Diabetic retinopathy 30-3-2011
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Diabetic retinopathyTopic assignment : medical ophthalmology
D 1.1 30/3/2011
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Diabetes Definition Risk factors Pathogenesis Classification : proliferative / non-
proliferative Sign & symptoms DDx & other ocular complication of
DM Treatment & follow up Screening for DR Apply with case study
Contents
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Group of common metabolic disorders
Caused by a complex interaction of genetics and environmental factors
Lack of insulin hyperglycemia
Diagnostic criteria : Fasting plasma glucose > 126 mg/dl
Type 1 DM – Insulin-dependent diabetes (IDDM)
Results from pancreatic beta-cell destruction, usually leading to absolute or
near total insulin deficiency
Type 2 DM - Non-insulin-dependent diabetes (NIDDM)
Variable degrees of insulin resistance and impaired insulin secretion,
resulting in hyperglycemia and other metabolic derangements due to
insufficient insulin action.
Diabetes mellitus
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Long-standing hyperglycemia leads to multiple organ damage
Macrovascular complications
Stroke
Heart disease and hypertension
Peripheral vascular disease
Foot problems
Microvascular complications
Diabetic eye disease : retinopathy and cataracts
Renal disease
Neuropathy
Foot problems
Diabetes mellitus
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Diabetic retinopathy
The most severe of ocular complications of diabetes Caused by damage to blood vessels of the retina,
leads to retinal damage Microvascular complication of longstanding diabetes
mellitus [1]
Most prevalence cause of legal blindness between the ages of 20 and 65 years
Common in DM type 1 > type 2
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Duration of diabetes Most important Pt diagnosed before age 30 yr
50% DR after 10 yrs 90% DR after 30 yrs
Poor metabolic control Less important, but relevant to development and
progression of DR HbA1c ass. with risk
Pregnancy Ass with rapid progression of DR Predicating factors : poor pre-pregnancy control of DM, too
rapid control during the early stages of pregnancy, pre-eclampsia and fluid imbalance
Risk factors
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Hypertension Very common in patients with DM type 2 Should strictly control (<140/80 mmHg)
Nephropathy Ass with worsening of DR Renal transplantation may be ass with improvement of
DR and better response to photocoagulation Other
Obesity, increased BMI, high waist-to-hip ratio Hyperlipidemia Anemia
Risk factors
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Microvascular occlusion Microvascular leakage
Pathogenesis
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Microvascular leakage
Degeneration and loss of pericytes
Plasma leakage
Intraretinal hemorrhageHard exudate(Circinate pattern)
Capillary wall weakening
microaneurysm
Retinal edema
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Non-proliferative diabetic retinopathy
Right eye: Micro aneurysm, few flame-shaped and dot-blot hemorrhages and hard exudate [with hard exudate in macula area] , ไม่�พบneovascularization เข้�าได้�กั�บ moderate non proliferative diabetic retinopathy Left eye: Micro aneurysm, numerous flame-shaped and dot-blot hemorrhage [more than 20 dots in 4 quadrant], hard exudate [with hard exudate in macula area] ไม่�พบ neovascularization เข้�าได้�กั�บ severe non proliferative diabetic retinopathy
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Microvascular occlusion
Neovascularizationand fibrovascular proliferation
VEGF
Increased plasma viscosityDeformation of RBCIncreased platelets stickiness
Decreased capillary blood flow
and perfusion
Endothelial cell damage and proliferation
Capillary basement membrane thickening
Retinal hypoxia
A-V shuntIRMA*
*intraretinal microvascular abnormalities
Proliferative
retinopathy
Rubeosis iridis
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Tractional retinal detachmentVitreous hemorrhage
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Classification
Non-proliferative diabetic retinopathy (NPDR)
Proliferative diabetic retinopathy (PDR)
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Non-proliferative diabetic retinopathy
Mild NPDR Moderate NPDR Severe NPDR
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Microaneurysm Retinal hemorrhage
“Dot or Blot” Spot “Flame or Splinter shape” hemorrhage
Hard exudate Cotton wool Spot Venous beading Intra-retinal microvascular abnormalities
(IRMA)
Sign NPDR
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Mild NPDR
Microaneurysm
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Moderate NPDR
More microaneurysms Scattered hard exudates Cotton-wool spots
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4-2-1 rule 4 quadrants of severe retinal hemorrhages 2 quadrants of venous beading 1 quadrant of IRMA
Very severe NPDR more than 1 of above
Severe NPDR
