The scope of the problem of the epidemic of diabetes
The prevalence of sight-threatening diabetic retinopathy worldwide
Incidence of DR
Advances in management of diabetes
Advances in management of diabetic retinopathy
Practice points
REFERENCE

Acknowledgements

About the companion website

Chapter 1: Introduction

PRACTICAL ASSESSMENT
MULTIDISCIPLINARY MANAGEMENT
INVESTIGATIVE TECHNIQUES TO ASSESS DIABETIC RETINOPATHY
THE APPLICATION OF LASERS IN DIABETIC RETINOPATHY
PRACTICE POINTS

Chapter 2: Diabetes

CLASSIFICATION OF DIABETES
AETIOPATHOLOGY OF DIABETES
RISK FACTORS FOR DIABETIC RETINOPATHY
PRACTICE POINTS
REFERENCE

Chapter 3: Lesions and classifications of diabetic retinopathy

ETDRS CLASSIFICATION
ENGLISH AND INTERNATIONAL CLASSIFICATION
PRACTICE POINTS
REFERENCE

Chapter 4: Screening for diabetic retinopathy

PRINCIPLES OF SCREENING
ADVANCES IN SCREENING
PRACTICE POINTS
REFERENCE

Chapter 5: Imaging techniques in diabetic retinopathy

RETINAL PHOTOGRAPHY
ULTRA-WIDEFIELD IMAGING
FUNDUS AUTOFLOURESCENCE
ULTRASONOGRAPHY
FLUORESCEIN ANGIOGRAPHY
INDOCYANINE GREEN ANGIOGRAPHY
ULTRA-WIDEFIELD ANGIOGRAPHY
OPTICAL COHERENCE TOMOGRAPHY
OCT ANGIOGRAPHY
REFERENCE

Chapter 6: The normal eye

THE RELEVANT ANATOMY OF THE EYE
THE PHOTOGRAPHIC APPEARANCE
PRACTICE POINTS

Chapter 7: Diabetic macular oedema

DIABETIC MACULOPATHY
OPTICAL COHERENCE TOMOGRAPHY
TREATMENT OF ASSOCIATED RISK FACTORS
LASER FOR DIABETIC MACULAR OEDEMA
ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR TREATMENT
INTRAVITREAL CORTICOSTEROIDS
COMBINATION THERAPY
VITRECTOMY
AUTHORS' TREATMENT RECOMMENDATIONS FOR DMO
CONCLUSIONS
PRACTICE POINTS
REFERENCE

Chapter 8: Mild non-proliferative diabetic retinopathy

MILD NPDR (ETDRS AND INTERNATIONAL) AND BACKGROUND DR (UK SCREENING)
PRACTICE POINTS
REFERENCE

Chapter 9: Moderate and severe non-proliferative diabetic retinopathy

MODERATE AND SEVERE NPDR (ETDRS AND INTERNATIONAL) AND PRE-PROLIFERATIVE DR (UK SCREENING)
PRACTICE POINTS
REFERENCE

Chapter 10: Proliferative and advanced diabetic retinopathy

PROLIFERATIVE AND ADVANCED DR
LASER TREATMENT FOR PROLIFERATIVE DR
PATIENT EXPERIENCES OF LASER
ANTI-VEGF TREATMENTS
VITREOUS HAEMORRHAGE OBSCURING THE RETINAL VIEW
PRACTICE POINTS
REFERENCE

Chapter 11: Proliferative diabetic retinopathy with maculopathy

LASER FOR PROLIFERATIVE DR AND CONCURRENT MACULOPATHY
LASER FOR PROLIFERATIVE DR AND INTRAVITREAL ANTI-VEGF THERAPY FOR MACULOPATHY
PRACTICE POINTS
References

Chapter 12: The stable treated eye

FOLLOWING MACULOPATHY TREATMENT
FOLLOWING NVD OR NVE TREATMENT
PRACTICE POINTS
REFERENCE

Chapter 13: Vitrectomy surgery in diabetic retinopathy

INTRODUCTION
VITREOUS SURGERY (VITRECTOMY)
TREATMENT TECHNIQUES FOR PDR
POST-OPERATIVE COMPLICATIONS
TREATMENT TECHNIQUES FOR DMO
PRACTICE POINTS
REFERENCE

Chapter 14: Cataract surgery in the diabetic eye: Pre-, intra- and postoperative considerations

INTRODUCTION
PATHOGENESIS OF CATARACT DEVELOPMENT IN DIABETES
PREOPERATIVE CONSIDERATIONS
OPERATIVE CONSIDERATIONS IN CATARACT SURGERY FOR PATIENTS WITH DIABETES
POSTOPERATIVE CONSIDERATIONS
ADJUNCTIVE PRE- AND INTRAOPERATIVE PHARMACOTHERAPY
ADJUNCTIVE PANRETINAL PHOTOCOAGULATION LASER
VISUAL OUTCOME AFTER CATARACT SURGERY IN PATIENTS WITH DIABETES
CONCLUSIONS
PRACTICE POINTS
REFERENCE

Chapter 15: Pregnancy and the diabetic eye

RISK FACTORS FOR PROGRESSION OF DIABETIC RETINOPATHY DURING PREGNANCY
BEFORE AND DURING PREGNANCY
POSTPARTUM REGRESSION
PRACTICE POINTS
REFERENCE

Chapter 16: Low vision and blindness from diabetic retinopathy

DEFINITION OF BLINDNESS
IN THE USA
IN EUROPE
IN THE REST OF THE WORLD
COSTS OF BLINDNESS DUE TO DIABETIC RETINOPATHY
COSTS OF TREATMENT FOR DIABETIC RETINOPATHY
REDUCED VISION AND QUALITY OF LIFE
LOW-VISION REHABILITATION
CAUSES OF LOSS OF VISION IN DIABETES AND DIABETIC RETINOPATHY
PRACTICE POINTS
REFERENCE

