Diabetic Eye Disease - American Diabetes Association
Diabetic Eye DiseaseJulie Rodman OD, MS, FAAO
nei.nih.gov
Diabetes Mellitus High blood glucose levels due to the body’s inability toproduce and/or use insulin Type 1: Usually diagnosed in children and young adults. Thebody does not produce insulin. Type 2: Either the body does not produce enough insulin orthe cells ignore the insulin. Most common form.DIABETIC EYE DISEASE AFFECTSBOTH!!!
Epidemiology: Diabetes 29.1 million people (9.3%) of population have diabetes 21.0 million diagnosed 8.1 million undiagnosednei.nih.gov
Diabetic Eye Disease: SCARY! Leading cause of blindness in Americans aged 20-74 Accounts for 12% of new blindness Diabetic patients 25x more likely to go blind Approximately 28.5% of diabetic patients will developsome form of diabetic eye disease
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nei.nih.gov
Risk Factors
Risk Factors for Developing DiabetesIf you have risk factors fordiabetes, you should haveyour glucose levels checked.https://nei.nih.gov/./Ojo DiabetesandHealthyEyestPPT.
Risk factors DiabeticRetinopathyDuration of diabetes is a major riskfactor associated with thedevelopment of diabetic retinopathyThe severity of hyperglycemia is the keyalterable risk factor associated with thedevelopment of diabetic s/PPP Content.aspx?cid d0c853d3-219f-487b-a524-326ab3cecd9a
Prevalence of diabetic retinopathyafter 20 years of diagnosis
Prevention of eye disease is possible with increased riskfactor controlCLINICAL SCIENCESThe Effect of Intensive Diabetes TreatmentOn the Progression of Diabetic RetinopathyIn Insulin-Dependent Diabetes MellitusThe Diabetes Control and Complications TrialThe Diabetes Control and Complications Trial ResearchGroupArch Ophthalmol. 1995; 113:36-51
How does Diabetes affect theeye?BEWARE!Diabetic RetinopathyGlaucomaCataracts
Diabetic Retinopathy Symptoms Blurred vision Floaters Fluctuating Vision Distorted visionFigure 3: Normal Vision Dark areas in vision Poor night vision Impaired color vision Partial or total loss of visionhttps://nei.nih.gov/./Ojo DiabetesandHealthyEyesFlipchartPPT.Figure 4: How vision maybe affected by diabetic retinopathy
What is the Retina? A multilayered, light-sensitive tissue lining the inner eye. Light focuses on retina and is then transmitted to brainvia optic nerve Macula: part of retina responsible for central vision
Retinal Anatomy
Diabetic Retinopathy Dysfunction of the retinal blood vessels as a result ofchronic hyperglycemia (high blood sugar) Can be a complication of Type 1 or Type 2 Diabetes Starts off asymptomatic, and if left untreated, can lead tolow vision or blindness.
PathophysiologyHigh blood sugar levels affect retinal capillaries Pericyte Loss Endothelial Cellloss Blood-retinabarrierbreakdown
Pathophysiology - Capillary Leakage Damaged capillariesleak Leakage into themacula results in visionloss
Healthy RetinaDiabetic Retinopathy
Classification of Diabetic Retinopathy Non-Proliferative (NPDR) MildModerateSevereVery Severe Proliferative (PDR) Clinically Significant Macular Edema (CSME) Alone or with NPDR/PDR
Classification of Diabetic Retinopathy Non-Proliferative (NPDR) MildModerateSevereVery Severe Proliferative (PDR) Clinically Significant Macular Edema (CSME) Alone or with NPDR/PDR
Mild Non-Proliferative DRPresence of at least one retinal microaneurysm or hemorrhageMicroaneurysms are outpouchings ofcapillary walls caused by loss of pericytesleading to weakeningseeing beyond vision loss
Mild Non-Proliferative DRPresence of at least one retinal microaneurysm or hemorrhageHemorrhages result fromleaking or ruptured MAsdeep within the retinaseeing beyond vision loss
