Basic Considerations for Prevention Basic Considerations for Prevention of Blindness in Diabetes Care and of Blindness in Diabetes Care and

EducationEducation

Prof. Morsi ArabProf. Morsi Arab Emeritus Professor of Medicine Emeritus Professor of Medicine

University of Alexandria University of Alexandria

Prevelance of DM in whole Egypt in Different Age Groups

0.62 0.80

3.08

8.25

12.04

15.06

0

2

4

6

8

10

12

14

16

% p

opul

atio

n

Age Group 10 20 30 40 50 60

0

5

10

15

20

25Pe

rcen

t

20 30 40 50 60 >60Age

Diabetes Prevelance & Age Groups

Causes of visual loss and blindness in Causes of visual loss and blindness in Diabetes Diabetes

- Diabetic Retinopathy ( DR) is most - Diabetic Retinopathy ( DR) is most common common - Glucoma less common - Glucoma less common - Cataract less common - Cataract less common - Vitreous hemorrhage - Vitreous hemorrhage

The Burden of diabetes on visual abilityThe Burden of diabetes on visual ability

The WHO identifiesThe WHO identifies DRDR as the leading causeas the leading cause ofof preventable blindnesspreventable blindness and visual disabilityand visual disability in adults inin adults in economically developedeconomically developed societiessocieties

Significant Observations in DRSignificant Observations in DR 1- DR takes a long time to become 1- DR takes a long time to become manifest. During this time it is asymptomatic manifest. During this time it is asymptomatic 2- DR. may not be arrested after establishment 2- DR. may not be arrested after establishment of normoglycaemia ( bec. glycated subs. of normoglycaemia ( bec. glycated subs. can continue to bind to proteins after …) can continue to bind to proteins after …) 3- However , glycaemic control at 3- However , glycaemic control at earlyearly stages stages is effective in controlling progression of DR is effective in controlling progression of DR ( DCCT) ( DCCT)

Prevalence of Diabetic Retinopathy ( DR)Prevalence of Diabetic Retinopathy ( DR)( The Wisconsin Study )( The Wisconsin Study ) all DR Prolif.DRall DR Prolif.DRin type 1in type 1 (onset of DM >30 ys) 71% 23 % (onset of DM >30 ys) 71% 23 %in type 2in type 2 (onset after 30ys ) (onset after 30ys ) - on insulin 70% 14 % - on insulin 70% 14 %

- no insulin 39% 2 - no insulin 39% 2% %

Retinopathy

68.9 %

9.5%

22.6 % FreeB.groundProlif.

Prevalence of DR in relation to GlycaemiaPrevalence of DR in relation to GlycaemiaThe DCCT ( type 1)The DCCT ( type 1)

intensified Rx reduced progression of DR intensified Rx reduced progression of DR by 76% in primary preven. cohort by 76% in primary preven. cohort 54% in secondary preven. cohort 54% in secondary preven. cohort 47% progression to severe NPDR 47% progression to severe NPDR 56% necessity for Laser Rx 56% necessity for Laser Rx

DCCT results show importance of both DCCT results show importance of both DurationDuration and and Glucose exposureGlucose exposure ( hyperglyceamia) for the ( hyperglyceamia) for the development of DRdevelopment of DR

Preval. of DR in relation to Preval. of DR in relation to Glycaemia UKPDS ( type 2)Glycaemia UKPDS ( type 2)intensified Rx with improved metabolicintensified Rx with improved metaboliccontrol control - risk of worsening DR by 21 % - risk of worsening DR by 21 %

- need for Laser Rx by 29% - need for Laser Rx by 29% - Cataract extraction by 24% - Cataract extraction by 24%

Prevalence of DR / Duration of DiabetesPrevalence of DR / Duration of Diabetes

The prev. of DR is highly correlated with the The prev. of DR is highly correlated with the duration of DMduration of DM

at 5ysat 5ys at 25 ysat 25 ys

in type 1 :in type 1 : (10 %) ( steep rise) 100 % (10 %) ( steep rise) 100 %

in type 2 :in type 2 : (25 %) almost 85% (25 %) almost 85%

Retinopathy in correlation with Retinopathy in correlation with Duration of DMDuration of DM

0%

20%

40%

60%

80%

100%

1 3 6 9 12 15 >15

Free Non-Prol. Prol.

