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Diabetes and the Eye. Karen B. Saland, M.D. August 18, 2008. Diabetes and Eye Disease: Learning Objectives. Identify Systemic Risk Factors Differentiate Clinical Stages Describe treatment strategies and screening guidelines Recognize importance of team approach. - PowerPoint PPT Presentation
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Diabetes and the Eye
Karen B. Saland, M.D.August 18, 2008
Diabetes and Eye Disease: Learning Objectives
Identify Systemic Risk FactorsDifferentiate Clinical StagesDescribe treatment strategies and screening guidelines Recognize importance of team approach
Diabetes Mellitus: Epidemiology
135 million people with diabetes worldwide (90% type 2)300 million with diabetes projected by 2025
Diabetes Mellitus: Epidemiology
16 million Americans affected800,000 new cases per year (type 2)2X greater risk in African-Americans, Latinos and Native Americans
Diabetic Retinopathy
Retinal complications of DiabetesLeading cause of blindness in working age Americans
DCCT Findings:
No Baseline Retinopathy
DCCT Findings:
Mild to Moderate Retinopathy
DCCT Findings:
Intensive Glucose Control, No baseline retinopathy
27% reduction in developing retinopathy76% reduction in risk of developing progressive retinopathy
DCCT FINDINGS
Intensive Glucose Control, Mild to Moderate Retinopathy
54 reduction in progression of retinopathy47% reduction in development of severe NPDR or PDR59% reduction in need for laser surgeryPre-existing retinopathy may worsen in early stages of treatment
UKPDS FindingsType 2 Diabetes
Increased glucose and BP control decreases progression of retinopathy
UKPDS FindingsResults
Hemoglobin A1C reduced from 7.9 to 7.0 = 25% decrease in microvascular complicationsBP reduced to <150/85 mm Hg = 34% decrease in retinopathy progression
UKPDS Findings
Hypertension ControlAs important as glucose control in lowering risk of diabetic retinopathyACE inhibitor or beta blocker decreases microvascular complications
DCCT/UKPDS Lessons
Professional and patient educationGood glucose and BP controlRegular examination
Additional Systemic Controls
Proteinuria is a risk factor for macular edemaLisinopril may benefit the diabetic kidney and retina even in normotensive patients
Lowering cholesterol may lead to decreased
hard exudates and improved vision.
WESDR Findings
Diabetic Retinopathy and Cardiovascular Disease
PDR a risk indicator for MI, stroke, amputationPDR elevates risk of developing nephropathy
Diabetic Retinopathy:Clinical Stages
Nonproliferative diabetic retinopathy (NPDR)Preproliferative diabetic retinopathyProliferative diabetic retinopathy (PDR)
NPDR: Early Clinical Signs
MicroaneurysmsHard ExudatesIntraretinal hemorrhages
Patients may be asymptomatic.
Diabetic Macular Edema
Diabetes < /= 5 years = 5% prevalenceDiabetes >/= 15 years =15% prevalence
PDR: Clinical Signs
NeovascularizationVitreous hemorrhage and tractionNPDR features, including macular edema
Vitreous Hemorrhage:Symptoms
FloatersSevere visual loss
Requires immediate ophthalmologic consultation
Review of Clinical Stages
Nonproliferative diabetic retinopathyPatients may be asymptomatic
Preproliferative retinopathyLaser therapy at this stage may help prevent long-term visual loss
Proliferative retinopathyMajor cause of severe visual loss
Panretinal Photocoagulation (PRP)
Outpatient procedureApproximately 1000-2000 burns1 to 3 sessions
PRP: Side Effects
Decreased night visionDecreased peripheral vision
Vitrectomy
Remove vitreous hemorrhageRepair retinal detachmentAllow treatment with PRP
Treatment options: SummaryLaser photocoagulation surgery
Focal macular laser for CSMEPanretinal photocoagulation for PDR
VitrectomyMay be necessary for vitreous hemorrhage or retinal detachment
New Therapies
Anti-VEGF agents decrease capillary permeability and angiogenesisUseful as adjuvant treatment to laser therapy for diabetic retinopathy
Screening Guidelines:Patients with Type 1 Diabetes
Annual ophthalmologic exams starting years after diagnosis and not before puberty
Patients with Type 2 Diabetes
Annual ophthalmologic exams starting at time of Dx
Diabetes and Pregnancy
Ophthalmologic exam before conceptionOphthalmologic exam during first trimesterFollow-up depends on baseline grade
WESDR FindingsPatients’ Access and
Compliance36% missed annual ocular exam60% missed laser surgery
Goals for Success
Timely screening reduces risk of blindness from 50% to 5%100% screening estimated to save $167 million annually
Goals for Success
Better systemic control of:Hemoglobin A1cBPKidney statusSerum Lipids
Reducing the Risk of Blindness
Team approach: primary care physician, nutritionist, endocrinologist, ophthalmologistAccess to eye careSystemic control