diabetic eye disease
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Diabetic Eye Disease. Evan (Jake) Waxman MD PhD. Diabetic Eye Disease Key Points. Diabetes is a major cause of visual loss. Diabetic Eye Disease Key Points. Risk factor control can prevent and slow visual loss. Diabetic Eye Disease Key Points. - PowerPoint PPT PresentationTRANSCRIPT
Diabetic Eye Disease
Evan (Jake) Waxman MD PhD
• Diabetes is a major cause of visual loss
Diabetic Eye DiseaseKey Points
• Risk factor control can prevent and slow visual loss
Diabetic Eye DiseaseKey Points
• Treatments exist but work best before vision is lost
Diabetic Eye DiseaseKey Points
• Diabetes is a major cause of visual loss• Risk factor control can prevent and slow visual loss• Treatments exist but work best before vision is lost
So … to prevent visual loss
• Control patient risk factors• Insist your patients get yearly dilated eye
exams with an ophthalmologist
Diabetic Eye DiseaseKey Points
Diabetic Eye Disease
Case Presentation - History• 27 year old woman• DM I for 16 years• poor blood sugar ctrl• HgbA1C = 10• c/o spot in L vision for
one day• Sees “Eye Doctor” every
year -- no previous eye disease diagnosed
Diabetic Eye Disease
Case Presentation - Exam• Visual Acuity 20/50
OU• Normal Pupils• Normal Anterior
Segment
Diabetic Eye Disease
Case Presentation - Exam
Diabetic Eye Disease
Case PresentationFluoroscein Angiography
Diabetic Eye Disease
Case Presentation - Course• Pan retinal photocoagulation OU• Focal photocoagulation OS• Vision dropped to 20/200 OD 1 month later • Vit heme OS 2 months later• Additional PRP• Glaucoma surgery x 2• Current Acuity 20/400 OD 20/200 OS• Prognosis Poor
• Treatments work best before vision is lost
• Many patients are diagnosed only after vision is lost
• Vision loss is a late symptom of diabetic eye disease
• Risk factor control is essential
Diabetic Eye DiseaseBackground
Diabetic Eye DiseaseBackground
• Catching disease prior to vision loss requires yearly screening with a dilated eye exam by an MD
• Diabetes is a major cause of visual loss• Risk factor control can prevent and slow visual loss• Treatments exist but work best before vision is lost
So … to prevent visual loss
• Control patient risk factors• Insist your patients get yearly dilated eye
exams with an ophthalmologist
Diabetic Eye DiseaseKey Points
• Leading cause of blindness in Americans aged 25- 65
• Accounts for 12% of new blindness
• Diabetic patients 25 times more likely to go blind
Diabetic Eye DiseaseBackground – Scary statistics
• 65,000 with new proliferative retinopathy yearly
• 75,000 with new macular edema yearly
• 700,000 have PDR• 500,000 have macular edema• 25% - 50% with high risk disease not
receiving care
Diabetic Eye DiseaseBackground – More scary statistics
•Duration•Poor Blood Sugar control•HTN•Hyperlipidemia•Barriers to care
Diabetic Eye DiseaseBackgroundRisk Factors
Diabetic Eye DiseaseBackground
• Prevention of eye disease is possible with increased risk factor control
The Effect of Intensive Diabetes TreatmentOn the Progression of Diabetic RetinopathyIn Insulin-Dependent Diabetes Mellitus
The Diabetes Control and Complications Trial
The Diabetes Control and Complications Trial Research Group
CLINICAL SCIENCES
Arch Ophthalmol. 1995; 113:36-51
Diabetic Eye DiseaseFramework
• 2 pathways of Visual Loss in DR–Capillary
