RETINOPATI DIABETES

Epidemiologi
Insidensi 40-50% penderita DM mengalami retinopati. Diabetes tipe I mengalami retinopati minimal 3-5 thn setelah onset penyakit DM, sedangkan diabetes tipe II dapat timbul saat diagnosis ditegakkan. Di AS, kebutaan 5000 org/thn akibat retinopati diabetik Di Inggris menjadi penyebab kebutaan no.4

Faktor Risiko
Hiperglikemia kronis Hipertensi Hiperkolesterolemia merokok

Patogenesis
Hiperglikemia

Akumulasi poliol

Tekanan osmotik & gangguan Morfologi & fungsional sel

Poliol tertimbun dalam jumlah banyak di dalam sel

Perubahan patologis pada kapiler retina

Pathogenesis of diabetic retinopathy

Signs of background diabetic retinopathy

Microaneurysms usually temporal to fovea

Intraretinal dot and blot haemorrhages

Hard exudates frequently arranged in clumps or rings

Retinal oedema seen as thickening on biomicroscopy

Natural History of Diabetic Retinopathy

Mild nonproliferative diabetic retinopathy (NPDR) Moderate NPDR Severe NPDR Proliferative diabetic retinopathy (PDR)

Nonproliferative diabetic retinopathy

Signs

Cotton-wool spots Venous irregularities

Dark blot haemorrhages Intraretinal microvascular abnormalities (IRMA)

Proliferative diabetic retinopathy

Affects 5-10% of diabetics

Flat or elevated Severity determined by comparing with area of disc

Neovascularization

Neovascularization of disc = NVD Neovascularization elsewhere = NVE

Hyperglycemia

R E Vascular T pericyte loss I N Loss of autoregulation O of blood flow P A T I D I A B E T I K

Hyperperfusion Vasoactive mediators Capillary occlusion

Capillary endothelial damage Loss of tight junction

RETINAL ISCHEMIA
Growth factors

Macular edema

Neovascularization
Neovascular glucoma Vitreous hemorrhage BLINDNESS

Preretinal hemorrhage Retinal detachment

Robert EJ, Sue E. Huether. Alterations of Hormonal Regulation Pathophysiology The Biologic Basis for Disease in Adult and C McCance, Huether, Editors. USA: Elsevier Mosby; 2006. p 716

Mild NPDR
At least 1 Microaneurysms (m) Microaneurysms only Remainder of fundus normal

Moderate NPDR
Cotton wool spots (w), Retinal hemorrhages (h) (Dot-blot, Flame), and Microaneurysms (m) Hemorrhages, Microaneurysms in at least 1 quadrant, and cotton wool spots or venous beading in 1 quadrant only Less than Severe

Severe NPDR
Hemorrhages (h) or Microaneurysms (m) in all 4 quadrants Venous beading (b) in 2 or more quadrants IRMA (i) in 1 or more quadrants

Pengobatan (laser)
Fotokoagulasi fokal: memulihkan kompetensi sawar retina-darah bag. dlm disertai edema & eksudat Fotokoagulasi panretina: neovaskularisasi melemah krn jar iskemik retinopati jd inaktif (2-4 x, selang waktu 2 mingg) Edema makula besar fotokoagulasi makula sebelum/bersama fotokoagulasi panretina menghindari eksaserbasi edema Indikasi :
NPDR bentuk berat PDR Edema makula

Komplikasi :
Defek lapang pandang Gangguan sensibilitas dan kontras

Fotokoagulasi Laser Panretina

Indikasi PDR M kan kemungkinan perdarahan masif korpus vitreum dan ablasio retina. Teknik, berupa :
pembentukan luka-luka bakar laser di seluruh retina berjarak teratur dengan tidak mengenai bagian sentral yang dibatasi oleh diskus dan pembuluh vaskular temporal utama.

Vitrektomi..
Indikasi :
Ablasio retina traksi Perdarahan vitreous tanpa resorpsi Perdarahan vitreous rekuren Edema makula kronik tanpa efek positif setelah terapi laser.

Preventif
DM tipe 1 pemeriksaan oftalmologik dlm 3 thn setelah diagnosis; diperiksa ulang minimal sekali setahun DM 2 pemeriksaan oftalmologik pd saat diagnosis; diperiksa ulang minimal sekali setahun Wanita hamil diabetes pemeriksaan oftalmologik pd trimester 1; diperiksa ulang minimal setiap 3 bulan-persalinan

 Kontrol gula darah NORMOGLIKEMIA

referensi
American Diabetes Association. Standards of medical care in diabetes--2012. Diabetes Care. 2012 Jan;35 Suppl 1:S11-63. Diabetic Retinopathy: What you should know. Bethesda, MD: National Eye Institute, National Institutes of Health (NIH), DHHS; 2004. Aiello LP, Gardner TW, King GL, Blankenship G, Cavallerano JD,Ferris FL 3rd, Klein R: Diabetic Retinopathy. Diabetes Care 21 (1): 143156,1998. Riodan-Eva P. In: Vaughan DG, Asbury T, Riodan-Eva P, editors. Oftalmologi umum: anatomi dan embriologi mata. 14th ed. Jakarta. Penerbit Widya Merdeka; 1996. p. 7-9 Lang GK. In: Ophtalmology a short textbook: retina. 1st ed. New York, Thieme Stuttgart Germany; 2000. p. 299-314, 323-5