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How does your glucose levels affect your life, sight, and life
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Damien Luviano, MD, FACS
What is Diabetes?
Damien Luviano, MD, FACS
Diabetes: • Impaired Insulin• leads increased glucose• Increased glucose Damages blood vessels• Tissues are deprived of blood, thus injured
Brain-Stroke Heart- Myocardial Infarctions Dental-Periodontal Disease Eye-Retinopathy Kidney-Nephropathy Nerves-Neuropathy
Damien Luviano, MD, FACS
How do I know I have it?
Diagnosis
Damien Luviano, MD, FACS
DIAGNOSE
Fasting Plasma Glucose FPG HgA1c
• 3 month Average Oral Glucose Tolerance
At 2 hrs 140-199 prediabetes 200 diabetes
FASTING PLASMA GLUCOSE FPG
Easy 100-125 Pre-Diabetes 126: Diabetes Closer to 126 bad
Patients with 95 are 50% more likely than 85 FPG
Damien Luviano, MD, FACS
CONTROLLED• HemoglobinA1c less
7.0
unCONTROLLED HemoglobinA1c
MORE 6.5• Higher incidence• Strokes• Blindness• Tooth Loss• Heart Attacks• Kidney Failure• Leg Loss • Life Loss
Damien Luviano, MD, FACS
What is the big deal with a little sugar?
Damien Luviano, MD, FACS
DEATH (MORTALITY)
Brain-Stroke Heart- Myocardial Infarctions Infections
MISERY (MORBIDITY)
Dental-Periodontal Disease Tooth loss
Eye-Retinopathy blindness
Kidney-Nephropathy Dialysis
Nerves-Neuropathy Pain
Limb loss Wheel Chair
Erectile dysfunction
Damien Luviano, MD, FACS
Lets talk about Eyes
Damien Luviano, MD, FACS
Blindness •Diabetes is LEADING cause of new cases of blindness among adults aged 20-74 years.
•Can occur from within months
Damien Luviano, MD, FACS
TWO TYPES• NON-PROLIFERATIVE (mild, moderate, severe)• PROLIFERATIVE (Laser)
MACULAR EDEMA • Present (LASER)• Absent
Damien Luviano, MD, FACS
How does diabetes hurt all these organs?
Are all these organs connected?
Damien Luviano, MD, FACS
PATHOPHYSIOLOGY (MECHANISM)
Damien Luviano, MD, FACS
GeneticEnvironmental ImmunologicalHLA-DR4+ and DR3
Long term hyperglycemiaMost important factor at present
Frank RN: Etiologic mechanisms in diabetic retinopathy. In Ryan SJ, ed: Retina, Schachat AP and Murphy RP, eds vol. 2 Medical Retina,, St. Louis, 1994, Mosby, p. 1245-1246
Damien Luviano, MD, FACS
Frank RN: Etiologic mechanisms in diabetic retinopathy. In Ryan SJ, ed: Retina, Schachat AP and Murphy RP, eds vol. 2 Medical Retina,, St. Louis, 1994, Mosby, p. 1263
Damien Luviano, MD, FACS
NUMBERS
STATISTICS DEMOGRAPHICS RISK FACTORS
Damien Luviano, MD, FACS
Damien Luviano, MD, FACS
Damien Luviano, MD, FACS
Damien Luviano, MD, FACS
HGA1C 1% REDUCES 50% RISK
Damien Luviano, MD, FACS
WHAT MAKES DISEASE WORSE?
Damien Luviano, MD, FACS
Adverse Risk Factors
1. Long duration of diabetes
• Obesity• Hyperlipidaemia
2. Poor metabolic control
3. Pregnancy
4. Hypertension
5. Renal disease
6. Other
• Smoking• Anemia
Damien Luviano, MD, FACS
I SEE FINE, I HAVE NO SYMPTOMS MY DOCTOR SAYS I HAVE DIABETES DAMAGE, CAN THAT BE TRUE?
Damien Luviano, MD, FACS
SYMPTOMS
Damien Luviano, MD, FACS
In the initial stages• NO Symptoms
Advanced stages of the disease• experience floaters• blurred vision• progressive visual acuity loss• Red eye• Pain
Damien Luviano, MD, FACS
What does the Doctor Actually see?
Damien Luviano, MD, FACS
CLINICAL FINDINGS (DOCTOR EXAM)
Damien Luviano, MD, FACS
Damien Luviano, MD, FACS
Preproliferative diabetic retinopathy
Treatment - not required but watch for proliferative disease
• Cotton-wool spots• Venous irregularities
• Dark blot haemorrhages• Intraretinal microvascular abnormalities (IRMA)
Signs
Damien Luviano, MD, FACS
Proliferative diabetic retinopathy
• Flat or elevated• Severity determined by comparing with area of disc
Neovascularization
Neovascularization of disc = NVD
• Affects 5-10% of diabetics• IDD at increased risk (60% after 30 years)
Neovascularization elsewhere = NVEDamien Luviano, MD, FACS
Indications for treatment of proliferativediabetic retinopathy
NVD > 1/3 disc in area Less extensive NVD + haemorrhage
NVE > 1/2 disc in area + haemorrhage
Damien Luviano, MD, FACS
How is the Doctor Going to Fix my eyes?