Chapter 17: Future advances in the management of diabetic retinopathy

PREDICTING RISK OF DIABETIC RETINOPATHY AND ITS PROGRESSION
TIMELY DETECTION OF DIABETIC RETINOPATHY
TREATMENT OPTIONS
ELECTRONIC MEDICAL RECORDS, CLOUD COMPUTING AND BIG DATA
CONCLUSION
REFERENCE

Chapter 18: Other retinal conditions in diabetes

HYPERTENSION
RETINAL ARTERIAL OCCLUSIONS
RETINAL VENOUS OCCLUSIONS
ANTERIOR ISCHAEMIC OPTIC NEUROPATHY
ASTEROID HYALOSIS
MACROANEURYSM
PRACTICE POINTS
REFERENCE

Chapter 19: Conditions with appearances similar to diabetic retinopathy

DRUSEN AND AMD
MYELINATED NERVE FIBRES
SICKLE CELL RETINOPATHY
COATS' DISEASE
RADIATION RETINOPATHY
INTERFERON RETINOPATHY
PRACTICE POINTS
REFERENCE

Glossary

Index

End User License Agreement

List of Illustrations

Prologue

Figure 1 World map showing rising incidence and prevalence of diabetes.
Figure 2 World map showing high prevalence of diabetic retinopathy (DR) and proliferative DR.
Figure 3 (a) Uncontrolled hypertension in a person with diabetes: right macula colour photo showing flame haemorrhages and cotton wool spots. (b) The result of treating the hypertension in this person.
Figure 4 Stable treated eye after panretinal photocoagulation for NVD.

Chapter 1: Introduction

Figure 1.1 Snellen visual acuity chart.
Figure 1.2 LogMar visual acuity chart.
Figure 1.3 Farnsworth-Munsell 100 hue discrimination test.
Figure 1.4 Direct ophthalmoscopy.
Figure 1.5 Slit-lamp biomicroscopy with 78D lens.
Figure 1.6 Contact lens biomicroscopy.
Figure 1.7 Binocular indirect ophthalmoscopy.
Figure 1.8 Binocular indirect ophthalmoscopy.
Figure 1.9 Goldmann Perimeter: (a) patient view and (b) operator view.
Figure 1.10 Example of a normal Goldmann visual field.
Figure 1.11 Humphrey visual field analyser: (a) operator's view and (b) subject's view of where the chin and forehead are rested and the view of where individual lights are presented to test the field of vision.
Figure 1.12 (a, b) Example of a normal Humphrey visual field for right and left eyes.
Figure 1.13 (a) Example of a normal Esterman visual field. (b) Example of a restricted Esterman field in a diabetic patient. The case history of this patient is described in Chapter 9 on proliferative and advanced diabetic retinopathy.

Chapter 2: Diabetes

Figure 2.1 (a) Right macular colour photograph at presentation. (b) Right nasal colour photograph at presentation. (c) Right macular colour photograph 4 months after presentation. (d) Right nasal colour photograph 4 months after presentation.
Figure 2.2 (a) Right macular colour photo in patient presenting with type 2 diabetes. (b) Right nasal colour photo in patient presenting with type 2 diabetes. (c) Left nasal colour photo in patient presenting with type 2 diabetes. (d) Left macular colour photo in patient presenting with type 2 diabetes. (e) Right macular colour photo 5 years after presentation. (f) Left macular colour photo 5 years after presentation.
Figure 2.3 Retinopathy in patient with MODY.
Figure 2.4 Family history of a person (P) with HNF-1α MODY diabetes.
Figure 2.5 A young woman showing signs of maculopathy with exudate encroaching on the central fovea. There are also some reflections from the flash, especially around the infero-temporal arcade which one sees in young people.
Figure 2.6 (a) Photograph taken 6 months after starting insulin pump therapy. (b) Colour and (c) red-free photograph taken 3 years after starting insulin pump therapy, showing clearing of the exudates in her macular area.
Figure 2.7 Uncontrolled hypertension in a person with diabetes. (a) Left macular colour photo showing flame haemorrhages and cotton wool spots and exudates. (b) Improvement in appearance following treatment of the hypertension.
Figure 2.8 (a) Macular exudates in diabetic retinopathy (a) pre–treatment and (b) post-treatment with laser treatment and a statin.

Chapter 3: Lesions and classifications of diabetic retinopathy

Figure 3.1 (a) An example of microaneurysms and small haemorrhages in the right macular area. (b) Figure (a) autofluorescence image. (c) Figure (a) fluorescein at 2min 17 s, showing leakage from some of the microaneurysms as shown by a fluffy fluorescence appearing around the microaneurysm.
Figure 3.2 An example of (a) a flame haemorrhage and (b) a superficial haemorrhage in the nerve fibre layer with Hmas and CWS.
Figure 3.3 (a) An example of blot haemorrhages in the right infero-temporal retina and a small patch of NVE. (b) Red-free photo of patient (a) with blot haemorrhages and small NVE.
Figure 3.4 An example of (hard) exudates encroaching on the central fovea.
Figure 3.5 An example of cotton wool spots (CWS) in (a) the nasal view and (b) the macular view of the same patient. (c) Fluorescein of patient (a)'s macular view showing ischaemia in the areas of CWS.
Figure 3.6 Example of IRMA: (a, c) colour photograph and (b, d) red-free photograph.
Figure 3.7 An example of a venous loop (a) in the temporal retina of a patient with mild NPDR and (b) in a more ischaemic retina (colour photograph superior retina).
Figure 3.8 An example of a venous reduplication: (a) colour photograph and (b) red-free photograph.
Figure 3.9 An example of venous dilation, venous beading and IRMA in an area of ischaemic retina.
Figure 3.10 An example of venous narrowing and perivenous exudates.
Figure 3.11 An example of venous sheathing: (a) nasal view left eye and (b) macular view left eye.
Figure 3.12 An example of perivenous exudates.
Figure 3.13 An example of arteriolar narrowing.
Figure 3.14 An example of opacification of arteriolar walls.
Figure 3.15 An example of arterio-venous nipping.
Figure 3.16 An example of FPD (fibrous proliferation on the disc).
Figure 3.17 An example of FPE (fibrous proliferation elsewhere), showing partial fibrosis of NVE in nasal retina.
Figure 3.18 (a) An example of NVD and (b) magnified view.
Figure 3.19 An example of NVE forming (a) on the edge of an ischaemic area due to an occluded arteriole and (b) in the right infero-temporal retina. (c) An example of large NVE forming in the right temporal retina.
Figure 3.20 (a, b) Examples of a preretinal haemorrhage (PRH): large boat-shaped with flat top and extension to nasal retina.
Figure 3.21 An example of (a) a small VH and (b) a larger VH.
Figure 3.22 An example of a B-scan of a more pronounced vitreous haemorrhage.
Figure 3.23 An example of laser scars resulting from maculopathy treatment.
Figure 3.24 Examples of laser scars post-scatter (panretinal) laser treatment: (a) right macular view and (b) right nasal view.
Figure 3.25 Avulsion of NVE, leaving horseshoe tear.

