EyePACS Grading System (Part 3): Detecting Proliferative (Neovascular) Diabetic Retinopathy. George Bresnick MD MPA Jorge Cuadros OD PhD

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1 EyePACS Grading System (Part 3): Detecting Proliferative (Neovascular) Diabetic Retinopathy George Bresnick MD MPA Jorge Cuadros OD PhD

2 Anatomy of the eye:

3 3 Normal Retina Retinal Arcades Macula Optic Nerve

4 Severe Nonproliferative Retinopathy (NPDR) 4 Latin American male, DM II X 12 years, Last eye exam 5 years ago

5 High-Risk Markers for Progression to Proliferative Retinopathy: Early Treatment of Diabetic Retinopathy Study Ischemic Retinal Lesion Extensive retinal hemorrhages (HMA) Progression rate to PDR (1 yr) 48% Venous beading (VB) 51% Intraretinal Microvascular Abnormalities (IRMA) Cotton Wool Spots (CWS) 44% No sig. increase

6 Proliferative Diabetic Retinopathy (PDR) Fibrovascular tissue on the inner surface of the retina and into the vitreous. Major cause of severe visual loss in diabetes Vitreous hemorrhage Macular traction Retinal detachment Courtesy of Fred Hollows Foundation NZ

7 Statistics from EyePACS Prevalence of PDR in our clinics: 6228 encounters with detected PDR 2.5% of entire database (252,000 encounters) Treatments for PDR: Laser in at least one eye: 2754 (44% of diagnosed PDR) Laser in both eyes: 1303 (21% of diagnosed PDR) Most patients detected with PDR in EyePACS don t know they have it.

8 8 Neovascularization (New Blood Vessels) 49 year old Caucasian male, DM II X 13 years, IDDM X 10 years, subjective DM control: Good ; last eye exam: more than 5 years

9 Proliferative Diabetic Retinopathy (PDR) Review the fundus lesions found in PDR Emphasize retinal ischemia stimulus for PDR Eyes with PDR at increased risk for vision loss

10 Fibrovascular Proliferation PDR New vessels Optic disc (NVD) Elsewhere (NVE) Fibrous proliferation Vitreous hemorrhage (VH)/preretinal hemorrhage (PRH)

11 NVD (Neovascularization of the disc) Fronds of new vessels emanate from optic disc (Arrows)

12 NVE (Neovascularization elsewhere) NVE Tuft of new vessels growing from feeding vessels

13 Significance of new vessels on the optic disc (NVD) NVD are a response to widespread retinal ischemia (lack of oxygen) NVD=High Risk for severe visual loss without treatment (DRS Results)

14 Significance of new vessels elsewhere (NVE) Reflect localized retinal ischemia High Risk for visual loss without treatment if: Extensive Associated with vitreous hemorrhage/preretinal hemorrhage

15 Fibrovascular Proliferation PDR New vessels optic disc (NVD) Elsewhere (NVE) Fibrous proliferation Vitreous hemorrhage (VH)/preretinal hemorrhage (PRH)

16 Fibrous Tissue Proliferation Accompanies new vessels May contract and cause: Localized retinal detachment Tractional displacement of macula

17 Fibrous tissue proliferation Localized retinal detachment Retina detached at base of elevated FP above (arrows)

18 Fibrovascular Proliferation PDR New vessels optic disc (NVD) Elsewhere (NVE) Fibrous proliferation Vitreous hemorrhage (VH)/preretinal hemorrhage (PRH)

19 Vitreous Hemorrhage (VH) Cloudy view of retina due to bleeding into the vitreous cavity

20 Preretinal Hemorrhage Boat-shaped PRH Lower edge of PRH below confined by curvilinear limit of posterior vitreous detachment (arrows)

21 High Risk PDR Diabetic Retinopathy Study (DRS) High risk for severe vision loss without laser 50% Reduction in severe vision loss with laser* Any one of the following: >=Moderate NVD with or without VH Mild NVD with VH >=Moderate NVE with VH * High Risk PDR generally requires prompt PRP laser treatment.

22 Proliferative Diabetic Retinopathy (PDR) Pathophysiology Stimulated by retinal ischemia Mediated by vascular endothelial growth factor (VEGF) Inhibited by Panretinal photocoagulation (PRP) Intravitreal anti-vegf factors (e.g., Avastin)

23 EyePACS Grading Template

24 NEW VESSELS (NV) OR FIBROUS PROLIFERATION (FP)? New vessels (NV) or fibrous proliferation (FP) present? no ( ) yes ( ) Cannot grade ( ) Consider NV on the disc (NVD) or elsewhere (NVE). Answer yes, if FP likely to be a frond originating from neovascular growth. Answer no, if FP likely to be fibrous (or glial) tissue from another condition e.g., epiretinal membrane; congenital glial remnant on optic disc.

