Diyabetik Retinopati
Özet
Diyabetik retinopati (DR), dünya genelinde hızla artan diyabetes mellitusun en önemli mikrovasküler komplikasyonlarından biri ve ciddi bir körlük nedenidir. Patogenezinde poliol yolu aktivasyonu, vasküler endotelyal büyüme faktörü (VEGF) artışı gibi karmaşık biyokimyasal mekanizmalar, retinal perisit kaybı, kan-retina bariyerinin bozulması ve son yıllarda önemi daha çok anlaşılan retinal nörodejenerasyon rol oynar. En major risk faktörü diyabet süresi olup, kan şekeri ve kan basıncı kontrolü hastalığın ilerlemesini geciktiren değiştirilebilir parametrelerdir. Klinik olarak lezyonların varlığına göre non-proliferatif ve proliferatif olmak üzere sınıflandırılan DR'nin tanısında renkli fundus fotoğrafları, optik koherens tomografi (OCT), floresein anjiyografi (FA) ve OCT anjiyografi gibi gelişmiş görüntüleme yöntemleri kullanılır. Görmeyi tehdit eden diyabetik makula ödemi (DMÖ) ise hastalığın her evresinde ortaya çıkabilen ayrı bir antitedir. Tedavide metabolik kontrolün yanı sıra panretinal/fokal lazer fotokoagülasyonu, intravitreal anti-VEGF ajanlar (ranibizumab, aflibercept vb.) ile steroid implantları tercih edilmektedir. İleri evrelerde gelişen vitreus kanaması ve traksiyonel retina dekolmanı gibi durumlarda ise pars plana vitrektomi cerrahisi uygulanır.
Diabetic retinopathy (DR) is a prominent microvascular complication of diabetes mellitus and a major cause of blindness worldwide. Its pathogenesis involves complex biochemical pathways, such as VEGF upregulation, retinal pericyte loss, blood-retinal barrier breakdown, and retinal neurodegeneration. The primary risk factor is diabetes duration, while blood glucose and blood pressure regulation are modifiable factors that delay progression. Classified into non-proliferative and proliferative stages based on clinical lesions, DR is diagnosed using fundus photography, optical coherence tomography (OCT), fluorescein angiography (FA), and OCT angiography. Diabetic macular edema (DME) is a vision-threatening condition that can occur at any stage. Management comprises metabolic control, panretinal/focal laser photocoagulation, and intravitreal anti-VEGF agents or steroid implants. Advanced complications like vitreous hemorrhage and tractional retinal detachment require pars plana vitrectomy.
Referanslar
International Diabetes Foundation. Diabetes: facts and figures. Available from: http://www.idf.org/about-diabetes/facts-figures. (Accessed December 1, 2017.)
Tarr JM, Kaul K, Chopra M, et al. Pathophysiology of diabetic retinopathy. ISRN Ophthalmol. 2013;2013:343560. doi: 10.1155/2013/343560
Wang W, Lo ACY. Diabetic retinopathy: pathophysiology and treatments. Int J Mol Sci. 2018;19(6):1816. doi: 10.3390/ijms19061816.
Abcouwer SF, Gardner TW. Diabetic retinopathy: loss of neuroretinal adaptation to the diabetic metabolic environment. Ann N Y Acad Sci. 2014;1311:174-190. doi: 10.1111/nyas.12412.
Podesta F, Romeo G, Liu WH, et al. Bax is increased in the retina of diabetic subjects and is associated with pericyte apoptosis in vivo and in vitro. Am. J. Pathol. 2000;156:1025–1032. doi: 10.1016/S0002-9440(10)64970-X.
Abu-El-Asrar AM, Dralands L, Missotten L, et al. Expression of apoptosis markers in the retinas of human subjects with diabetes. Invest Ophthalmol Vis Sci. 2004;45:2760–2766. doi: 10.1167/iovs.03-1392.
Klein R, Klein BE, Moss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. II. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol. 1984;102(4):520-526. doi: 10.1001/archopht.1984.01040030398010.
Mitchell SL, Neininger AC, Bruce CN, et al. Mitochondrial haplogroups modify the effect of diabetes duration and HbA1c on proliferative diabetic retinopathy risk in patients with type 2 diabetes. Invest Ophthalmol Vis Sci. 2017;58(14):6481-6488. doi: 10.1167/iovs.17-22804.
Salmon JF. Kanski Clinical Ophthalmology A Systematic Approach.(9th edition) London: Elsevier; 2019.
Early Treatment Diabetic Retinopathy Study Research Group. Grading diabetic retinopathy from stereoscopic color fundus photographs—an extension of the modified Airlie House classification: ETDRS report number 10. Ophthalmology. 1991;98(5):786–806.
Wilkinson CP, Ferris FL III, Klein RE et al (2003) Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales. Ophthalmology. 2003;110(9):1677–1682. doi: 10.1016/S0161-6420(03)00475-5.