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Localized saccular outpouchings of capillary wall red dots Focal dilatation of capillary wall where pericytes are
absent Fusion of 2 arms of capillary loop
Usually seen in relation to areas of capillary non-perfusion at the posterior pole esp temporal to fovea
The earliest signs of DR
Microaneurysm
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Microaneurysm
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Microaneurysms may leak plasma constituents into the retina
Scattered hyperfluorescent
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Capillary or microaneurysm is weakened rupture intraretinal hemorrhages
Dot & blot hemorrhages Deep hemorrhage - inner nuclear layer or outer plexiform
layer Usually round or oval Dot hemorrhages - bright red dots (same size as large
microaneurysms) Blot hemorrhages - larger lesions
Flame-shape or splinter hemorrhages More superficial - in nerve fiber layer Absorbed slowly after several weeks Indistinguishable from hemorrhage in hypertensive
retinopathy May have co-existence of systemic hypertension BP must
be checked
Retinal Hemorrhage
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Dot & blot VS splinter hemorrhage
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Dot Spot VS Flame Shape
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Dot Spot VS Flame Shape
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Hemorrhage
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Intra-retinal lipid exudates Yellow deposits of lipid and protein within the retina Accumulations of lipids leak from surrounding
capillaries and microaneuryisms May form a circinate pattern Hyperlipidemia may correlate with the
development of hard exudates
Hard exudate
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White fluffy lesions in nerve fiber layer Result from occlusion of retinal pre-capillary
arterioles supplying the nerve fibre layer with concomitant swelling of local nerve fibre axons
Also called "soft exudates" or "nerve fiber layer infarctions"
Fluorescein angiography shows no capillary perfusion in the area of the soft exudate
Very common in DR, esp if pt with HT
Cotton Wool Spot
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Hard Exudate VS Cotton Wool Spot
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Dilatation and beading of retinal vein Appearance resembling sausage-shaped
dilatation of the retinal veins Sign of severe NPDR
Venous beading
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Abnormal dilated retinal capillaries or may represent intraretinal neovacularization which has not breached the internal limiting membrane of the retina
Indicate severe NPDR rapidly progress to PDR
Intra-retinal microvascular abnormalities (IRMA)
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Area of capillary non-perfusion
FA shows extensive areas of hypofluorescence due to capillary non-perfusion and venous beading
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Macular ischemia Retinal capillary non-perfusion Progressive NPDR
Macular edema Increased retinal vascular permeability Seen in both NPDR and PDR Focal or diffuse or mixed Cause of visual loss in DR Ass with planning for treatment
Diabetic maculopathy
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Focal macular edema
Diffuse macular edema
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Macular ischemia
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Clinical Significant Macular Edema (CSME)
1 of 3
Retinal edema within 500 microns of
centre fovea
Hard exudates within 500
microns of fovea if ass with
adjacent retinal thickening
Retinal edema > 1 disc diameter, any part is within 1 disc diameter of centre
of fovea
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microaneurysm
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microaneurysm and blot dot hemorrhage
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blot dot hemorrhage
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IRMAs
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hard exudate
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Cotton wool spots
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Venous beading
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5% of DM pt. Finding
Neovascularization : NVD, NVE Vitreous changes
Advanced diabetic eye disease Final stage of Uncontrolled PRD Glaucoma (neovascularization) Blindness from persistent vitreous hemorrhage,
tractional RD, opaque membrane formation,
Proliferative diabetic retinopathy
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Neovascularization of disc
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Fluorescein dye leakage is seen in neovascularized area
Neovascularization of elsewhere
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Rubeosis iridis(neovascularisation of the iris)
Neovascular glaucoma
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Vitreous changes
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Tractional retinal detachment