Chapter 4: Screening for diabetic retinopathy

Figure 4.1 Diabetic retinopathy detected during screening.
Figure 4.2 Macular exudates before argon laser photocoagulation.
Figure 4.3 Macular exudates immediately after laser photocoagulation.
Figure 4.4 Macular exudates 6 months after laser photocoagulation.
Figure 4.5 (a) Screening using two-field mydriatic digital photography as recommended in the English Screening Programme. (b) A screening episode being undertaken.
Figure 4.6 Year 0 macula colour (a) right and (b) left. Year 1 left (c) macula red-free and (d) fluorescein showing left macular oedema and leakage from NVE above the left macula. (e) Year 1 left disc/nasal view fluorescein showing extensive leakage and ischaemic area in left nasal retina. Year 2 left macula (f) red-free, showing retrohayloid haemorrhage with sparing around the fovea, and (g) fluorescein, showing vitreous haemorrhage with sparing around the fovea. Year 2 right macula (h) red-free showing exudates in right macular area, (i) fluorescein of right macular area at 21 s, and (j) fluorescein of right macular area at 2min 31 s. (k) B-scan appearance caused by retrohyaloid haemorrhage. Year 5 right macula (l) colour and (m) fluorescein at 25 s. Year 5 left macula (n) colour and (o) fluorescein at 2min 44 s.
Figure 4.7 (a) Year 0, first screening episode: right macula colour. (b) Year 3, second screening episode: (b) right macula colour and (c) right and (d) left disc colour. (e) Year 3, second screening episode: left macula colour. OCT (f) right and (g) left macular area. (h) OCT right macular area 2 months after macular and first panretinal laser treatment.

Chapter 5: Imaging techniques in diabetic retinopathy

Figure 5.1 Normal left macular field image.
Figure 5.2 Left macular field image with preretinal haemorrhage, small NVD, NVE, intraretinal haemorrhages and hard exudates.
Figure 5.3 Stereo fluorescein angiogram images of the left eye showing two images of the same retinal location captured at slightly different angles in a patient with microaneurysms.
Figure 5.4 Topcon fundus camera.
Figure 5.5 Viewing a digital fundus image.
Figure 5.6 Viewing a magnified red-free digital fundus image.
Figure 5.7 Disc-centred image of a left eye showing IRMA, venous loops, NVD, NVE and preretinal haemorrhage. A large tuft of NVE is seen in the superonasal quadrant.
Figure 5.8 Macular centred image of the same eye showing NVD, NVE and preretinal haemorrhage.
Figure 5.9 Seven-field montage of a right eye: normal fundus.
Figure 5.10 Seven-field montage of a left eye: normal fundus.
Figure 5.11 Colour fundus image showing HMas below the left fovea.
Figure 5.12 Heidelberg UWF imaging system.
Figure 5.13 Red-free image of the same eye showing HMas below the left fovea.
Figure 5.14 Optos UWF imaging system.
Figure 5.15 (a) Optos UWF 200 degree image and (b) Optos UWF 200 degree fluorescein angiogram image. Schematic overlays depict the area captured in conventional seven-field photography.
Figure 5.16 Optos image showing NVD, NVE, macular HMas and exudate, venous beading and peripheral scatter laser scars.
Figure 5.17 (a) Optos UWF image showing eyelash artefact and peripheral distortion in a normal right eye. (b) Optos UWF image of a right eye that has had scatter laser treatment for proliferative DR. (c) Optos UWF image showing extensive exudates in the right macula.
Figure 5.18 Optos image of a right eye showing pathology in the temporal retina outside the conventional seven-field zone.
Figure 5.19 Heidelberg UWF fluorescein angiogram image showing HMas and macular oedema.
Figure 5.20 Left macular fundus autofluorescence image exhibiting normal foveal hypoautofluorescence.
Figure 5.21 (a) Colour fundus image of the left macular area in a patient with diabetic macular oedema. (b) Loss of foveal hypoautofluorescence is seen in this patient (same patient as in (a)) with diabetic macular oedema and poor vision. Haemorrhages are seen in the temporal macula and exudate in the nasal macula.
Figure 5.22 An A-scan (a) being taken and (b) image.
Figure 5.23 An ophthalmic B-scan ultrasound machine.
Figure 5.27 Ultrasound B-scan showing retro-hyaloid vitreous haemorrhage with attached retina.
Figure 5.28 (a) Fluorescein ampoule; (b) intravenous canula; and (c) fluorescein being injected intravenously.
Figure 5.29 A patient undergoing FFA.
Figure 5.30 Fluorescence: a form of photoluminescence that occurs when certain molecules (fluorophores) absorb electromagnetic energy of a particular wavelength (excitation spectrum) and are temporarily excited into a higher energy state. When the fluorophore returns to its original energy state it releases electromagnetic energy, usually of a longer wavelength (emission spectrum). A characteristic feature of fluorescence is the requirement for continuous excitation; emission is extinguished rapidly upon the cessation of excitation.
Figure 5.31 A normal macular colour image.
Figure 5.32 A normal macular autofluorescence image.
Figure 5.33 Combined fluorescein and ICG angiograms demonstrating choroidal flush and early arterial filling, 11 s after injection.
Figure 5.34 Arteriovenous phase 58 s after injection.
Figure 5.35 Arteriovenous phase 2min 11 s after injection.
Figure 5.38 HMas in arteriovenous phase of angiogram that leak at a later stage.
Figure 5.39 (a) A preretinal haemorrhage masks underlying retinal fluorescence (FFA image). (b) A preretinal haemorrhage in the same patient (colour image).
Figure 5.40 (a) A crescentic area of hypofluorescence in the temporal macula due to masking of fluorescence by hard exudates. (b) A colour image of the same patient showing the crescentic area of exudate.
Figure 5.41 (a) Extensive capillary non-perfusion (hypofluorescence) is seen peripheral to NVE in this angiogram image. (b) Capillary non-perfusion (hypofluorescence) temporal to left fovea in this FFA image. Note disruption of the perifoveal capillary net, a marker of macular ischaemia.
Figure 5.42 UWF FFA image demonstrating window defects from photocoagulation scars. This patient has numerous NVE and a preretinal haemorrhage.
Figure 5.43 Characteristic intense hyperfluorescence of NVD and NVE in the late arteriovenuos phase. Note areas of capillary non-perfusion adjacent to the NVE.
Figure 5.44 DME with diffuse hyperfluorescence of the macula in later stages of angiogram (same patient as Figure 5.38).
Figure 5.45 Vessel wall hyperfluorescence/staining hyperfluorescence in an area with surrounding capillary non-perfusion (hypofluorescence).
Figure 5.46 Normal left eye (a) colour photograph and (b) UWF fluorescein image.
Figure 5.47 (a) Central colour photograph and (b) UWF fluorescein image of the same patient, demonstrating capillary non-perfusion and vessel staining within the conventional seven-field zone.
Figure 5.48 (a) Central colour photograph and (b) UWF fluorescein image in the same patient, demonstrating pathology outside the zone of the 45 degree colour image in image (a).
Figure 5.49 Time-domain OCT machine.
Figure 5.50 TD-OCT image of a normal macula.
Figure 5.51 TD-OCT image of diabetic macular oedema.
Figure 5.52 Spectral-domain OCT machine.
Figure 5.53 SD-OCT image of a normal macula.
Figure 5.54 SD-OCT image showing progression of DME.
Figure 5.55 (a, b) Correlation of histology layers of the retina to reflective layers on an OCT.
Figure 5.56 (a) A 3D OCT image with (a) FFA (normal) and thickness measurements and (b) FFA (normal).
Figure 5.57 3D OCT image with FFA showing DME.
Figure 5.58 For same patient as in Figure 5.53: (a) diabetic macular oedema and (b) 3D OCT reconstruction.
Figure 5.59 SS-OCT images. (a, b) DME
Figure 5.60 Graphic comparing A-, B- and C-scans.
Figure 5.61 Normal OCT angiography image showing the perifoveal vessels in exquisite detail
Figure 5.62 OCT angiography image in mild NPDR. Note the loss of some perifoveal capillaries and early widening of the foveal avascular zone
Figure 5.63 OCT angiography image in proliferative DR. There is extensive capillary non-perfusion and coarsening of capillary networks
Figure 5.64 OCT angiography of superficial retinal vessels
Figure 5.65 OCT angiography of deeper retinal vessels