25 Case NVD NVD

26 34 yr. old African American DM II X 5 yrs, HbA1c= 8.0 Lifelong Medical Clinic, 5/22/2014 NVE NVE

27 FP superiorly-no obvious NV Case 50276

28 EyePACS Grading Template

29 PRERETINAL HEMORRHAGE (PRH) OR VITREOUS HEMORRHAGE (VH)? Preretinal hemorrhage (PRH) or vitreous hemorrhage (VH) present? no ( ) yes ( ) Cannot grade ( ) Consider hemorrhage on the surface of the retina (preretinal space) and/or hemorrhage into the vitreous. Answer yes, even if hazy image precludes grading of other lesions of DR if haze is thought to be due to PRH and/or VH.

30 Preretinal Hemorrhages Lower edge of PRH below confined by curvilinear limit of posterior vitreous detachment (arrows) Boat-shaped PRH

31 Vitreous Hemorrhage Case VH

32 Questions 9, 10 Laser Scars?

33 LASER SCARS? Panretinal laser scars present? no ( ) yes ( ) Cannot grade ( ) Consider laser scars usually between 200 microns and 500 microns in diameter, and located beyond the posterior pole The presence of PRP scars will be considered presumptive evidence of prior PDR in the automated computer algorithm Patients who have had PRP are assumed to need continued follow up retinal care unless explicitly discharged.

34 Panretinal Photocoagulation (PRP)

35 Case PRP Laser Scars

36 What happens when patients are not treated in time?

37 24 year old Latin American female Image from EyePACS visit on 1/31/2006: HbA1c 12.6 Pregnant DM Type 1 since 7 months Advised to have close follow up due to pregnancy. Pregnancy accelerates retinopathy Type 1 DM usually has no retinopathy for first 5 years. Prominent IRMA

38 Case 2: 24 year old Latin American female Image from EyePACS visit on 7/16/2009: HbA1c 9.3 Pregnant Per pt, around July 4th, started seeing "webs" on the right eye. Referred for treatment within one week.

39 24 year old Latin American female New Blood Vessels HbA1c = 9.5 Meds: prenatal vitamins, humalog/nph insulin Photographed on 9/21/2011 at 12:21 PM

Retinal Detachment April 14, 2014 44 yr.

40 Retinal Detachment April 14, yr. old Latin American male 2 yrs with DM II HbA1c = 10.9 Other eye is blind

Retinal Detachment October 2, 2013 30 yr.

41 Retinal Detachment October 2, yr. old African American male yrs with DM II Left eye treated 8/2013 Photographer: Per pt. he is able to see straight, but on his right side of his right eye is blurry and shaped like a cone.

42 Retinal Detachment June 24, yr. old Latin American male 4 yrs with DM II HbA1c = 11.7 Photographer: patient states cannot follow fixation light

Iris Neovascularization November 4, 2013 58 yr.

43 Iris Neovascularization November 4, yr. old Caucasian female 6-10 yrs with DM II HbA1c = 7.8 Stopped seeing retinal specialist due to change in insurance

Iris Neovascularization May 20, 2014 60 yr.

44 Iris Neovascularization May 20, yr. old Latin American male 6-10 yrs with DM II HbA1c = 8.3 Urgent referral (within one day, if possible) Very painful

Iris Neovascularization October 24, 2013 55 yr.

45 Iris Neovascularization October 24, yr. old Latin American male yrs with DM II IDDM for 1 year Permanently blind

46 Preventing blindness from PDR Diagnosis and treatment of PDR can prevent 50% of severe vision loss in advanced diabetic retinopathy EARLY diagnosis and treatment of PDR can prevent 90% of severe vision loss. - Center for Disease Control If a patient waits until visual symptoms arise in order to be treated, then it may be too late..

47 For more information about EyePACS certification for interpreting retinal images, please visit: Thank You!

EyePACS Grading System (Part 2): Detecting Presence and Severity of Background (Non-Proliferative) Diabetic Retinopathy Lesion

EyePACS Grading System (Part 2): Detecting Presence and Severity of Background (Non-Proliferative) Diabetic Retinopathy Lesion George Bresnick MD MPA Jorge Cuadros OD PhD Anatomy of the eye: 3 Normal Retina