Vitreous hemorrhage
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NVE
Venous beading
IRMA
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New vessels elsewhere
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New vessels elsewhere
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New vessels of the disc
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New vessels of the disc (advanced)
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Subhyaloid hemorrhage
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Subhyaloid hemorrhage
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Blurred or distorted vision or difficulty reading
Floaters Partial or total loss of vision
a shadow or veil across patient’s visual field Eye pain
Signs & symptoms of DR
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Differential DiagnosisDiabetic retinopathy
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Hypertensive retinopathy Radiation retinopathy Central retinal vein occlusion (CRVO) Branch retinal vein occlusion (BRVO) Ocular ischemic syndrome HIV-related retinopathy
Mostly miss
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Hypertensive retinopathy
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Radiation retinopathy
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Central retinal vein occlusion (CRVO)
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Branch retinal vein occlusion (BRVO)
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For symptoms
Cataract Glaucoma Hypertensive retinopathy Radiation retinopathy Retinal vitreous obstruction Retinitis pigmentosa Senile macular degeneration
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For cotton wool spot
Similar lesions are also caused by the alpha-toxin of Clostridium novyi
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For Cotton wool spot
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For Hard exudates
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For Hemorrhage
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Laser Photocoagulation** Vitreoretinal surgery** Intravitreal triamcinolone acetonide
Treatment
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Prevention Treat underlying conditions
Control blood sugar – HbA1c < 7 Control blood pressure – SBP < 130 mmHg Control lipid profile – TG, LDL Correct anemia Control diabetic nephropathy
Pregnancy makes DR worsen
Medical therapy
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Panretinal photocoagulation (PRP) High-risk PDR (3/4)
Vitreous or preretinal hemorrhage New vessels New vessels on optic disc or within 1,500 microns
from optic disc rim Large new vessels
Iris or angle neovascularization CSME
Laser
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Focal or Grid CSME in both NPDR and
PDR Panretinal (PRP)
PDR
Photocoagulation
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Inducing involution of new vessels Preventing vitreous hemorrhage and preventing
visual loss Limitations :
Patient must have clear lens and vitreous If cataract treat before laser PRP If vitreous hemorrhage vitrectomy + laser
photocoagulation
Laser panretinal photocoagulation (PRP)
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Focal photocoagulation
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Grid photocoagulation
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Panretinal photocoagulation (PRP)
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Indications for pars plana vitrectomy (PPV) in DR Severe persistent vitreous hemorrhage Progressive tractional RD (threatening or
involving macula) Combined tractional and rhegmatogenous RD Premacular subhyaloid hemorrhage Recurrent vitreous hemorrhage after laser PRP
Surgery
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Pars plana vitrectomy (PPV) Membrane peeling (MP) Endolaser (EL) Fluid gas exchange (FGX)
SF6
C3F8
Vitreoretinal Surgery
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Juvenile onset DM > 5 years then every year
Adult onset DM at diagnosis (> 30) then every year
DM with pregnancy in first trimester then every trimester
Screening for DR
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Retinal abnormality Follow up
Normal or rare microaneurysms
Once a year
Mild NPDR q 9 months
Mod NPDR q 6 months
Severe NPDR q 4 months or laser
CSME q 2-4 months ** or laser
PDR q 2-3 months ** or laser
Follow up
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Serious vision-threatening complications of DR
persistent vitreous hemorrhage tractional retinal detachment opaque membrane formation neovascular glaucoma
Treatment : complicated vitrectomy Poor prognosis
Advanced diabetic eye disease
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Case scenario
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Identification data : ผู้��ป่�วยหญิ�งไทยคู่�� อาย� 49 ป่� อาชี�พ คู่�าข้าย ภู�ม่�ลำ!าเนา อ.สู�งเม่�น จ. แพร่�
Chief complaint : ตาซ้�ายม่�ว 6 เด้)อน กั�อนม่าร่พ.