Hypertension and DRHypertension and DRmost studies show a causal association most studies show a causal association UKPDS :UKPDS : Tight control of B.P. 34 % of progress DRTight control of B.P. 34 % of progress DR 47 % of moderate loss 47 % of moderate loss

of Vis. Acuity of Vis. Acuity( ( N.B. independent on the degree of glycaemic N.B. independent on the degree of glycaemic control ) control )

No specific type of anti hypertensive No specific type of anti hypertensive medication is superior than other medication is superior than other

The Genetic factor in DRThe Genetic factor in DR

There is evidence that severity of There is evidence that severity of DRDR is is influenced by influenced by familialfamilial , and possibly a , and possibly a geneticgenetic factor factor

Dyslipidaemia and DRDyslipidaemia and DR

an association is found between more an association is found between more severe DR and severe DR and - Total cholesterol - Total cholesterol - but not with TG - but not with TG ( (lipid modulation by statins…?lipid modulation by statins…? not conclusive ) not conclusive )

Smoking and DRSmoking and DR Although smoking is a risk factor Although smoking is a risk factor in albuminuria and nephropathy , in albuminuria and nephropathy , its effect on DR is its effect on DR is not clearnot clear

Aspirin in DRAspirin in DR - Anti inflam. agents did not show effect - Anti inflam. agents did not show effect in Rx vasc. complications in Rx vasc. complications - aspirin failed to prevent dev. of DR - aspirin failed to prevent dev. of DR - aspirin can be used if indicated ( card) - aspirin can be used if indicated ( card) without adverse effect on DR without adverse effect on DR

The Risk Factors for DRThe Risk Factors for DRMostMost definitive:definitive: 1- Duration of DM1- Duration of DM 2- High glycaemic level 2- High glycaemic levelLess definite:Less definite: 1- Hypertension 1- Hypertension 2- Pregnancy 2- Pregnancy 3- Genetic factor 3- Genetic factor 4- Hyperlipidaemia 4- Hyperlipidaemia 5- Close assoc. with 5- Close assoc. with albuminuria albuminuria 6- ? Smoking 6- ? Smoking

Screening for and follow up of DRScreening for and follow up of DRin type 1 :in type 1 : screen within 3-5 yrs after diag. ( onset)screen within 3-5 yrs after diag. ( onset) ( not necessary before age 10 ) ( not necessary before age 10 )in type 2 :in type 2 : screen shortly after diagnosis screen shortly after diagnosis

Follow up :Follow up : - repeat annually if no DR - repeat annually if no DR - more frequently if DR is progressing - more frequently if DR is progressing N.B. : In Pregnancy :N.B. : In Pregnancy : -- Screen at planning preg. or during first trimest. -- Screen at planning preg. or during first trimest.

– Follow up through preg – Follow up through preg..

Education for Prevention of DR ( basic Education for Prevention of DR ( basic considerations )considerations )

1- knowledge of the Risk factors 1- knowledge of the Risk factors 2- control of glycaemic level 2- control of glycaemic level 3- control hypertension 3- control hypertension 4- screen + follows up , and early intervention 4- screen + follows up , and early intervention 5- close observation in pregnancy 5- close observation in pregnancy 6- control serum lipids 6- control serum lipids 7- discourage smoking 7- discourage smoking 8- no restriction on aspirin ( if required for cardiac ) 8- no restriction on aspirin ( if required for cardiac )

Alexandrie – Palais du Montazah

Thank You