Lecture: Guidelines for the Prevention and Management of Diabetic Retinopathy and Diabetic Eye Disease in India

Dr. Kuldeep Dole: Thank you, friends, for joining in this today afternoon Cybersight Webinar. There are host of webinar that are being planned on this topic. But what I wanted to discuss with you all is primarily the guidelines that are developed by London School of Hygiene and Tropical Medicine, Queen’s Diamond Jubilee Trust and Public Health Foundation of India after a successful completion of their initiative in India for diabetic retinopathy.

So, why these Queen’s Diamond Jubilee Trust and London School and PHFI integrate and interested in developing this sort of guideline is because we all know that a diabetics are increasing at a very rapid rate in India and we are likely to reach a population of 134 million by 2045. Out of that from 1 in 5 that is 20% off all diabetics are likely to have some sort of retinopathy. And out of those all who are suffering from retinopathy, some 10 % will have a sight threatening retinopathy. That is, that comes out to be 7 million.

The important aspect of blindness due to visually impaired and visual impairment due to diabetic retinopathy is, this happens primarily in the productive years of life and we know that by successful screening strategy we can prevent almost 90% of this blindness or visual loss. We also know that a management of risk factors can reduce the risk of complication. Unfortunately, diabetic retinopathy is although a problem of ophthalmologist, the primary management of diabetes is not in our hands. So, we have to rely on various stakeholders for referring patients with diabetes to us.

So, from that point of view, what can be done, what all guidelines should be adopted in detecting these patients earlier and giving them a timely advice as well as timely treatment to prevent visual loss is very important. Why this is important? Because this study that it was done in 2014. It has successfully showed that the delay in the diagnosis of screening, delay in screening from detection of diabetes leads to more complications.

You can see in this green bar, almost 20% off population had some retinopathy and some 3.7% of population had treatable retinopathy. And this is quite evidently seen in our clinical practice in day to day clinical practice because we are still seeing majority of the patient in this stage when advanced stage of disease already has taken place in them. And very limited options are available to us to give them their vision back, and our main treatment focus becomes to stabilize their vision.

So, from that point of view based on the learning that Queen’s Diamond Jubilee Trust project had across India, this was implemented in all areas of India like north, south, west, central. And this was discussed at length and Guidelines were developed to help prevent diabetic retinopathy to decide which approaches are there for the early detection, what clinical investigations and clinical management have to be followed and it also includes management off cataract after in a patients with diabetes mellitus.

So, I will be discussing all these aspects in detail in my further slides. These Guidelines were developed in consultation with physicians, ophthalmologist, community physicians, policymakers, public health professionals from Government of India as well as non-government organizations and public health schools in India and United Kingdom.
The important aspect was, before the guidelines were developed on the topic that I discussed in my previous slide, a questionnaire was developed. This questionnaire is called as a PICO questionnaire, Population, Intervention, Competitors and Outcome questionnaires. And then these questions were given to information scientists Cochrane Eyes and Vision Group. And they did a thorough literature search by creation of EndNote database.

So, an evidence based these guidelines are evidence based. What do we mean by evidence base? That these are there is a hierarchy of evidence from Level 1 to Level 4. And Level 1 is the strongest evidence where a systematic review of all randomized clinical trials are assessed and a systematic review is written on that topic. Level 2 is at least one properly designed randomized control trial is there. And similarly, Level 4 comes out to be a case series. So, that is the weakest evidence. So, from Level 1 is strongest, Level 4 is the weakest evidence. So, in my presentation, you will see that in front of lot of sentences these levels are written. That means how strong is the evidence for that sentence.

The first question that was addressed by this group was, which classification system should be used for clinical management? So, they agreed on that the International Clinical Diabetic Retinopathy and Diabetic Macular Edema Severity Scale referred an International Classifications, which was given in 2003, is should be used. And the recommendation for practice is that International Classifications is used and this classification should be determined after detailed dilated retinal examination using biomicroscopy. This will allow consistency and indications for follow up treatment and also comparison across various national-international collaborative trials. What is this classification? This classifications has two main components proliferative, non-proliferative and diabetic macular, three components are there. In the non-proliferative section, no apparent diabetic retinopathy, that is no abnormality seen. In the mild section only microaneurysms are seen. In the moderate section, microaneurysms with other science like dot, blot haemorrahage, hard exudates and cotton wool, but less severe than non-proliferative in severe non-proliferative. What do we mean by severe non-proliferative? That hemorrhages are seen in at least in all the four quadrants then venous beading in two quadrants and IRMA in one quadrant. Proliferative retinopathy is signs of neovascularisat either on disc or elsewhere or vitreous or preretinal hemorrhage.

