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