Leakage–Capillary
Closure
Diabetes
Preclinical Changes
Background DR
Preproliferative DR Macular Edema
ClinicallySignificantMacular Edema
Proliferative DR
Vitreous Hemorrhage
Retinal DetachmentNeovascular Glaucoma
Vision Loss
and/or
and/or
Diabetic Eye DiseasePathophysiology – Capillary Leakage
• Pericyte Loss
• Endothelial Cell loss
• Blood-retina barrier breakdown
High blood sugar levels affect retinal capillariesHigh blood sugar levels affect retinal capillaries
Diabetic Eye DiseasePathophysiology - Capillary Leakage
• Non proliferative diabetic retinopathy– Damaged
capillaries leak– Leakage into the
macula results in vision loss
Diabetic Eye DiseaseSymptoms/Signs - Preclinical
–None on exam–Special techniques
demonstrate• Leakage• VEGF secretion
Diabetic Eye DiseaseSymptoms/Signs – NPDR
• Usually no symptoms
• Dot heme– Microaneurysms– Leakage
• Blot heme– Leakage
• Flame heme
Diabetic Eye DiseaseSymptoms/Signs – NPDR / Macular Edema
• +/- Symptoms• Dot heme
– Microaneurysms– Leakage
• Blot heme– Leakage
• Hard exudates
Diabetic Eye DiseaseSymptoms/Signs – NPDR / Macular Edema
• Hard exudates• Retinal edema• Vision loss
when edema occurs in central visual area
Diabetic Eye DiseaseNPDR / Macular Edema
• Prevalence–5% for pts
with DM for ≤ 5 years
–15% for pts with DM for≥ 15 years
Diabetic Eye DiseaseNPDR – Macular Edema
• Prevalence–Higher for
insulin dependence
–Higher with increased HgbA1C
Diabetic Eye DiseaseTreatment – NPDR – Macular Edema• Fluoroscein Angiography
Diabetic Eye DiseaseTreatment – NPDR – Macular Edema
• Focal Laser
Diabetic Eye DiseaseTreatment – NPDR – Macular Edema
• Focal Laser
Diabetic Eye DiseaseTreatment – NPDR – Macular Edema
Focal Laser reduces risk of visual loss by 50%
Early Photocoagulation forDiabetic Retinopathy
ETDRS Report Number 9
EARLY TREATMENT DIABETIC RETINOPATHY STUDY RESEARCH GROUP
Ophthalmology 1991; 98; 766-785
Diabetic Eye DiseaseFramework
• 2 pathways of Visual Loss in DR–Capillary
Leakage–Capillary
Closure
Diabetes
Preclinical Changes
Background DR
Preproliferative DR Macular Edema
ClinicallySignificantMacular Edema
Proliferative DR
Vitreous Hemorrhage
Retinal DetachmentNeovascular Glaucoma
Vision Loss
and/or
and/or
Diabetic Eye DiseasePathophysiology – Capillary Closure
• Basement membrane thickening
• Increased platelet and erythrocyte adhesion
• Closure of capillaries
High blood sugar levels affect retinal capillariesHigh blood sugar levels affect retinal capillaries
Diabetic Eye DiseasePathophysiology – Capillary Closure
• Proliferative diabetic retinopathy– Damaged capillaries
close off– Ischemic retina
secretes VEGF– New vessels form in
response to VEGF
• Proliferative diabetic retinopathy– Neovascularization
• Fibrous Proliferation• Traction with
vitreous hemorrhage• Traction retinal
detachment• Neovascular
glaucoma
Diabetic Eye DiseasePathophysiology
Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR
• Symptoms - None
• Cotton Wool Spots – Nerve fiber
layer ischemia & infarction
Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR
• Symptoms - None• Cotton Wool Spots
– Nerve fiber layer ischemia & infarction
• Venous beading• Intraretinal
microvascular abnormalities (IRMA)
Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR
• Symptoms - None• Cotton Wool Spots
– Nerve fiber layer ischemia & infarction
• Venous beading• IRMA• More heme