Diabetic macular edema is classified based on clinical examination and no retinal thickening or hard exudates in the macula. And the other two is non-central involving, that is the retinal thickening in the macula that does not involve the central subfield zone that is 1mm in diameter. And center involving is, when the central thickening is in the center of the macula. That is in the central macula.

So, this is a pictorial pic of this. Mild is only microaneurysms, moderate and microaneurysms that’s hard and soft exudates with hemorrhages. Severe is the hemorrhages are in four quadrant, beading are in two quadrants and IRMA in at least one quadrant. And very severe is two to three, two or three, out of these are seen, then it is called a very severe. And macular, this central involving and nin-central involving. This classification is very easy to understand and this is used for treatment purpose also.

So, I will go into the, this I have already discussed. Now, let’s look at what are the various risk factors for retinopathy. Why it is important that up to this mild all the retinopathy can be prevented if we manage risk factors. Now, risk factors all in column one, all the risk factors are enumerated but out of these very few are modifiable which we have to focus on. Because non-modifiable, we can’t do anything about it but modifiable by active counseling if we give a detailed awareness about these two stakeholders primarily the patients with diabetes then there is less likelihood that they will develop a significant retinopathy. And there are lots of trials which have given this in a detailed evidences available.

So, the recommendation for practice to reduce the risk of diabetic retinopathy in diabetic macular edema is all people with diabetes should be managed by a physician or diabetologist, to control blood glucose, hypertension and lipids and also to support their lifestyle by cessation off smoking and reduction in dietary salt intake. So, that is the recommendation.

Now, let’s look at what are the target values that we ought to look into for diabetes control. For Type 1 as well as Type 2 diabetes, HemoglobinA1C of 7% adjusted in the range of 6.5 to 7.5 is indicated for control of retinopathy. Then blood pressure systolic less than 130 if in a patient who doesn’t have a diabetic retinopathy or cardio-renal complication. In patients who have diabetic retinopathy or cardio-renal complication, this is less than 140. As far as lipids are concerned, lipids help reduces diabetic macrovascular complication. This is macrovascular not micro. But there is very less evidence as far as PDR is concerned. And we need more evidence for diabetic macular edema.

Now, there is a drug called a glitazone which actually is used in the management of diabetes mellitus, which tend to cause water retention in body and that is sure to have a detrimental effect on diabetic macular edema. So, it is recommended to shift it from to some other anti-diabetic. And this HbA1c and blood pressure has to be managed and has to be looked after on a regular basis.

Also, we need to counsel patients whenever they come to us to visit their physicians regularly because in diabetic the tendencies are there, that once at the time of diagnosis a prescription is given, that prescription they continue for their life. So, they have to visit physicians regularly to look at other complication as well as for change in medication.

As I discussed earlier, role of lipids especially in Indian population where we see hyperlipidemia in large quantities, we need to have more evidence to find out what is its role in progression of diabetic retinopathy. Now, how should this individual, how these interventions which we know for promotion and prevention be delivered to people with diabetes? Now, we all know that diabetics are, it’s not a one day treatment. So, we have to promote self-management of diabetes like their sugar, they have to check on their own. They can, if the patient is insulin independent especially Type 1, they can control their — they can look into their diabetic insulin dosage on their own. As well as their exercise, yoga has to be advocated on regular basis to these individuals. And these people are likely to suffer from anxiety, depression, and they have a very day to day issues in their practice, what to eat, what not to eat. So, for them establishing a self-help of a peer support group is critically important to have sustainability in the interventions that we are planning with them and to help alleviate their anxiety, so that they don’t going to a type of anxiety and desperation.