Case
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6 เด้)อน กั�อนม่าร่พ. ผู้��ป่�วยม่�อากัาร่ตาซ้�ายม่�ว อากัาร่คู่�อยๆ เป่+น แลำะเป่+นม่ากัข้-.นเร่)/อยๆ ตาข้วาม่องเห0นป่กัต�ด้� ไม่�ม่�ป่วด้ตา ป่วด้ศี�ร่ษะ ไม่�ม่�ตาแด้ง น!.าตา-ข้�.ตาป่ร่�ม่าณเท�าเด้�ม่ อากัาร่ตาซ้�ายม่�ว ม่องใกัลำ�ม่�วพอๆ กั�บ ม่องไกัลำ กัลำางว�นม่�วพอๆ กั�บกัลำางคู่)น ไม่�ม่�แสูงร่อบด้วงไฟ
1 สู�ป่ด้าห6กั�อนม่าร่พ. ตาซ้�ายม่�วม่ากั ป่ร่ะกัอบกั�บ
เห0นภูาพซ้�อน ม่�ว�ตถุ�ลำอยไป่ม่า ป่8ด้ตาแลำ�วม่�ไฟกัร่ะพร่�บเป่+นบางคู่ร่�.ง ไม่�ม่�ป่วด้ตา ป่วด้ศี�ร่ษะ จ-งม่าร่พ.แพร่� ได้�ร่�บกัาร่ร่�กัษา แต�อากัาร่ไม่�ด้�ข้-.น จ-งสู�งต�วม่าร่�กัษาต�อท�/ร่พ. ม่หาร่าชี
Present illness
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Underlying diseases : DM (poor controlled), HT (poor controlled)
Current medication metformin 500 mg 2*1 o pc Nifedipine 20 mg 1*2 o pc Amlopine 10 mg 1*1 o pc
ไม่�เคู่ยตร่วจตาม่ากั�อน ป่ฏิ�เสูธป่ร่ะว�ต�กัาร่ผู้�าต�ด้ท�/ตาม่ากั�อน แลำะอ�บ�ต�เหต�ท�/
ตา Family history : แม่�เป่+น DM, ป่ฏิ�เสูธโร่คู่ตาใน
คู่ร่อบคู่ร่�ว
Past history
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GA : a middle aged woman with normal consciousness, good co-operation
V/S : T 36.9 BP 157/83 mmHg P 94/min RR 16/min
HENT : no discharge per ears, nose, no bleeding per gum, cervical LN cant’ be palpable
Heart : normal S1S2, no murmurs Lungs : clear & equal breath sounds
both lungs Abdomen : soft, not tender Ext : no pitting edema
Physical examination
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OD OS
VA c C 6/9 -2 Pj
VA c PH 6/9 -
Lids & Lashes & Conjunctiva
Normal Normal
Cornea Clear Clear
Iris
Lens Clear Clear
Anterior chamber Normal depth, clear Normal depth, clear
Pupil 3 mmRTLBE RAPD -
EOM Full Full
IOP 20 20
Ocular examination
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OD OS
Red reflex Normal Normal
Vessels Normal 2:3 Normal 2:3
Background & Macula
Dot & blot hemorrhageNVE
dot blot hemorrhage ,
NVE , old hemorrhage
Fibrous and retinal break involve macula
Disc No NVD , C:D 0.3 No NVD , C:D 0.3
Fundus examination
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Problem lists
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Unilateral chronic painless visual loss
Flashing and Floaters
Poor controlled DM, poor controlled HT
Dot & blot hemorrhages with NVE BE
Fibrous & Retinal break involve macula LE
Problem list
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Right eye : PDR
Left eye : PDR with TRD+RRD
Provisional diagnosis
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Hypertensive retinopathy
Central retinal vein occlusion (CRVO)
Branch retinal vein occlusion (BRVO)
Ocular ischemic syndrome
Differential diagnosis
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LE
Pars plana vitrectomy
membrane peeling
Endolaser
silicone oil injection
Management in this case
Indications for PPV in DRSevere persistent VHProgressive tractional RDCombined TRD & RRDPremacular subhyaloid hemorrhageRecurrent VH after laser PRP
DR ร่ายน�.จ!าเป่+นต�องผู้�าต�ด้ PPV
หร่)อไม่�?
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Closed observe (q 2-3 months)
Laser PRP
PPV + MP + EL + SOI
จะท!าอะไร่กั�บตาข้�างข้วาต�อไป่??
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เคู่ยตร่วจตาหร่)อย�ง?
ตร่วจตาคู่ร่�.งลำ�าสู�ด้เม่)/อไหร่�?
คู่!าถุาม่ท�/ต�องต�ด้ป่ากัเม่)/อเจอคู่นไข้�เบาหวาน
คู่วร่ตร่วจตาท�นท�ท�/ว�น�จฉั�ยเป่+นเบาหวานชีน�ด้ท�/ 2 คู่วร่ตร่วจตาท�กัป่�
กัาร่คู่วบคู่�ม่เบาหวานให�ด้� ชี�วยชีะลำอกัาร่เกั�ด้ภูาวะแทร่กัซ้�อนทางตาได้�
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Thank you