Diabetic Eye DiseaseSymptoms/Signs – Proliferative Retinopathy
• Symptoms - None• Optic Nerve
Neovascularization (NVD)
Diabetic Eye DiseaseSymptoms/Signs – Proliferative Retinopathy
• Symptoms - None• Optic Nerve
Neovascularization (NVD)
• Peripheral Neovascularization (NVE)
Diabetic Eye DiseaseSigns – Proliferative Retinopathy
• Prevalence ≤ 5 years – 0% ≥ 15 yrs – 25% ≥ 20 yrs – 55%
Diabetic Eye DiseaseTreatment – PDR
• Panretinal photocoagulation (PRP)
Diabetic Eye DiseaseTreatment – PDR
• Panretinal photocoagulation (PRP)
Before After
Diabetic Eye DiseaseTreatment – PDR
• Panretinal photocoagulation (PRP)
Before After
Diabetic Eye DiseaseTreatment – PDR
PRP reduces the risk of severe vision loss by more than 50%
Photocoagulation Treatment ofProliferative Diabetic Retinopathy
Clinical Application of Diabetic Retinopathy Study(DRS) Findings, DRS Report Number 8
THE DIABETIC RETINOPATHY STUDY RESEARCH GROUP
Ophthalmology 1991; 88; 583-600
Diabetic Eye DiseaseSigns/Symptoms – Vitreous Heme
• Symptoms– Floaters/Streaks– Loss of vision
• Blood in vitreous• Loss of red reflex• No View
Diabetic Eye DiseaseSymptoms/Signs – Retinal Detachment
• Symptom– Visual Loss; often
severe• Retinal Elevation• Fibrous Proliferation• Loss of red reflex• Marcus/Gunn Pupil
Diabetic Eye DiseaseTreatment – Vitreous Heme
• Panretinal photocoagulation (PRP)• Vitrectomy
– Removes blood– Removes Traction– Allows addnl PRP
Diabetic Eye DiseaseTreatment – Vitreous Heme
Vitrectomy
Diabetic Eye DiseaseTreatment – PDR
Vitrectomy results in improved vision in patients with persistent vitreous hemorrhage
Early Vitrectomy fo Severe VitreousHemorrhage in Diabetic RetinopathyTwo-Year Results of a Randomized TrialDiabetic Retinopathy Virectomy Report 2
THE DIABETIC RETINOPATHY VITRECTOMY STUDY RESEARCH GROUP
Arch Ophthalmol. 1985; 103 1644-1652
Diabetic Eye DiseaseSymptoms/ Signs – Neovascular Glaucoma
• Symptoms– Loss of Vision– Pain
• “Red Eye”• Iris Neovascularization• High Intraocular
Pressure• Marcus Gunn pupil
Diabetic Eye DiseaseOther Manifestation of Diabetes in the Eye
• Branch Retinal Artery Occlusion
• Central Retinal Artery Occlusion
• Branch Retinal Vein Occlusion
• Central Retinal Vein Occlusion
Diabetic Eye DiseaseOther Manifestation of Diabetes in the Eye
• Increased risk of cataract
• Increased risk of glaucoma
• Diabetic papillitis• Acute CN III, IV or VI
paresis
Diabetic Eye DiseaseWhat’s new and cool
• Intraocular steroid– Injection– Sustained release
device• Stabilizes blood-retina
barrier• Reduces Macular
Edema
Diabetic Eye DiseaseWhat’s new and cool
• Anti VEGF drugs• Protein Kinase C beta
inhibitors• Intravitreal
hyaluronidase
Diabetic Eye DiseaseWhat’s new and cool
• Ocular Coherence Tomography– Noninvasive imaging
of retina– Can detect subtle
retinal thickening
• Diabetes is a major cause of visual loss
Diabetic Eye DiseaseKey Points
• Risk factor control can prevent and slow visual loss
Diabetic Eye DiseaseKey Points
• Treatments exist but work best before vision is lost
Diabetic Eye DiseaseKey Points
• Diabetes is a major cause of visual loss• Risk factor control can prevent and slow visual loss• Treatments exist but work best before vision is lost
So … to prevent visual loss
• Control patient risk factors• Insist your patients get yearly dilated eye
exams with an ophthalmologist
Diabetic Eye DiseaseKey Points