Now, to increase their awareness about this, we need to educate them through an intensive information and education and communication campaign. We conducted a study in Pune, that study is called a KAP study, Knowledge, Attitude and Practice study amongst various stakeholders. And what we have found, that the knowledge, attitude and practice amongst diabetics, non-diabetics and people who are delivering care for diabetic is not good for diabetic retinopathy and in general diabetes mellitus management. So, we require a huge amount of awareness campaigns in stalk holders to prevent this complication developing.

In health professionals, we need to primarily to tell them about the complications and need for annual eye examination. This is critically important because diabetics are reluctant to go for their eye exam if the vision is good. They have negative attitude towards laser treatment as well as they keep on changing doctors because they don’t find vision improvement. If the person has already developed poor vision because of retinopathy, then our goal becomes to stabilize their vision and then they lose hope in that doctor and they keep on changing. On that point of view, a communication has to be there and for that we need to give them a various handouts, posters, guest lectures, education materials, press materials, workshops, seminars. So, all the metabolites of health education has to be implemented if we really want to prevent these people from developing significant retinopathy.

Now, let’s look at what diagnostic tests should be done for people to diagnose retinopathy and diabetic macular edema. A simplest test which a physician or any stakeholder can do is a visual acuity examination and detailed dilated fundus examination. So, this preferably has to be done by slit lamp bio-microscopy or indirect ophthalmoscopy. OCT is not for all the patients but it has to be restricted for patients when we want to quantify characteristic and characterize macular change and when the clinical picture and visual acuity do not co-relate.

So, these table is important that in column one various situations are described. So, OCT it generally asked as per the AAO guideline to investigate unexplained visual loss, to identify areas of vitreo-macular traction, to evaluate patients who are difficult to examine and to monitor response to treatment. It is occasionally used to investigate other possible causes and it is rarely used to screen with no or minimal diabetic retinopathy or it should not be used for that purpose.

The next investigation is angiography. So, angiography is primarily indicated when severe NPDR or PDR is suspected to identify neovascularisation and to asses peripheral and macular vascular competency. Being invasive, it is not, when right clinical examination and OCT cannot determined DME, then this is used. But when we’re doing FFA, resuscitation equipment and consumables has to be available because this can have, show a severe anaphylactic reaction also.

So, angiography is used to investigate unexplained visual loss to guided laser treatment for DME because primarily if there is an estimate maculopathy, then we cannot treat that person. To identify suspected but clinically obscure neovascularization, sometimes to identify areas of traction, to identify large areas of capillary non-perfusion, to rule out other possible causes of macular swelling and to evaluate patients who are difficult to examine. I will like to give a classical examination of this macular swelling.

If a patient of macular edema presents to us after cataract surgery and that person also had a diabetic macular edema, then if we do angiography because the macular edema can happen because of cataracts surgery also and it can happen because of diabetic macular edema progression also. Now, to differentiate between this, if we do angiography and if we find that the optic nerve head is also showing hyper fluorescent then that goes more in favor of favor of Irvine-Gass syndrome that is cataract induced macular edema. But if the disc is not hyper fluorescent, then that goes more in favor of diabetic macular edema where we have to give AntiVEGF treatment not Steroid treatment. So, this is how angiography can help differentiate between these two conditions.

Other two indication, other two, other investigations are ultrasound, which is mainly used in as a pre-operative tool to identify diabetic retinal detachments, like, a traction detachment or a mature cataract is there whether there is a and also, vitreous hemorrhage is there. For that ultrasound is used in the pre-operative the area.

Now, as far as other new indications like OCT Angiography and ultra-wide field imaging, these are not the must, because they are very expensive. If these are there, then this can be used for better disease characterization and for research purpose. So, this is about investigation. Now, let’s look at the schedule of screening. In patients who are Type 1 diabetic we have to differentiate Type 1 diabetics in two groups. Type-1 diabetics with the onset of is, before puberty, we have to start screening at 10 years of age and then annual screening if no or mild NPDR. And in-patients of Type-1 when the onset is after puberty, we have to do detailed eye examination at diagnosis. And if no diabetic retinopathy is there, then start screening five years after diagnosis and then annual screening thereafter. As far as Type 2 including Youth-onset diabetes, we have to start at diagnosis and annual screening thereafter if no or mild non-proliferative retinopathy.