How do we differentiatebetween the two?FLUORESCEIN ANGIOGRAPHYMicroaneurysms: HyperfluoresceHemorrhages:Hypofluoresceseeing beyond vision loss
When to re-examine mild NPDR? Re-examination within a year 5-10% will increase to further stages of retinopathy overthe course of the year Obtain fundus photo
Classification of Diabetic Retinopathy Non-Proliferative (NPDR) MildModerateSevereVery Severe Proliferative (PDR) Clinically Significant Macular Edema (CSME) Alone or with NPDR/PDR
Moderate Non-Proliferative DRIncreasing microaneurysms and/or hemorrhagesCotton wool spots-areas of ischemiaVenous beading or mild IRMA (intraretinalmicrovascular abnormalities)IRMA: new vessel growth deepwithin the retina OR pre-existingvessels that shunt blood throughareas of nonperfusionseeing beyond vision loss
When to re-examine moderateNPDR? Re-examination within 6 months Approximately 16% of patients progress to proliferativedisease within four years Obtain fundus photo
Classification of Diabetic Retinopathy Non-Proliferative (NPDR) MildModerateSevereVery Severe Proliferative (PDR) Clinically Significant Macular Edema (CSME) Alone or with NPDR/PDR
Severe Non-Proliferative DR Any one of the following 3features is present: Microaneurysms and/orhemorrhages in all 4quadrants Venous beading in 2 ormore quadrants Moderate IRMA in at least1 quadrant Known as the 4-2-1 ruleseeing beyond vision loss
When to re-examine severe NPDR? Two to four months Strongly consider retina referral Fluorescein angiography to assess capillary perfusion Obtain fundus photo
Classification of Diabetic Retinopathy Non-Proliferative (NPDR) MildModerateSevereVery Severe Proliferative (PDR) Clinically Significant Macular Edema (CSME) Alone or with NPDR/PDR
Very Severe Non-Proliferative DR Any two of the following 3features is present: Microaneurysms and/orhemorrhages in all 4quadrants Venous beading in 2 ormore quadrants Moderate IRMA in at least1 quadrant Known as the 4-2-1 ruleseeing beyond vision loss
Classification of Diabetic Retinopathy Non-Proliferative (NPDR) MildModerateSevereVery Severe Proliferative (PDR) Clinically Significant Macular Edema (CSME) Alone or with NPDR/PDR
Proliferative Diabetic Retinopathy(PDR) Neovascularization: On or within one disc diameter of the Optic Disc(NVD) or elsewhere on the retina (NVE) Preretinal hemorrhage Vitreous hemorrhageseeing beyond vision loss
Neovascularization of the discPDR
Neovascularization elsewhere (NVE)PDR
Preretinal hemorrhagePDR
Vitreous hemorrhagePDR
Tractional Retinal DetachmentPDR
When to re-examine PDR? Refer promptly to retina specialist for treatment Within one day to one week depending on severity Without treatment, approximately 50% of eyes with PDRare blind within 5 years
Treatments: PDRLaser surgery: PRP Microscopic thermal laser burnsare made in the retina Shrinks and prevents abnormal newblood vessel growth, and stopsleaking of blood vessels Can reduce risk of furthervision loss by 50%Figure 10: Laser photocoagulationseeing beyond vision loss
Panretinal photocoagulation (PRP)BeforeAfter
Panretinal photocoagulation (PRP)BeforeAfter
PRP reduces the risk of severevision loss by more than 50%Photocoagulation TreatmentofProliferative DiabeticRetinopathyClinical Application of Diabetic Retinopathy Study(DRS) Findings, DRS Report Number 8THE DIABETIC RETINOPATHY STUDY RESEARCH GROUPOphthalmology 1991; 88; 583-600
Treatments: PDRIntraocular (anti-VEGF) injections: Lucentis, Avastin, Eylea Reduces swelling in the retina and causes abnormal vessels to regressAlone or in conjunction with PRPIntraocular injectionseeing beyond vision loss
