Diabetic Eye Disease - American Diabetes Association

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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

nei.nih.gov

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 .

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