Now, before they start anybody when we subject them for screening we have to explain them procedure in detail including the procedure for pupil dilation. We also have to tell them about the outcome of screening and importance of follow-up advice that they will be given. Why it is so? Because based on the severity of retinopathy the follow-up examination changes.
If there is no retinopathy, then examination happens annually, if mild retinopathy is there, then 6 to 12 months, moderate is there, then four to six. Severe is there, two to four. And PDR we have to treat within four weeks. But this, why we have given this as arranged? Because if the risk factors are more, like, there is a poor glycemic control, patient is hypertensive, already had some evidence of renal pathology or diabetic foot or neuropathy, then they are more likely to progress faster, so they have to be seen more frequently.

Now, we have to balance between how frequently we call and how much gap we give between two screening increments. If we give too much of a gap then we will lose contact with patient. We will miss opportunity to detect other eye conditions like cataract and glaucoma. And most important, we will lose our counseling session to reinforce the importance of glycemic control.

But on the other hand, if we do too frequent follow-up, then patients will have a socio economic constraint, there will be a follow-up wear out and there will be too much of a burden on health care delivery system. So, we have to balance it to prevent retinopathy as well as not to burden our system and not to stacks the patient socio-economically.

Now, what approach has to be followed? Should we go and detect diabetic in the community? No. We have to primarily restrict our screening for in-patients who are known diabetic. We have to ensure that this service is integrated in the diabetes management system. Like in Government of India, there is a non-clinical disease program, non-communicable disease program. So, these NCD clinics can be a starting point for our screening program.

So, what all people, what all instruments, what all approaches how to be adopted, there are multiple ways by which this screening can take place. And we need to have a balanced approach looking at our infrastructure, looking at our human resource, looking at the training program that we have. So, I will be discussing this in my future slides. What all instruments can be used, direct opthalmoscope, indirect, slit lamp. And in camera, traditional that is Mydriatic camera, non-mydriatic that is an infrared based cameras and third is a smart-phone assistant camera.

Let’s look about one — another. But what is the accepted modality of a mass screening approach? Well, it is a fundus photography. Why? It is because it is a reproducible technique. It’s time tested in many clinical research study. It creates a permanent record. It is useful in documenting about the severity. And it’s a minimum training and skill and non-medical person also can give this screening in the door steps of patients. So, this is a traditional camera, it’s costly, so generally it is not used for screening. It is used in a retina clinics for angiographies and for before treatment is planned. But these multiple non-mydratic camera that are available in the market, they are primarily nowadays used for screening purposes. Now, the recent advance is to use this smart-phone based digital photography. It has the advantage that it can be used as an image capture device as well as an image transfer device. So, in one go, we can do both the functioning.

But disadvantage is this is that generally it requires us a dilatation of pupil. So, it cannot be used in a mass screening approach. Non-mydratic cameras have low cost. They are portable. They have a function of photo focus. It’s a infrared camera so patient comfort is best. So, this is the main stay of a screening program across globe in nowadays.

So, the recommendation that has come from the group is retinal digital photography using validated imaging system is recommended for screening and that it has a high level of sensitivity and specificity and it provides documentary evidence. Image grading has to be granted by health personnel trained in grading at the time of imaging or remotely as soon as possible.

Let’s see how this can be done. So, this is a diabetologists clinic where a technician takes photograph or it is either through AI or this person can be trained in basic referable and non-referable algorithms. Or it can be graded at a reading center through Internet Reported Generated and then that can go there. Or this person itself can be trained in giving a report immediately with help from AI algorithms or manual algorithms which are already available, so that patient can immediately receive a report and further action can be planned.

The limitation of photography based screening is the initial cost is little high compared to of opthalmoscope. Training of staff is required and a person has to be able to take a good quality image because these patients, most of these diabetic patients will have some amount of cataract or can however, non pupil which is not very diluting properly, and sometimes because it is done by a non ophthalmologist or non medical patient acceptability can be a little less.

Now, based on location whether where we are doing this system, we can look at what we can do. Now, if it is done in an on communicable disease clinic and city clinic without eye care services like Primary Health Center, then we have to do this examination without dilatation and grading has to be done remotely. If it is done where refraction is already performed again the same protocol has to be followed but this can be done, this person who is there who is doing this refraction can be trained in grading this image.