TreatmentsPatients who fail to have vessel regression with PRP or anti-VEGF:Vitrectomy Cloudy vitreous is removed and replaced with a clear solutionthat mimics the normal eye fluids Allows light rays to focus on the retina againFigure 12: Pars plana vitrectomyseeing beyond vision loss
Diabetic Eye DiseaseTreatment – Vitreous HemeVitrectomy
Vitrectomy results in improved visionin patients with persistent vitreoushemorrhageEarly Vitrectomy for SevereVitreousHemorrhage in DiabeticRetinopathyTwo-Year Results of a Randomized TrialDiabetic Retinopathy Vitrectomy Report 2THE DIABETIC RETINOPATHY VITRECTOMY STUDY RESEARCH GROUPArch Ophthalmol. 1985; 103 1644-1652
Classification of Diabetic Retinopathy Non-Proliferative (NPDR) MildModerateSevereVery Severe Proliferative (PDR) Clinically Significant Macular Edema(CSME) Alone or with NPDR/PDR
Diabetic Macular Edema:The other problem!!! Macula is responsible for central vision Fluid at macula leads to blurry vision Leading cause of legal blindness in diabetics Can be present at any stage of the disease
Clinically significant macular edemaNormalMacular edema
When to re-examine DiabeticMacular Edema? Non-center involving DME Every two to four months Prompt referral when center becomes involved Referral to PCP to optimize glycemic control Center involving DME Referral to retina specialist within one to two weeks
Treatments Laser surgery: Focal Anti-VEGF agents
Focal Laser
Focal Laser reduces risk ofvisual loss by 50%Early Photocoagulation forDiabetic RetinopathyETDRS Report Number 9EARLY TREATMENT DIABETIC RETINOPATHY STUDY RESEARCH GROUPOphthalmology 1991; 98; 766-785
What about Optical CoherenceTomography? Non-invasive technology that uses light waves to imagethe retina and other ocular tissues New method of assessing for diabetic retinopathy Classify macular edema: CENTER INVOLVING NON CENTER INVOLVING Greater risk of vision loss
MaculaNormalAbnormal
Other Ocular Complications ofDiabetesBEWARE!!
Anatomy of the Eye and Its FunctionVision is wonderful, but you could lose it if you have diabetes.The main parts of the eye—https://nei.nih.gov/./Ojo DiabetesandHealthyEyesFlipchartPPT.
Diabetes and CataractNormal vision.A cataract is a clouding of the lens.People with cataract see through a haze.Same scene viewed by a personwith cataract.https://nei.nih.gov/./Ojo DiabetesandHealthyEyesFlipchartPPT.
Anatomy of the Eye and Its FunctionVision is wonderful, but you could lose it if you have diabetes.The main parts of the eye—https://nei.nih.gov/./Ojo DiabetesandHealthyEyesFlipchartPPT.
Diabetes and GlaucomaGlaucoma is a group of diseases thatcan damage the optic nerve and resultin vision loss and blindness.Normal vision.Same scene viewed by a personwith glaucoma.https://nei.nih.gov/./Ojo DiabetesandHealthyEyesFlipchartPPT.
Neovascular Glaucoma Symptoms Loss of Vision Pain “Red Eye” IrisNeovascularization High IntraocularPressure Abnormal pupilresponse
The Eye Health TeamPeople with diabetes can protect their vision.Health professionals who are partof an eye health team include— Certified diabetes educator Health promoter Nurse Ophthalmologist Optometrist Pharmacist Primary care provider Social workerRemember— Visit an eye care professional andtake care of your eyes. Ask for a dilated eye exam. Have a dilated eye exam at leastonce a year.https://nei.nih.gov/./Ojo DiabetesandHealthyEyesFlipchartPPT.
CONCLUSIONSDiabetic Eye Disease ispreventable through strictglycemic control andannual dilated eye examsby an eye doctor.