Chapter 6: The normal eye

Figure 6.1 Cross-section of (a) the eye and major structures and (b) anterior segment and aqueous flow.
Figure 6.2 (a) Basic retinal appearance on examination. (b) Normal human fovea: the inner and outer nuclear cell layers at the edge of the fovea and the concentration of cones centrally. (c) The receptive retina: the ganglion cell layer, the bipolar layer, the nuclei of the cones and rods, the pigment epithelium and the choroid. (d) The retina following laser treatment: the gliosis of the retina following laser treatment.
Figure 6.3 Retinal structure cross-section diagram.
Figure 6.4 Normal Caucasian retinal appearance: (a) macular view and (b) nasal view. Normal Asian Indian retinal appearance: (c) macular view and (d) nasal view. Normal Caribbean retinal appearance: (e) macular view and (f) nasal view.
Figure 6.5 Image of young person's retina: (a) nasal view, showing posterior hyaloid reflections and (b) macular view, showing posterior hyaloid reflections. There are also some mild changes of diabetic retinopathy in each image.
Figure 6.6 Image of nerve fibre layer patterns: (a) colour photograph and (b) red-free photograph.
Figure 6.7 Image of nerve fibre layer patterns from a patient who has had a left central retinal vein thrombosis with haemorrhages under the nerve fibre layer.