The third is where medical officer is available then this can be done after dilatation and reading can be graded, image can be graded by imager or a remote grader. Now, in a secondary or tertiary level institute, where ophthalmologist or some physician is available, then this can be done by imager and pupil dilatation can be followed.

The important take home message from this slide is, wherever medical officer or a registered medical practitioner is available, we can look at pupilated dilatation. And wherever a mid level ophthalmic personal is available, we can look at grading that image at the spot or we can refer it for a remote grading, okay?

So, the next slide describes how many photographs this person has to take for image grading. If it is done in a non-communicable disease clinic or a physician’s clinic, then two images and one centered on macula and another centered on optic disc, each has to be done. And the referral criteria I will go into the next slide. If opportunistic screening is done in a eye clinic, then we have to do four photograph after dilatation, one on a center on a macula, another center on optic disc, one in upper field and one in lower field. And we have to grade it like this.

And the referral criteria is, when the image is gradable, if there is no diabetic retinopathy or DME or normal vision, then repeat screening at one year. If visual acuity is less than non urgent referral to ophthalmologist, if there is more rate non-proliferating or non central involving diabetic macular edema, regardless of vision non urgent referral, if there is a sever retinopathy or non-central involving DME, then we have to do an urgent referral. So, moderate, non-proliferative, non-urgent, severe, DR is there, urgently referral. And if the visual acuity is less than 6/12, non-urgent referral. And if the macular is DME is involving central then that also is a part of the urgent referral.

So, after this let’s go to the treatment parts. So, we’ve what, up till now what we have covered is a screening protocol, we have screening, we have looked at what diagnostic is. Now we have come to a conclusion that this person has treatable retinopathy.

Now, we all know that the gold standard for treatment for proliferated diabetic retinopathy is Laser Photocoagulation and various studies. As for this slide showed have evidence to support that Laser Photocoagulation is gold standard for treatment off PDR. Recently, monthly injections of AntiVEGF also is approved in United States as a treatment for PDR. But look looking at scenario in India, we prefer Panretinal Photocoagulation either by a sub-threshold diode laser, micropulse therapy or various other conventional laser or a multi spot laser or this is a NAVILAS is a new technique where it is a image guided technique.

So, let’s look at the advantage of sub-threshold, sub threshold diode microsecond laser helps in good results because it does not damage RPE and can be helped in retreatment with less inflammation, less fibrosis and less contraction. So, nowadays most of these lasers are coming in the sub-threshold category. And we also now have got this PASCAL as a multi-spot laser therapy. And NAVILAS is the image guided. Why this has come? Is because conventional laser therapy is painful, it takes more time per session, person has to come more repeatedly, there is a worsening in vision because of diabetic macular edema.

So, this PASCAL has come into existence where multiple spots are given. Thus this is less painful, the duration is less. The biggest disadvantage with this is cost. It is very costly. So, it still has not got wider acceptance. People are still, majority of the people are still using conventional laser. NAVILAS is a very new technique and it is still not being very widely used.

As I discussed earlier that this PDR and AntiVEGF is nowadays used in some of the countries but it requires monthly injection for year or longer and decides this had the advantage of prolonged treatment follow up. It has, there is no definitive end point. There could be some worsening of retinopathy. The chances of infection and ophthalmitis are there. Cost is more. So, this is not practiced in India. So, these are the comparison between laser and anti laser. I have already discussed that so I will not go into details again.

So, let’s look at the treatment protocol that we have which we can follow in India. Now this treatment protocol is based on three assumptions. Whether there is a diabetic macular edema present, is the patient likely to come on a regular basis for follow up or patient not likely to comply to follow up.

So, one, when a physician is taking decision, these three characteristics have to be done. What is the ocular characteristic and this is a personal characteristic often individual looking at that person previous history. So, if the patient with PDR has no diabetic macular edema then Laser PRP or AntiVEGF monotherapy can be given. Before laser treatment, we can think about giving laser to prevent DME if there is a likelihood of development of diabetic macular edema if patient is likely to comply to follow up.

But if patient is not likely to comply to follow up, then laser PRP within four weeks have to be given and then we have to give AntiVEGF injection one week prior to laser treatment. If diabetic macular edema is present, then we have to give AntiVEGF before PRP and in patients who are not likely to comply instead of Anti VEGF we can give a micro dot laser, then it can be followed up with laser PRPC.