Damien Luviano, MD, FACS
TREATMENT• NONPROLIFERATIVE
Glucose Control• PROLIFERATIVE
Glucose Control Laser of retina outside macula Surgery to remove vitreous and scars (jelly)
• MACULAR EDEMA Glucose Control Laser of Macula Steroids and Avastin not FDA approved Lucentis in Clinical Trials
Damien Luviano, MD, FACS
• Spot size (200-500 m) depends on contact lens magnification
• Gentle intensity burn (0.10-0.05 sec)
• Follow-up 4 to 8 weeks
• Area covered by complete PRP• Initial treatment is 2000-3000 burns
Laser panretinal photocoagulation
Damien Luviano, MD, FACS
Assessment after photocoagulation
• Persistent neovascularization
• Hemorrhage
Poor involution
• Re-treatment required
• Regression of neovascularization• Residual ‘ghost’ vessels or fibrous tissue
Good involution
• Disc pallorDamien Luviano, MD, FACS
Treatment of clinically significant macular oedema
• For microaneurysms in centre of hard exudate rings located 500-3000 m from centre of fovea
Focal treatment
• Gentle whitening or darkening of microaneurysm (100-200 m, 0.10 sec)
• For diffuse retinal thickening located more than 500 m from centre of fovea and 500 m from temporal margin of disc
Grid treatment
• Gentle burns (100-200 m, 0.10 sec), one burn width apart
Damien Luviano, MD, FACS
Indications for vitreoretinal surgery
Retinal detachment involving macula
Severe persistent vitreous haemorrhage
Dense, persistent premacular haemorrhage
Progressive proliferation despite laser therapy
Damien Luviano, MD, FACS
DOCTOR Glucose Control
• Goal less HgA1c 7.0 Hypertension Control Lipid Control Lasers (temporary) Injections (temporary)
PATIENT Weight Control Smoking Control Exercise Alcohol Control
Damien Luviano, MD, FACS
How often should I see the Eye Doctor?
Damien Luviano, MD, FACS
FOLLOW UP• Controlled Diabetes
12 months• Diabetic Retinopathy Present
1-16 weeks
Damien Luviano, MD, FACS
How many kinds of eye doctors are there?
Damien Luviano, MD, FACS
PHYSICIANS
M.D Surgeons
• Laser • Surgery• Eyeglasses prescription
Medical School• Manage medical problems
12-14 years of Training Mandatory Dilation
EYE GLASS DOCTORS
O.D Optometrist
• Eyeglasses prescription• Optical Service (optician)
Optometry School 6-8 years of Training Optional Dilation (cost extra)
Damien Luviano, MD, FACS
PROBLEMS
DIABETES IS SERIOUS HURT MANY ORGANS PREVENTABLE
SOLUTIONS
GLUCOSE CONTROL FOLLOW PHYSICIANS ADVICE
Damien Luviano, MD, FACS
Damien Luviano, MD, FACS
INTERPRETATION: Treatment with fenofibrate in individuals with type 2 diabetes mellitus reduces the need for laser treatment for diabetic retinopathy, although the mechanism of this effect does not seem to be related to plasma concentrations of lipids.
Damien Luviano, MD, FACS
CONCLUSIONS: Intensive glycemic control and intensive combination treatment of dyslipidemia, but not intensive blood-pressure control, reduced the rate of progression of diabetic retinopathy. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov numbers, NCT00000620 for the ACCORD study and NCT00542178 for the ACCORD Eye study.)
Damien Luviano, MD, FACS
CONCLUSIONS: Early blockade of the renin-angiotensin system in patients with type 1 diabetes did not slow nephropathy progression but slowed the progression of retinopathy.
Damien Luviano, MD, FACS
Regardless of vision, PRP is beneficial (reduced severe vision loss by 50%-60%) in the management of patients with severe NPDR, preproliferative and especially beneficial in high-risk proliferative retinopathy. PRP is also indicated for NVI
Damien Luviano, MD, FACS
Conclusions: Early vitrectomy is recommended for type 1 DM with severe visual loss secondary to vitreous hemorrhage. Earlyvitrectomy is recommended for eyes with useful vision and advancedactive PDR, especially with extensive neovascularization. Endolaser at the time of vitrectomy was not preformed at the time of vitrectomy
Damien Luviano, MD, FACS
Aspirin has no benefitOnly patients with high-risk PDR and possibly severe NPDR in both eyes should receive immediate PRP in nasal and inferior quadrantsAll patients with CSME should be treated regardless of visionIn NPDR focal macular laser is performed before scatter PRP
Damien Luviano, MD, FACS
Results:Tighter BP control decreased diabetes related mortality by 32%.Tighter BP control decreased deterioration of retinopathy and visual acuity by 34% and 47% respectively. Conclusion:Tighter BP control is beneficial in reducing complications from diabetic retinopathy.
Damien Luviano, MD, FACS
Result: Intensive treatment group had a 12% reduced risk of diabetes associated complication when compared with the conventional group.Intensive treatment reduced mortality by 10% and morbidity by 6%.Intensive treatment had a significant 25% risk reduction in microvascular endpoints (fewer cases of PRP) Conclusion:Tighter BS control is beneficial in type 2 DM.
Damien Luviano, MD, FACS
Results: (6.5 years follow up)Intensive therapy reduced– development of DR by 76% and severe NPDR/PDR by 47%, progression ofDR by 54%, macular edema by 23%, and risk of laser treatment by 56%.HgA1c is strongly related to incidence of diabetic retinopathy Conclusion: Tighter BS control should be recommended. Aim for HgA1c o 7% or less
Damien Luviano, MD, FACS
Objective: Follow up patients after termination of DCCTResults: (Additional 4 years follow up)Intensive therapy reduced - progression of DR by 75%, macular edema by 58%, risk of laser treatment by 52%. Despite a similar HgA1c of 7.5%-8% in each group. Conclusion:Tighter BS control has long-term benefit.
Damien Luviano, MD, FACS
THE END
QUESTIONS
Damien Luviano, MD, FACS