Chapter 7: Diabetic macular oedema

Figure 7.1 Focal maculopathy. (a) Colour fundus and (b) red-free showing focal leakage and hard exudates superiotemporal to the fovea. (c) Fluorescein angiography, late phase, depicting some leaking microaneurysms superiotemporal to the fovea. (d) OCT scan through the area of leakage showing focal retinal thickening. (e) Macular thickness map shows only localised retinal thickening.
Figure 7.2 Diffuse maculopathy. (a) Colour fundus and (b) red-free showing diffuse maculopathy. (c) Fluorescein angiography depicting multiple areas of leakage. (d) OCT scan through the fovea showing focal diffuse retinal thickening. (e) Macular thickness map shows diffuse oedema.
Figure 7.3 Ischaemic DMO. (a) Colour fundus and (b) red-free showing minimal mid-diabetic changes at the macula. (c) Fluorescein angiography, early phase, depicting ischaemic changes with widening of the foveal avascular zone, pruning of perifoveal vessels and capillary drop-out at the fovea. There are multiple areas of capillary drop-out temporal to the fovea. (d) OCT scan through the fovea showing only mild oedema. (e) Macular thickness map shows only minimal retinal thickening.
Figure 7.4 Severe ischaemic maculopathy. Fluorescein angiography left eye (a) 54 s and (b) 4min 20 s showing marked capillary drop-outs at the macula and irregular foveal avascular zone in a patient with markedly uncontrolled diabetes and hypertension.
Figure 7.5 Diffuse (sponge-like) retinal thickening.
Figure 7.6 Cystoid macular oedema.
Figure 7.7 Subfoveal serous detachment (in addition to cystic inner and outer retinal spaces).
Figure 7.8 Foveal traction due to antero-posterior vitreomacular traction.
Figure 7.9 Foveal traction due to epiretinal membrane.
Figure 7.10 (a) Right and (b) left macula red-free. Flourescein right macula (c) 15 s; (d) 19 s; and (e) 40 s. (f) Fluorescein left nasal 1min 9 s. Fluorescein right macula (g) 1min 16 s and (h) 4min 4 s. (i) Fluorescein left macula 4min 13 s. Year 4: (j) colour right macula; (k) colour left macula; (l) venous phase fluorescein right macula; and (m) colour venous phase fluorescein left macula.
Figure 7.11 Red-free image at 3 months of (a) right macula and disc and (b) left macula and disc. Colour image at 18 months of (c) the right macula and disc and (d) left macula and disc, showing the development of new vessels at the disc (NVD). Colour image of the (e) right and (f) left macula post-vitrectomy.
Figure 7.12 Left macula colour (a) pre-laser, (b) immediately post-laser and (c) 4 months post-laser.
Figure 7.13 Right macular area: (a) colour photo at presentation; (b) red-free image 7 months after presentation; and colour photo (c) 10 months, (d) 19 months, (e) 27 months and (f) 8 years after presentation.
Figure 7.14 Colour fundus photograph of the right eye (top, left) and red-free photograph (top, middle) showing centre-involving DMO. Infrared image depicting the diabetic changes (top, right) with the green line indicating the position of the OCT scan. Foveal OCT scan (middle, left) and macular thickness map (middle, right) at baseline and following three consecutive intravitreal injections of ranibizumab (bottom, left). CST, central retinal thickness; IVR, intravitreal ranibizumab; VA, visual acuity.
Figure 7.15 Colour fundus photograph of the left eye (top, left) and infrared fundus image (top, middle) showing diffuse maculopathy. Late-phase fluorescein angiography showing diffuse macular leakage (top, right). In addition, OCT scan and macular thickness maps are shown at baseline and following 6 months and 9 months of intravitreal treatment with intravitreal ranibizumab. CST, central retinal thickness; IVR, intravitreal ranibizumab; VA. visual acuity.
Figure 7.16 Intravitreal fluocinolone acetonide (Iluvien) applicator
Figure 7.17 Colour fundus photograph of the right eye (top, left) and red-free image (top, right) depicting DMO. OCT scan and macular thickness map (topographic and numerical) showing DMO (second row), after a period of 3 years, having received four sessions of focal macular laser treatment and one intravitreal injection of triamcinolone acetonide (third row), following three intravitreal ranibizumab injections (fourth row) and following treatment with intravitreal flucinolone acetonide implant (fifth row). CST, central retinal thickness; IVR, intravitreal ranibizumab; VA, visual acuity.

Chapter 8: Mild non-proliferative diabetic retinopathy

Figure 8.1 Microaneurysms and fine exudate in mild NPDR: (a) right macula colour and (b) right macula red-free. Microaneurysms in mild NPDR: (c) left macula autofluorescence photo; (d) fluorescein angiogram at 1min 9 s showing fluorescence from microaneurysms in the left macular area but no signs of leakage and (e) fluorescein angiogram at 5min 39 s showing a small amount of leakage from microaneurysms in the left macular area.
Figure 8.2 (a) Haemorrhages and microaneurysms in mild NPDR: colour photo left macula. (b) Flame-shaped haemorrhages in mild NPDR: colour photo right disc. (c) Example of blot haemorrhages.
Figure 8.3 Exudates in mild NPDR developing in right macular area: (a) colour photograph and (b) red-free photograph, both right macula view.
Figure 8.4 Cotton wool spot in mild NPDR.
Figure 8.5 Venous loop in mild NPDR.

Chapter 9: Moderate and severe non-proliferative diabetic retinopathy

Figure 9.1 (a, b) Retinal haemorrhages.
Figure 9.2 (a) IRMA in superior retina. Example of IRMA below left optic disc: (b) red-free image and (c) colour image. (d) Example of IRMA in superior and nasal retina of right eye.
Figure 9.3 Venous beading in (a) superior retina and (b) infero-nasal retina. (c) Venous beading and ischaemia on fluorescein of the same area as (b).
Figure 9.4 Right macula colour photograph at (a) presentation; (b) 1 year after presentation; (c) 2 years after presentation; and (d) 5 years after presentation.
Figure 9.5