In-patients who are severe in PDR, there is no diabetic macular edema and likely to comply. They can be just followed up, no need to give laser at this point of time. But if patient is not likely to be followed up then we can give our edema dilated and photocoagulation. If laser NPDR is present, DME is present in the patient of severe NPDR, then AntiVEGF or a steroid injection has to be given.

Generally steroid injections are given in a very, when the OCT shows high reflective areas in the cystic spaces or there is a specialty sort of fatigue. Then we can if the patient is likely to com — not likely to comply then we can give a scattered laser treatment and a focal grid laser treatment also instead of AntiVEGF injection. So, the conclusion is, if patient is likely to be followed up we can give AntiVEGF. If patient is not likely to follow up, give a macula laser treatment.

After giving treatment when should patient follow up? First follow up after completion of the PRPC is three to five months, ideally it is two months. And if after this duration if the vessels are still not regress then we can give further laser sparks. If AntiVEGF monotherapy is given, then that person has to come on a more regular basis and we have to give a repeat injection, if again this vascularization is not regressing.

Vitrectomy, generally indicated earlier within three months in patients with severe vitreous hemorrhage in whom severe PDR is suspected from their ultrasound or from their previous records. We can also do up a vitrectomy even after extensive and aggressive laser, vitreous hemorrhage is not deciding.

We can also do victrectomy in patients who are tractional retinal detachment. We can also give injection if, in cases of vitrectomy we can give intravitreal injection in addition to vitrectomy one week prior to prevent complications during vitrectomy, like, bleeding during vitratomy or post vitractomy. We can also consider doing cataract surgery along with vitractomy in eyes with diabetic retinopathy or diabetic macular edema in whom cataract is also present in addition to PDR or DME. But when we’re trying to do with vitractomy, what we have to ensure is good communication with patients because patients’ expectations had to be tone and had to be toned down so that their expectations are appropriate as per their eye condition

So, what are the various side effects and complications in patients with PRP? That could be transient central vision loss, peripheral vision loss, vitreous hemorrhage, accommodation can be compromised, popular dilatation can happen. In patients with vitractomy there could be recurrent vitreous hemorrhage, retnal tear, vision loss, infectious endophthalmitis, cataract, AntiVEGF, cataract, worsening of traction and thrombo-embolic event and intracocular information. So, all these have to be part of our consent before we start with a new order treatment modality.

So, in summary there is high level of evident that Laser Photocoagulation for PDR and severe NPDR preserves vision. But we also know that the complications are there. Repeated injections of AntiVEGF agents can also be effective for PDR but they also have a complication. And we need to look at various factors when we decide to do any treatment. There is a good evident that vitrectomy is of benefit if vitreous hemorrhage is there and advance diabetic retinopathy is also there. So, this is about PDR. Now let’s look at diabetic macular edema.

The management of DME had changed considerably over a period of time. Initially, we used to do only macular laser but now AntiVEGF is the mainstay of treatment. But various DRCR net trials have shown us that in which patients this AntiVEGF have to be used and at what level we have to use it. So, and what are the various treatment morality? So, in an early stage off diabetic macular edema control off risk factors remains the mainstay of treatment. In patients who are not likely to be followed up focal or grid laser remained the mainstay of treatment. Patients who are likely to be followed up for both regularly, we have to do AntiVEGF as our mainstay of treatment. Intravenous steroids are given when AntiVEGF fails and also specific OCT pictures, like, when there’s a hyper reflective areas in OCT and Vitrectomy, there is a tractional, retinal traction on the retina in addition to diabetic macular edema.

But before we start any treatment for diabetic macular edema important note is, we have to exclude ischemic maculopathy by fluorescein angiography. And in that or in OCT if we find this organizing inner retinal layer that what we call is a loss of ISOA (phonetics) junction, external limiting membrane breakage or ellipsoid zone loss, then we know that these patients are less likely to have a benefit from any of this treatment.

