Diabetic Retinopathy — पूरा MBBS/MD स्तर गाइड (Hindi + English)
Updated: 20 August 2025 • Mahfooz Medical Health • Audience: Ophthalmologists, MBBS/MD students, endocrinologists & informed patients
Short overview / संक्षिप्त परिचय
Diabetic retinopathy (DR) diabetes का retinal microvascular complication है जिसे timely detection और intervention से blindness से रोका जा सकता है। DR दो मुख्य प्रकार में आता है: Diabetic macular edema (DME) और neovascular / proliferative changes (PDR). Screening और glycemic/BP control DR progression को significantly slow कर सकते हैं.
Clinical pearl: Retina में होने वाले microvascular changes पहले asymptomatic होते हैं — screening kaafi important hai; Type 2 diabetes diagnosis के समय retina check करना जरूरी है।
Epidemiology / प्रसार
Worldwide DR prevalence diabetes population में लगभग 20–40% reported है (population और screening coverage के हिसाब से vary करता है). Diabetic macular edema (clinically significant DME) का prevalence कम लेकिन vision-threatening होता है. Longer diabetes duration, poor glycemic control (high HbA1c), hypertension, nephropathy और pregnancy risk बढ़ाते हैं — इसलिए DR को multisystem complication के रूप में देखें (see related: Diabetic Nephropathy, Diabetic Neuropathy).
Pathophysiology / रोगजनन (MBBS/MD level)
Chronic hyperglycemia leads to biochemical and hemodynamic changes in retinal microvasculature:
- Microaneurysms: pericyte loss and capillary wall weakness → microaneurysm formation (earliest sign).
- Capillary nonperfusion / ischemia: leads to upregulation of VEGF (vascular endothelial growth factor) → neovascularization in PDR.
- Breakdown of blood-retinal barrier: leads to leakage → hard exudates and macular edema (DME).
- Basement membrane thickening, endothelial cell loss, and retinal ischemia: contribute to progressive vision loss.
Histology: microaneurysms, dot-and-blot hemorrhages, cotton wool spots (nerve fiber layer infarcts), intraretinal microvascular abnormalities (IRMA), neovascular fronds in advanced disease.
Risk factors / जोखिम
- Longer duration of diabetes (strongest predictor).
- Poor glycemic control (high HbA1c).
- Hypertension — BP control reduces progression.
- Hyperlipidemia, nephropathy (proteinuria), pregnancy, anemia, smoking.
Clinical presentation / रोगी में दिखने वाले लक्षण
Early diabetic retinopathy often asymptomatic. Symptoms when present:
- Blurred or fluctuating vision (especially DME).
- Floaters or sudden visual field defects (vitreous hemorrhage from PDR).
- Sudden profound visual loss (tractional retinal detachment or dense vitreous hemorrhage).
- Difficulty reading/fine work (macular involvement).
Patient education: "Agar akal se aankhon me floaters, flashing lights, ya sudden vision loss ho — turant ophthalmologist/retina specialist ko dikhayein."
Screening & Referral (practical protocols)
Who and when
- Type 1 diabetes: start screening 5 years after diagnosis (or at puberty for pediatric cases); annual thereafter if stable.
- Type 2 diabetes: screen at diagnosis (many have DR at diagnosis) and then annually or per ophthalmic grading.
- Pregnancy: preconception retinal exam and in first trimester, then close follow-up each trimester if DR present — pregnancy can worsen DR rapidly.
Screening methods
- Dilated fundus examination by ophthalmologist with slit-lamp biomicroscopy and indirect ophthalmoscopy.
- Fundus photography (7-field ETDRS or wide-field imaging) for documentation and telemedicine screening.
- Optical coherence tomography (OCT) for macular edema detection/monitoring.
- Fluorescein angiography (FFA) when planning laser or to assess ischemia/neovascularization.
Grading / Staging (practical)
Common clinical categories — (use terms consistently in notes):
- Non-proliferative diabetic retinopathy (NPDR): mild, moderate, severe — characterized by microaneurysms, dot-blot hemorrhages, hard exudates, cotton wool spots, IRMA.
- Proliferative diabetic retinopathy (PDR): neovascularization on disc (NVD) or elsewhere (NVE), vitreous hemorrhage, tractional retinal detachment.
- Diabetic macular edema (DME): focal or diffuse retinal thickening involving the macula — clinically significant macular edema (CSME) per ETDRS criteria.