Chapter 10: Proliferative and advanced diabetic retinopathy

Figure 10.1 (a) NVD and NVE colour photo. Fluorescein angiogram in early arterial phase: (b) 7 s from patient in (a) showing some early filling in NVD and (c) 12 s showing leakage from NVD and NVE. Fluorescein angiogram in late arteriovenous phase (d) 1min 8 s showing leakage from NVD and NVE and (e) 1min 46 s showing areas of ischaemic non-perfusion in temporal retina adjacent to NVE. (f) Fluorescein angiogram in the late venous phase (6min 34 s) showing leakage from NVD and NVE.
Figure 10.2 (a, b) NVE showing minimal or no leakage that have not yet penetrated the internal limiting membrane. (c) Laser treatment on a patient with diabetic retinopathy.
Figure 10.3 (a, b) Example of a preretinal haemorrhage.
Figure 10.4 (a) Example of a preretinal haemorrhage and (b) organising.
Figure 10.5 Example of a vitreous haemorrhage
Figure 10.6 NVD > one-third disc area.
Figure 10.7 (a, b) NVE equalling > half disc area with haemorrhage.
Figure 10.8 NVD (a) < one-third and (b) > one-third disc area. NVE equalling < half disc area without haemorrhage (c) colour photo.
Figure 10.9 Persistent cystoid macula following panretinal laser treatment: (a) colour photo; (b) fluorescein photo 1min 9 s post-injection; and (c) fluorescein and OCT photo 9min 24 s post-injection.
Figure 10.10 (a) A restricted Esterman field in a diabetic patient. Colour photo: (b) right macula; (c) right nasal retina; (d) left nasal retina; (e) left macula; and (f) Fluorescein left macular area 45 s after injection, showing ischaemia and IRMA in the area around the left macula. (g) Fluorescein right macular area 1min 10 s after injection, showing ischaemia and IRMA in the area around the left macula.
Figure 10.11 (a) Iris neovascularisation. (b) Ischaemic eye with venous beading, preretinal haemorrhage, NVE and extensive exudation.
Figure 10.12 (a) Right macula colour pre-treatment; (b) left disc colour pre-treatment; and (c) left macula colour pre-treatment. Left (d) disc and (e) macula colour immediately post-treatment.
Figure 10.13 (a) Colour right macular area. Fluorescein right macular area: (b) 35 s, (c) 52 s and (c) 1min 45 s after injection.
Figure 10.14 (a) Colour and (b) red-free photograph of NVD at right disc; (c) colour and (d) red-free photograph of NVD at left disc.
Figure 10.15 Colour image of the left eye showing (a) macular laser scars and (b) preretinal haemorrhage. Photograph of the left eye in the (c) arteriovenous phase of the fluorescein angiogram, showing darker areas of non-perfusion and leakage from NVE and (d) venous phase of the angiogram, showing areas of non-perfusion and leakage from NVE. (e) Photograph of the right eye in the venous phase of the angiogram showing incomplete coverage of panretinal laser scars, areas of non-perfusion and leakage from NVE.
Figure 10.16 Avulsion of NVE leaving horseshoe tear: (a) colour photograph; and (b, c) magnified. (d) Colour photograph taken immediately after laser treatment to encircle horseshoe tear.
Figure 10.17 (a) Leakage from neovascularisation at the optic disc (NVD) before treatment. (b) Regression to normal disc vessels after treatment.
Figure 10.18 (a) Preretinal haemorrhage. (b) B-scan showing intragel haemorrhage. The retina is flat in all quadrants.
Figure 10.19 Vitreous haemorrhage with underlying retinal detachment: B-scan.

Chapter 11: Proliferative diabetic retinopathy with maculopathy

Figure 11.1 (a) Proliferative DR with maculopathy: left macula colour photo. (b) Proliferative DR: right macula colour photo.
Figure 11.2 Left macular area: (a) colour; (b) fluorescein image 29 s; (c) 57 s; and (c) 4min 15 s after injection.
Figure 11.3 (a) Late fundus fluorescein frame of the left eye with OCT scan of the centre of the fovea. (b) Infrared photograph of the same eye and OCT of the fovea after treatment with intravitreal ranibizumab. (c) Late fundus fluorescein frame of the left eye after scatter laser treatment.
Figure 11.4 Colour photographs showing (a) exudate in the right macular area; (b) preretinal haemorrhage in right nasal retina; (c, d) exudate in the left macular area; and (e) preretinal haemorrhage below the right macula over the right infero-temporal arcade. OCTs showing diabetic macular oedema pre-treatment in (f) right eye and (h) left eye and post-treatment in (g) right eye and (i) left eye.

Chapter 12: The stable treated eye

Figure 12.1 OCT right macular area (a) before treatment with VEGF inhibitor; (b) after 5 months of treatment with VEGF inhibitor; and (c) at month 16.
Figure 12.2 OCT left macular area (a) before treatment with laser and (b) 3 months and (c) 9 months after treatment with laser.
Figure 12.3 Treated NVD proliferative DR: (a) left disc colour photo and (b) left macula colour photo.
Figure 12.4 (a, b) Right superior colour showing ischaemia before NVE developed. Treated NVE proliferative DR: (c) right macula colour; (d) right nasal colour; and (e) right superior colour.
Figure 12.5 Right macula showing (a) exudate infero-temporal to right fovea and (b) old macular laser scars and NVD developing at the right optic disc. (c) Left macula showing NVD developing at the left optic disc and a preretinal haemorrhage over the left supero-temporal arcade of vessels. (d) Left superior retina: venous beading present between laser scars. Stable treated: (e) right macular area; (f) right disc area; (g) left disc area; (h) left macular area; and (i) left superior retina with no further signs of venous beading.

Chapter 13: Vitrectomy surgery in diabetic retinopathy

Figure 13.1 Neovascularisation on the optic nerve and elsewhere occurs at locations at which there are vitreoretinal interfaces.
Figure 13.2 OCT studies provide a means of more accurately identifying vitreoretinal traction forces that are occasionally responsible for DMO. In this case a partial vitreous detachment is causing persistent traction upon the macula.
Figure 13.3 Vitreous surgery usually includes three incisions for a cutting/aspiration device, an illumination system and a continuous infusion site (not pictured). Vitreous haemorrhage in the gel is easily removed if the posterior vitreous cortical face is separated from the surface of the retina.
Figure 13.4 Fibrovascular tissue growth and secondary changes in the vitreous gel cause traction at sites of vitreovascular attachments, resulting in haemorrhage and traction retinal detachment. Retinal breaks and rhegmatogenous detachments can also occur.
Figure 13.5 The major surgical goal in vitrectomy for PDR is to separate and excise the posterior cortical vitreous surface and associated areas of fibrovascular proliferation from the retinal surface.
Figure 13.6 Segmentation ‘delamination’ techniques can be employed to remove fibrovascular proliferation from the surface of the retina.
Figure 13.7 Some surgeons prefer to employ ‘en bloc’ excision (‘delamination’) of fibrovascular tissue from the retinal surface. Vitreous traction can assist in elevating the abnormal vessels from portions of the retina.
Figure 13.8 Intraocular diathermy is employed to treat bleeding foci on the surface of the retina.
Figure 13.9 (a, b) Vitreous haemorrhage in the right eye with neovascularisation at the right optic disc.
Figure 13.10 (a, b) Retinal appearance post-vitrectomy with laser scars from the panretinal laser treatment.
Figure 13.11 (a–c) Signs of the tractional retinal detachment and vitreous haemorrhage in her left eye.
Figure 13.12 The appearance of her left retina (a) 6 months and (b) 12 years after the vitrectomy.
Figure 13.13 (a) The appearance of the left retina with traction from the fibrotic neovascular complexes and (b) the OCT of the macular area demonstrating the traction.
Figure 13.14 (a, b) The appearance of the left retina and the OCT following surgery.
Figure 13.15 OCT that shows the appearance of the macular area (a) with epiretinal membrane pre-surgery and (b) post-surgery.

