![]() ![]() Patients with severe NPDR have a 17% chance of developing high-risk PDR within one year, and 40% chance of high-risk PDR within three years. Remember that the severe category is characterized by the 4-2-1 rule, and any eye meeting any one of the 4-2-1 criteria gets the distinction of severe NPDR. Prominent intraretinal microvascular abnormality (IRMA) in 1 or more quadrants.Definite venous beading in 2 or more quadrants.20 or more intraretinal hemorrhages (dot blot hemorrhages) in each of all four quadrants.Severe nonproliferative diabetic retinopathy (Severe NPDR) Severe NPDR Proposed Diabetic Retinopathy Severity Level ![]() Standard Photo 2A showing intraretinal (dot-blot) hemorrhages and microaneurysms. This seems to be a fair number of patients I see in our VA Hospital retina clinic and are at a stage just before considering panretinal photocoagulation (PRP). The WESDR stated that moderate NPDR contains dot blot hemorrhages (DBH) or microaneurysms (MA) as numerous and severe as the standard photo 2A below in at least one quadrant, with or without cotton wool spots (CWS), venous beading, or IRMA, but not achieving the 4:2:1 rule. It helps me to simply remember that these eyes have more than just microaneurysms but less than any of the criteria in the 4:2:1 rule (described below). More than just micro aneurysms (with or without cotton-wool spots, venous beading, or IRMA) but less than the 4:2:1 rule Moderate nonproliferative diabetic retinopathy (Moderate NPDR) Moderate NPDR Proposed Diabetic Retinopathy Severity Level ![]() ![]() These patients can be followed every 12 months. All things considered, this is pretty low risk. In other words, a diabetic patient with no retinopathy has a <1% chance of developing PDR and a diabetic patient with a rare MA/DBH has a <5% chance of progressing to PDR in the next four years. However, the Wisconsin Epidemiological Study of Diabetic Retinopathy (WESDR) did include these individuals in its study, and found that the rate of progression to PDR after four years was less than 1% for both young and older patients with no diabetic retinopathy, compared to 4.1% in younger patients with a rare microaneurysm and hemorrhage and even less in older patients with these findings. Both have a very low risk of progressing to PDR in fact, the Early Treatment Diabetic Retinopathy Study (ETDRS) did not examine those with no retinopathy nor mild NPDR. In reality, there is not much difference in risk between diabetic eyes with no retinopathy and those with mild retinopathy. Mild nonproliferative diabetic retinopathy (Mild NPDR) No retinopathy and mild NPDR Proposed Diabetic Retinopathy Severity Level After nervously searching Google in the physicians workroom for the diabetic retinopathy grading scale more often than I care to admit, I have decided to summarize the classification criteria for diabetic retinopathy, at least in a way that makes sense to me. Accurately grading diabetic retinopathy can be a significant challenge for beginning ophthalmology residents. ![]()
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