ETDRS (Early Treatment Diabetic Retinopathy Study) classification still used for research and treatment thresholds; in clinic, the presence of center-involving DME or any high-risk PDR guides urgent intervention.
Investigations — fundus tests & systemic workup
- Ophthalmic: Dilated fundus exam (slit lamp + 90D/78D), OCT (macular thickness maps), fundus photography, FFA (to map ischemia/neovascularization), B-scan ultrasound if vitreous hemorrhage obscures view.
- Systemic: HbA1c, fasting & postprandial glucose, BP measurement, lipid profile, renal function tests (eGFR, urine albumin) — interlink with renal/neuropathy topics for comprehensive diabetes care: Diabetic Nephropathy, Diabetic Neuropathy.
Management — overview (medical, laser, surgical)
DR management is multidisciplinary: endocrinologist for systemic control, retina specialist for ocular therapies. Mainstays:
- Strict systemic control: glycemia, BP, lipids (tight control slows progression).
- Anti-VEGF intravitreal injections for DME and certain PDR situations.
- Focal/grid or panretinal photocoagulation (PRP) laser for PDR/ischemia.
- Vitrectomy surgery for non-clearing vitreous hemorrhage, tractional retinal detachment, or combined indications.
Anti-VEGF therapy — details, dosing, timing, monitoring
Anti-VEGF agents revolutionized DME and PDR management. Examples below are typical dosing regimens used in many retina practices—local labels/guidelines and specialist preference guide exact protocols.
Common intravitreal anti-VEGF agents (examples & doses)
| Drug | Typical intravitreal dose | Usual schedule (example) |
|---|---|---|
| Bevacizumab (Avastin) — off-label | 1.25 mg / 0.05 mL intravitreal | Loading: monthly × 3 then PRN or treat-and-extend per response |
| Ranibizumab (Lucentis) | 0.5 mg / 0.05 mL intravitreal | Monthly loading (3) then PRN or treat-and-extend |
| Aflibercept (Eylea) | 2.0 mg / 0.05 mL intravitreal | Often 2 mg every 4 weeks × 5 then q8 weekly or treat-and-extend; shown effective in DME and PDR |
Indications
- Center-involving DME with vision impairment: first-line therapy in many centers.
- PDR with high risk features or before/after PRP in selected cases; anti-VEGF can cause rapid regression of neovascularization and reduce intraoperative bleeding if vitrectomy planned.
Procedure & monitoring
- Explain risks/benefits; obtain informed consent.
- Aseptic intravitreal injection technique in minor OT/sterile room: topical anaesthetic, povidone-iodine prep, eyelid speculum, inject in inferotemporal quadrant 3.5–4.0 mm posterior to limbus (pseudophakic vs phakic considerations), post-injection IOP check and topical antibiotic per local practice.
- Follow-up: OCT at 4–6 weeks to assess response; monitor for IOP rise, endophthalmitis (rare), vitreous hemorrhage.
Safety considerations
- Endophthalmitis risk low (≈0.02–0.1%)—aseptic technique crucial.
- Systemic arterial thromboembolic events: theoretical risk; discuss with cardiologist in high-risk patients.
- Monitor IOP in glaucoma patients; consider prophylactic meds if needed.
Laser therapy — focal/grid and panretinal photocoagulation (PRP)
Focal/grid laser
Indication: focal DME with leaking microaneurysms outside foveal center—laser reduces local leakage. OCT helps guide treatment.
Panretinal photocoagulation (PRP)
- Indication: PDR with high-risk features (NVD, extensive NVE) or severe NPDR with ischemia.
- Mechanism: PRP reduces ischemic drive by ablating peripheral retina, thus decreasing VEGF production and causing regression of neovascularization.
- Procedure: multiple sessions may be needed; post-op side effects include peripheral field loss, nyctalopia (night vision) and sometimes temporary macular edema increase — combine with anti-VEGF if needed for DME.
Vitrectomy & surgical management
Vitrectomy indicated for:
- Non-clearing vitreous hemorrhage (weeks to months with no clearance and visual impairment).
- Tractional retinal detachment involving macula or threatening macula (urgent surgery).
- Combined tractional/rhegmatogenous detachments — complex vitreoretinal surgery with membrane peeling, endolaser, tamponade (gas or silicone oil) as indicated.
Pre-op anti-VEGF may be used to reduce intraoperative bleeding. Surgical outcomes depend on pre-op macular ischemia, duration of detachment and surgeon expertise.