Chapter 14: Cataract surgery in the diabetic eye: Pre-, intra- and postoperative considerations

Figure 14.1 Neovascularisation of the iris.
Figure 14.2 Contraction of the anterior capsule.
Figure 14.3 Pupillary dilatation by flexible iris retractors (or hooks): (a) before dilation and (b) after dilatation by iris hooks. The retractors are used to mechanically stretch and stabilise the pupil during surgery. Usually 4–5 hooks are used for pupillary dilation, according to surgeon preference.
Figure 14.4 Pupillary dilatation during surgery using a 6.25 mm Malyugin ring at the time of combined cataract and vitrectomy surgery. This ring has two sizes (6.25 and 7 mm) and is injected into the anterior chamber via a special device through the main cataract incision. We prefer the 6.25 mm size as we find it easier to insert, it provides good pupillary dilation and is less traumatic to the iris tissue.
Figure 14.5 Silicon oil droplets on the posterior surface of the posterior chamber intraocular lens.
Figure 14.6 Diabetic macular oedema.
Figure 14.7 Cystoid macular oedema following cataract surgery.
Figure 14.8 Intravitreal triamcinolone acetonide injection in a patient with co-existing diabetic macular oedema and cataract. The injection (4 mg in 0.1 mL) is performed through the pars plana near the end of the cataract surgery before removing the ophthalmic viscosurgical device from the eye.
Figure 14.9 Operative photograph of intravitreal cavity dexamethasone implant administered after combined cataract surgery and pars plana vitrectomy surgery. Note the posterior location of implant, which is usually the case in vitrectomised eyes.

Chapter 15: Pregnancy and the diabetic eye

Figure 15.1 Colour (a) right and (b) left macula at presentation. Colour (c) right and (d) left macula 1 year after presentation. (e) Colour right macula 2 years after presentation at about 34 weeks gestation. Colour (f) right and (g) left macula 8 years after presentation.
Figure 15.2 Red-free (a) right and (b) left macula at presentation. Colour (c) right macula, (d) right disc, (e) left disc and (f) left macula 3 years and 6 months after initial presentation. Colour (g) right and (h) left macula 3 years and 10 months after initial presentation.
Figure 15.3 Right (a) macula and (b) nasal colour, and left (c) nasal and (d) macula colour at presentation. Right (e) macula and (f) nasal colour, and left (g) nasal and (h) macula colour at 25/40 pregnant. (i) Right and (j) left macula colour at 29/40 pregnant. Right (k) macula and (l) nasal colour, and left (m) nasal and (n) macula colour at 34/40 pregnant. Right (o) macula and (p) nasal colour, and left (q) nasal and (r) macula colour at 1 year postpartum.

Chapter 16: Low vision and blindness from diabetic retinopathy

Figure 16.1 (a, b) A blind patient using his guide dog.
Figure 16.2 Right (a) macula and (b) disc colour. Left (c) disc and (d) macula colour. (e) OCT left macular area.
Figure 16.3 (a) Right and (b) left macula colour at presentation. Fluorescein (c) right macula 1 min 57 s and (d) left macula 1 min 30 s after injection.
Figure 16.4 (a) Right and (b) left macula colour. Right (c) macula and (d) nasal colour. Left (e) nasal and (f) macula colour.
Figure 16.5 Right (a) macula and (b) nasal colour. Left (c) nasal and (d) macula colour. (e) Right and (f) left eye visual field after recovering from cardiac arrest.

Chapter 17: Future advances in the management of diabetic retinopathy

Figure 17.1 Red-free image of NVE in nasal retina.
Figure 17.2 Hyperspectral image showing high venular blood oxygenation in areas of the retina where new vessels have grown.

Chapter 18: Other retinal conditions in diabetes

Figure 18.1 Acute systemic hypertensive retinopathy: (a) right and (b) left eye day 1; (c) right and (d) left eye day 14; (e) right and (f) left eye 6 weeks; (g) right and (h) left eye 6 months; and (i) right and (j) left eye 12 months. OCT hypertensive retinopathy: (k) right and (l) left eye day 1; (m) right and (n) left eye day 14; (o) right and (p) left eye 6 weeks
Figure 18.2 (a) Colour photo right macular area showing CWS just above right central fovea due to small arteriolar occlusion. (b) Fluorescein right macular area 57 s after injection of dye.
Figure 18.3 (a) Central retinal artery occlusion. (b) Cherry red spot. (c) CRAO with a pre-existing cilioretinal artery supplying the macular region.
Figure 18.4 (a) Left superior branch retinal artery occlusion. (b) Left infero-temporal branch retinal artery occlusion.
Figure 18.5 (a) Fibrino-platelet arterial embolus. Left macular appearance (b) before and (c) after asymptomatic cholesterol emboli. (d) Red-free photograph of left macular appearance after asymptomatic cholesterol emboli. Multiple emboli (e) lodging at junctions in arterial tree and (f) causing pale areas of oedema in areas of retinal ischaemia.
Figure 18.6 Right CVRO: (a) colour photograph; fluorescein (b) 29 s; (c) 45 s; and (d) 4 min 5 s after injection. (e) Disc-centred view of multiple haemorrhages caused by a CRVO in a left eye and (f) macula-centred view of the same left eye showing multiple haemorrhages caused by a central retinal vein occlusion.
Figure 18.7 (a) Recent left superior BRVO and (b) with haemorrhage in macular area. Older right infero-temporal BRVO: (c) with some collaterals; fluorescein angiogram (d) 37 s after injection, showing ischaemia in distribution of occluded vein; (e) 1 min 58 s after injection, showing ischaemia and leakage in the distribution of occluded vein; and (f) 3 min 31 s after injection, showing ischaemia and leakage in the distribution of occluded vein.
Figure 18.8 AION: (a) colour photo of disc showing blurring and haemorrhage of inferior disc margin and (b) visual field demonstrating superior and inferonasal field loss.
Figure 18.9 Asteroid hyalosis: (a) right anterior and (b) macular colour; fluorescein angiogram (c) 47 s and (d) 3min 30 s after injection of dye, showing cystoid macular oedema.
Figure 18.10 Macroaneurysm (a) leaking, threatening left macular area; (b, c) immediately after treatment; (d) 4 months after treatment, showing clearing of most of the exudates; and (e) 14 years after treatment.
Figure 18.11 (a) Macroaneurysm leaking blood in the left macular area. (b) Left macular colour photograph 7 months later.
Figure 18.12 (a) Colour photograph showing a macroaneurysm infero-temporal to the right central fovea. (b) OCT showing leakage from a macroaneurysm infero-temporal to the right central fovea. Fluorescein angiogram showing the macroaneurysm (c) 41 s and (d) 7min 31 s after injection.
Figure 18.13 (a) Colour photograph showing a macroaneurysm below the right central fovea. (b) OCT showing leakage from a macroaneurysm below the right central fovea. Fluorescein angiogram showing the macroaneurysm (c) 1min 31 s and (d) 6 min 17 s after injection.