QUIZDiabetes and the Eye
What is the category of diabeticretinopathy imaged below?A. Mild non-proliferativediabetic retinopathyB. Clinically significantmacular edemaC. Severe non-proliferativediabetic retinopathyA. Proliferative diabeticretinopathy
What is the category of diabeticretinopathy imaged below?A. Mild non-proliferativediabetic retinopathyB. Clinically significantmacular edemaC. Severe non-proliferativediabetic retinopathyA. Proliferative diabeticretinopathy
Diabetic retinopathy can result invision loss due to:A. Vitreous hemorrhageB. Retinal detachmentC. Macular edemaA. All of the above
Diabetic retinopathy can result invision loss due to:A. Vitreous hemorrhageB. Retinal detachmentC. Macular edemaA. All of the above
Which of the following may result in visualreduction or symptomatology?A. Mild non-proliferativediabetic retinopathyB. Macular edemaC. Neovascularization ofthe discA. NeovascularizationelsewhereB. All of the above
Which of the following may result in visualreduction or symptomatology?A. Mild non-proliferativediabetic retinopathyB. Macular edemaC. Neovascularization ofthe discA. NeovascularizationelsewhereB. All of the above
NVD is apparent on the photo below. Why are the vesselsout of focus?A. Because the vessels aregrowing into the vitreouscavityB. Because the vessels aregrowing into the retinaC. Poor photo qualityA. Because they are toosmall to focus on
NVD is apparent on the photo below. Why are the vesselsout of focus?A. Because the vessels aregrowing into the vitreouscavityB. Because the vessels aregrowing into the retinaC. Poor photo qualityA. Because they are toosmall to focus on
Which is not one of the biggest risk factors fordiabetic retinopathy?A. Duration of diabetesB. EthnicityC. Blood glucoseA. Hypertension
Which is not one of the biggest risk factors fordiabetic retinopathy?A. Duration of diabetesB. EthnicityC. Blood glucoseA. Hypertension
Which of the following treatments is appropriatefor proliferative diabetic retinopathy?A. PhotocoagulationB. Vitreoretinal surgeryC. Anti-VEGFA. All of the above
Which of the following treatments is appropriatefor proliferative diabetic retinopathy?A. PhotocoagulationB. Vitreoretinal surgeryC. Anti-VEGFA. All of the above
Which of the following statements is incorrectregarding managing diabetic retinopathy?A. Blood glucose control is not only important in preventing the developmentof retinopathy but in affecting the progression of established retinopathyA. Patients with any amount of non-proliferative retinopathy should bereferred for a dilated eye examB. Hard exudates in the macula imply vascular leakage and are an indicationfor referralA. The retina can be adequately screened for diabetic retinopathy withoutdilating the pupils if the room is dark
Which of the following statements is incorrectregarding managing diabetic retinopathy?A. Blood glucose control is not only important in preventing the developmentof retinopathy but in affecting the progression of established retinopathyA. Patients with any amount of non-proliferative retinopathy should bereferred for a dilated eye examB. Hard exudates in the macula imply vascular leakage and are an indicationfor referralA. The retina can be adequately screened for diabetic retinopathy withoutdilating the pupils if the room is dark
THANK YOU!!rjulie@nova.edu
Blurred vision Floaters Fluctuating Vision Distorted vision Dark areas in vision Poor night vision . Macula is responsible for central vision Fluid at macula leads to blurry vision Leading cause of legal blindness in diabetics Can be present at any stage of the disease .
The development of severe vision loss due to diabetic eye disease can be reduced by an estimated 50% to 60% through scatter laser therapy.1 o Laser therapy works best in the early stages of diabetic retinopathy o Annual dilated eye exams allow eye care professionals to detect diabetic retinopathy in the earlier stages11
diabetes distress in patients with type 2 diabetes. To find out the gender differences on diabetic self-care and diabetic distress in patients with type 2 diabetes. Hypotheses There is likely to be negative relationship between self-care and diabetes di
Diabetic Diet Diabetic Diet for diabetics is simply a balanced healthy diet which is vital for diabetic treatment. The regulation of blood sugar in the non-diabetic is automatic, adjusting to whatever foods are eaten. But, for the diabetic, extra caution is needed to balance food intake with exercise, insulin injections and any other glucose .
Non-diabetic hyperglycaemia, also known as pre-diabetes or impaired glucose regulation, refers to raised blood glucose levels, but not in the diabetic range. People with non-diabetic hyperglycaemia are at increased risk of developing Type 2 diabetes.1,2 They are also at increased risk of other cardiovascular conditions.3
Keywords: Diabetic nephropathy, Low protein diet, RCT, Meta-analysis Introduction Diabetes is a highly prevalent chronic disease constitutes a major public health issue and inflicts a severe financial bur-den on the society and family. About 40% of diabetes pa-tients would develop diabetic nephropathy [ 1]. Diabetic
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mell
ICD -10 ICD -9 E11.341 Type 2 diabetes mellitus with severe non proliferative diabetic retinopathy with macular edema 250.50 Diabetes type II with ophthalmic manifestations 362.06 362.07 Diabetic macular edema E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy 250.60 Diabetes type 2 wi
Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia American Diabetes Association. Facts and Figures. Available at: http://www.diabetes.org/ada/facts.asp. Accessed January 18, 2000. Diagnosed Type 1 Diabetes 0.5 - 1.0 Million Diagnosed Type 2 Diabetes 10.3 Million Undiagnosed Diabetes 5.4 Million Prevalence of Diabetes in the US 3