Systemic management — glycemic, BP, lipids & multidisciplinary care
- Glycemic control: tight control reduces development/progression — aim individualized HbA1c (often ≈7% unless contraindicated).
- BP control: targets individualized (e.g., <130/80 mmHg) — ACEi/ARB useful for nephropathy and cardiovascular risk reduction; coordinate with physician/endocrinologist.
- Lipid management: statins reduce vascular risk and may help DR progression indirectly.
- Address associated comorbidities: nephropathy (see Diabetic Nephropathy), neuropathy (Diabetic Neuropathy), cardiovascular disease.
Follow-up & monitoring (practical schedules)
- Normal retina: annual screening.
- NPDR mild–moderate: ophthalmic review every 6–12 months depending on severity.
- Severe NPDR / PDR / any DME treated: follow-up as advised by retina specialist (often 4–12 weeks after therapy then individualized).
- OCT monitoring for DME response after anti-VEGF (usually 4–6 weekly during loading phase).
Pregnancy considerations
Pregnancy may accelerate DR progression—preconception ophthalmic exam and trimester-wise follow-ups recommended. Treatment decisions (laser vs anti-VEGF) should weigh maternal benefits and fetal risks—PRP generally considered safer; anti-VEGF systemic absorption is possible and used cautiously.
Children & adolescents
Type 1 diabetes pediatric screening begins ~5 years after diagnosis or at puberty—coordinate with pediatric endocrinology and pediatric retina services. Early intensive glycemic control essential to reduce lifetime DR risk.
Prevention & patient counselling (practical)
- Maintain HbA1c targets — discuss SMBG/CGM as appropriate.
- BP & lipid control — adherence to antihypertensives & statins.
- Smoking cessation.
- Annual retinal screening and prompt reporting of visual symptoms (floaters, blurring, field defects).
- Coordinate diabetes care with nephrology if there's kidney disease (see Diabetic Nephropathy).
Related articles / संबंधित लेख (internal links)
यहां कुछ महत्वपूर्ण internal links दिए गए हैं — site-wide linking policy के अनुसार जहाँ भी keywords article में आए हैं, उन जगहों पर भी links जोड़े गए हैं:
Complications & referral triggers
- Vitreous hemorrhage → urgent retina referral.
- Tractional retinal detachment involving macula → urgent vitrectomy referral.
- Non-clearing DME with vision loss despite treatment → consider second-line treatments or combination therapy; refer to tertiary retina center.
- Rapid progression (e.g., from mild NPDR to PDR in months) → check systemic controls and urgent ophthalmology review.
Exam / clinical pearls (for MBBS/MD students)
- Earliest ophthalmoscopic sign: microaneurysm (tiny red dots) — look carefully in macular area.
- Hard exudates in a circinate ring around the macula suggest chronic leakage — check OCT for edema.
- Any new floater or flash in a diabetic patient warrants urgent fundus evaluation for vitreous hemorrhage or traction.
FAQs / अक्सर पूछे जाने वाले प्रश्न
Q: Diabetic retinopathy reverseहो सकती है ?
A: Advanced structural damage (e.g., ischemic retina, tractional detachment) rarely reversible. Early changes and DME often improve with anti-VEGF/laser + systemic control. Prevention & early treatment key hain.
Q: Anti-VEGF कितने टाइम तक लगवाते हैं??
A: Initial loading phase commonly monthly for 3–5 doses, then PRN/treat-and-extend. Kuch patients ko lifelong periodic injections chahiye hote hain; response depends on ischemia and systemic control.
Q: Agar patient pregnant हो तो anti-VEGF दे सकते हैं?
A: Pregnancy me anti-VEGF ka use caution ke sath—systemic absorption ki wajah se fetal effects ko lekar caution. Multidisciplinary discussion (obstetrics + retina) zaroori. PRP laser often preferred when possible.
References & further reading
Key guideline sources: ADA Standards of Care (Ophthalmology), AAO Retina Preferred Practice Patterns, ETDRS and major RCTs for anti-VEGF in DME/PDR. (For patient-facing summaries, internal links and guideline synopses have been provided.)
Conclusion / निष्कर्ष
Diabetic retinopathy diabetes की एक preventable और treatable complication है अगर early detection और timely intervention हो। Systemic control (glycemia, BP, lipids), annual screening, prompt anti-VEGF/PRP या vitrectomy where indicated, और patient education — इन सबका combined approach blindness को रोक सकता है. Regular coordination between diabetes care team and retina specialist critical है.