Chapter 19: Conditions with appearances similar to diabetic retinopathy

Figure 19.1 Drusen: (a) surrounding the central foveal area; (b) scattered throughout the retina; Fluorescein from same patient showing minimal uptake of fluorescein by drusen at (c) 19 s; (d) 58 s and (e) 3 min 49 s.
Figure 19.2 (a, b) Myelinated nerve fibres: right infero-temporal colour.
Figure 19.3 (a) Normal red blood cells (high power): compare red blood cell size with that of lymphocyte. Sickle cell crisis: (b) low power, sickle cells and target cells and (c) high power, one red blood cell (arrowed) contains a Howell–Jolly body. (d, e) Fibrotic bands in the retinal periphery of a patient with sickle cell retinopathy.
Figure 19.4 Coats' disease: (a) right macula colour photo; (b) right peripheral retinal colour photo; fluorescein peripheral retina showing peripheral aneurysms and vascular patterns in (c) arterial phase and (d) arteriovenous phase. Fluorescein (e) peripheral retina showing leakage from peripheral aneurysms in early venous phase; (f) macular area showing some secondary oedema in the macular area and (g) peripheral retina showing leakage from peripheral aneurysms in late venous phase. (h) Right peripheral retinal colour photo showing some clearing of exudate 3 months after first laser treatment.
Figure 19.5 Radiation retinopathy. (a) Right and (b) left macular colour photo. Fluorescein angiogram (c) 23 s; (d) 33 s; (e) 1 min; (f) 3 min 45 s; and (g) 4 min 11 s post injection.
Figure 19.6 (a) Right and (b) left macular view, showing cotton wool spots in both eyes in a person treated with interferon.

List of Tables

Chapter 2: Diabetes

Table 2.1 Differences between type 1 and type 2 diabetes
Table 2.2 Monogenic aetiologies of maturity-onset diabetes of the young (MODY)

Chapter 3: Lesions and classifications of diabetic retinopathy

Table 3.1 ETDRS diabetic retinopathy classification of progression to proliferative DR based on 7 × 30 degree field stereo photographs of each eye
Table 3.2 ETDRS maculopathy classification
Table 3.3 International and English retinopathy classifications
Table 3.4 International and English maculopathy classification

Chapter 8: Mild non-proliferative diabetic retinopathy

Table 8.1 ETDRS description of the lesions at the grade of mild non-proliferative diabetic retinopathy

Chapter 9: Moderate and severe non-proliferative diabetic retinopathy

Table 9.1 ETDRS description of the lesions at the grade of moderate and severe non-proliferative diabetic retinopathy

Chapter 14: Cataract surgery in the diabetic eye: Pre-, intra- and postoperative considerations

Table 14.1 Types of post-cataract-surgery macular oedema in patients with diabetes
Table 14.2 Summary of studies evaluating intravitreal anti-VEGF use for prevention or treatment of diabetic macular oedema at the time of cataract surgery

A Practical Manual of Diabetic Retinopathy Management

Second Edition

Edited by

Peter H. Scanlon MD FRCP FRCOphth

Consultant Ophthalmologist, Gloucestershire and Oxford Eye Units
Senior Research Fellow, Harris Manchester College, University of Oxford
Visiting Professor of Medical Ophthalmology, University of Gloucestershire, UK

Ahmed Sallam MD PhD FRCOphth

Staff Surgeon, Jones Eye Institute
Assistant Professor of Ophthalmology
University of Arkansas for Medical Sciences, USA

Peter van Wijngaarden MBBS PhD FRANZCO

Consultant Ophthalmologist, Centre for Eye Research Australia,
Royal Victorian Eye and Ear Hospital, Australia; Ophthalmology,
Department of Surgery, University of Melbourne, Australia

Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell

The right of Peter H. Scanlon, Ahmed Sallam and Peter van Wijngaarden to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Names: Scanlon, Peter H., editor. | Sallam, Ahmed, editor. | Wijngaarden, Peter van, editor.

Title: A Practical manual of diabetic retinopathy management / edited by Peter H. Scanlon, Ahmed Sallam, Peter van Wijngaarden.

Description: 2nd edition. | Chichester, West Sussex ; Hoboken, NJ : John Wiley & Sons, Ltd, 2017. | Includes bibliographical references and index.

Identifiers: LCCN 2016055390 (print) | LCCN 2016056036 (ebook) | ISBN 9781119058953 (cloth) | ISBN 9781119058960 (pdf) | ISBN 9781119058977 (epub)

Classification: LCC RE661.D5 (print) | LCC RE661.D5 (ebook) | NLM WK 835 | DDC 617.7/35-dc23