The Royal College of Ophthalmologists. Diabetic Retinopathy Guidelines. Available from: https ://www.rcoph th.ac.uk/wpcontent/uploa ds/2014/12/2013-SCI-301-FINAL -DR-GUIDELINES -DEC-2012-updat ed-July-2013.pdf. (Accessed 4 Mar 2020.)
International Council of Ophthalmology. ICO guidelines for diabetic eye care. Available from: http://www.icoph.org/downloads/ICOGuidelinesforDiabeticEyeCare. pdf. (Accessed December 1, 2017.)
Flaxel CJ, Adelman RA, Bailey ST, et al. Diabetic retinopathy preferred practice pattern. Ophthalmology. 2020;127(1):66-145. doi: 10.1016/j.ophtha.2019.09.025.
Nesper PL, Roberts PK, Onishi AC, et al. Quantifying microvascular abnormalities with increasing severity of diabetic retinopathy using optical coherence tomography angiography. Invest Ophthalmol Vis Sci. 2017;58(6):BIO307-BIO315. doi: 10.1167/iovs.17-21787.
Diabetes Control and Complications Trial Research Group. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the Diabetes Control and Complications Trial. Diabetes. 1995;44(8):968-983.
Takase N, Nozaki M, Kato A, et al. Enlargement of foveal avascular zone in diabetic eyes evaluated by en face optical coherence tomography angiography. Retina. 2015;35(11):2377–2383. doi: 10.1097/IAE.0000000000000849.
Early Treatment Diabetic Retinopathy Study Research Group. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2. Ophthalmology. 1987;94(7):761–774. doi: 10.1016/s0161-6420(87)33527-4.
Elman MJ, Bressler NM, Qin H, et al. Diabetic Retinopathy Clinical Research Network. Expanded 2-year follow-up of ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology. 2011;118(4):609-614. doi: 10.1016/j.ophtha.2010.12.033.
Early Treatment Diabetic Retinopathy Study Research Group. Early photocoagulation for diabetic retinopathy: ETDRS report number 9. Ophthalmology. 1991;98(5):766-785.
Ferris F. Early photocoagulation in patients with either type I or type II diabetes. Trans Am Ophthalmol Soc. 1996;94:505-537.
Fong DS, Strauber SF, Aiello LP, et al. Comparison of the modified Early Treatment Diabetic Retinopathy Study and mild macular grid laser photocoagulation strategies for diabetic macular edema. Arch Ophthalmol. 2007;125(4):469-480. doi: 10.1001/archopht.125.4.469.
Gao X, Xing D. Molecular mechanisms of cell proliferation induced by low power laser irradiation. J Biomed Sci. 2009;16(1):4. doi: 10.1186/1423-0127-16-4.
Do DV, Nguyen QD, Khwaja AA, et al. READ-2 Study Group. Ranibizumab for edema of the macula in diabetes study: 3-year outcomes and the need for prolonged frequent treatment. JAMA Ophthalmol. 2013;131(2):139-145. doi: 10.1001/2013.jamaophthalmol.91.
Early Treatment Diabetic Retinopathy Study Research Group. Focal photocoagulation treatment of diabetic macular edema. Relationship of treatment effect to fluorescein angiographic and other retinal characteristics at baseline: ETDRS report number 19. Arch Ophthalmol. 1995;113(9):1144-1155.
Nguyen QD, Brown DM, Marcus DM, et al. Ranibizumab for diabetic macular edema: results from 2 phase III randomized trials: RISE and RIDE. Ophthalmology. 2012;119(4):789-801. doi: 10.1016/j.ophtha.2011.12.039.
Wong TY, Sun J, Kawasaki R, et al. Guidelines on diabetic eye care: The International Council of Ophthalmology recommendations for screening, follow-up, referral, and treatment based on resource settings. Ophthalmology. 2018;125(10):1608-1622. doi: 10.1016/j.ophtha.2018.04.007.
Maturi RK, Glassman AR, Liu D, et al. Effect of adding dexamethasone to continued ranibizumab treatment in patients with persistent diabetic macular edema: a DRCR Network phase 2 randomized clinical trial. JAMA Ophthalmol. 2018;136(1):29-38. doi: 10.1001/jamaophthalmol.2017.4914.
Mehta H, Hennings C, Gillies MC, et al. Anti-vascular endothelial growth factor combined with intravitreal steroids for diabetic macular oedema. Cochrane Database Syst Rev. 2018;4:CD011599. doi: 10.1002/14651858.CD011599.pub2.
Simunovic MP, Maberley DA. Antı-vascular endothelıal growth factor therapy for prolıferatıve dıabetıc retınopathy: A Systematic Review and Meta-Analysis. Retina. 2015;35(10):1931-1942. doi: 10.1097/IAE.0000000000000723.
Recchia FM, Scott IU, Brown GC, et al. Small-gauge pars plana vitrectomy: a report by the American Academy of Ophthalmology. Ophthalmology. 2010;117(9):1851-1857. doi: 10.1016/j.ophtha.2010.06.014.