So, when we are deciding about treatment for diabetic macular edema, we have to look at visual acuity of a person on at what level that means at what service delivery level, like, whether we are giving treatment in a retina clinic or we are giving treatment in a non-retina clinic that the ophthalmologist is aware about diagnosis and management. So, what we have to follow if the macular edema is non-central involving and vision is better than 6/12, just observe in compliant patient. In non-complaint, we can give laser or based on angiography and OCT.

So, the guideline remains the same like PDR. In patients who are non-compliant resort to laser. In patients who are compliant resort to AntiVEGF injection. In patients whose vision is good better than 6/18, just observe in patients with good patient with in compliant patient. But even if vision is good and patient is not likely to follow we can think about giving laser. In patients in presence off PDR or severe and PDR, we can think about giving AntiVEGF in addition to giving laser. In patients who are refractory who refractory DME, we can give them, we can think about giving steroids and local or laser focal or grid laser.

Generally, macular laser is to be given by a person who is trained in retina than a general ophthalmologist because it can harm macula and can cause permanent vision loss. So, this is this summary of this slide.

Now, after macula treatment in laser after laser treatment patient has to be followed at every after every three to four months and after intraocular steroids it has to be followed for regularly more regularly for pressure and the lens status, Anti-VEGF monthly during the first year and vitrectomy after every two months.

Again in patients with diabetic macular edema we have to explain them the procedure and we also have to explain them the need for repeated treatment in patients with macular edema. So, this also has to be communicated very well with the patient. Now, let’s look at the role of pregnancy, the role of diabetes in pregnancy.

We all know that diabetic retinopathy is easy risk pregnancy can a lead to progression of retinopathy faster. So, a person who is diabetic then that person has to undergo a dilated retina examination before conception and after conception also on a more regular basis. The good thing is laser treatment is not contraindicated in patients with pregnancy. But AntiVEGF treatment we have to be very cautious about teratogenic effect of triamcinolone and AntiVEGF efficient agents. So, that is the guideline for pregnancy.

Now, in patients, if you want to do a cataract surgery in patients with retinopathy or in patients with diabetes, then what we have to do is we have to give more chair time in counseling because these patients are likely to have more complications of like progression of diabetes retinopathy and DME as well as they are more likely to develop infections PCO and we also need to give a good glycemic control. But unfortunately what do we mean that good glycemic control is, no there is no still clear cut evident. What we follow in clinical practice is we even see less than 7.5 or 8 and random blood sugar less than 200.

Now, as far as pre-operative examination is concerned if the person is undergoing premium IOL OCT or ultrasound is recommended as well as iris angles also have to be done. Early surgery is recommended because then we can treat diabetes retinopathy and DME more regularly. Also their pupils don’t dilate properly, they also have the little corneal endothelium function, a specular microscopy has to be done as well as OCT and dilated retinal examination and counseling of the patient has to be done.

Now, PDR is treated immediately after surgery as soon as possible while endophthalmitis delivery. DME can be treated during surgery also by giving AntiVEGF injection. Or they also can be given in high risk patients or post surgery 90 days course of non-steroidal anti-inflammatory agent. And if vitreous hemorrhage is detected, we can perform combined cataract and vitrectomy surgery with endolaser photocoagulation.

During surgery we have to maintain aseptic, we may have to do a larger capsulorhexis and we also need to use iris hooks or Malyugin ring to direct the pupil, hydrophobic acrylic lenses are referred because these in patients of vitractomy these lenses are more preferable. And if the patient is likely to develop DME then these patients can be given subconjunctival triamcinolone or intravitreal preservative-free triamcinolone. It is recommended to give intracameral antibiotics like moxifloxacin at the end of the surgery.

Post-surgery the diluted retinal examination has to be done as well as we need to give them a little longer, those off steroids on and a course of topical antibiotic. The roll of subconjunctival triamcinolone, topical NSAI or topical steroids after progression of DME, a need is there for doing more research.

So, this is about my presentation. It’s a little vast topic so I have to rush through some slide. But these Guidelines book will be shared with all the participants by Albis(phonetics) so you can read through all these guidelines in detail and formulate your, if you’re doing a good practice let’s formulate, and so, please, so that everybody becomes on one page and this data collection and good evidence based practice can be followed up in future. Diabetic retinopathy just like cataract surgery now needs to be part of every ophthalmologist domain and they have to look into this as their mainstay of care giving. Thank you very much.