Diagnosis & Diagnosis & Management of Management of

Diabetic Eye DiseaseDiabetic Eye Disease

Paul Chous, M.A., O.D., F.A.A.O.Paul Chous, M.A., O.D., F.A.A.O.Specializing in Diabetes Eye Care & EducationSpecializing in Diabetes Eye Care & Education

Part 3Part 3

CataractCataract

Hyperglycemia leads to sorbitol Hyperglycemia leads to sorbitol accumulation via aldose reductase accumulation via aldose reductase (the polyol pathway)(the polyol pathway) True diabetic “snowflake” cataractsTrue diabetic “snowflake” cataracts

Typical age-related cataracts Typical age-related cataracts develop prematurely due to AGE develop prematurely due to AGE formationformation Decreased elasticity of lens proteins Decreased elasticity of lens proteins

causes premature presbyopia and, causes premature presbyopia and, eventually, loss of tranparencyeventually, loss of tranparency

Diabetic “Snowflake” Cortical Cataract

Nuclear Sclerotic Cataract – 52 yo diabetic

The Maillard Reaction

Advanced Glycation Endproducts:AGEs – they’re what’s for dinner

Cataract - ManagementCataract - Management Improve & stabilize blood glucoseImprove & stabilize blood glucose

A1c < 6.5% (ideally)A1c < 6.5% (ideally) Strive for a low standard deviationStrive for a low standard deviation

Phacoemulsification when prudent or Phacoemulsification when prudent or necessarynecessary Much higher risk of post-operative CME Much higher risk of post-operative CME

and worsening retinopathyand worsening retinopathy Always address retinopathy prior to Always address retinopathy prior to

surgerysurgery

Diabetic KeratopathyDiabetic Keratopathy

Hyperglycemia & corneal sensory Hyperglycemia & corneal sensory neuropathy weaken hemidesmosomal neuropathy weaken hemidesmosomal attachments between the basal epithelium attachments between the basal epithelium and its basement membraneand its basement membrane PEK, Erosions, Neurotrophic Keratitis & PEK, Erosions, Neurotrophic Keratitis &

UlcerationUlceration

Increased tear osmolarity and lacrimal Increased tear osmolarity and lacrimal autonomic neuropathy result in dry eyeautonomic neuropathy result in dry eye

Photonic Colloidal Crystalline Array

Diabetic Keratopathy

Prevalence of Dry Eye Syndrome and use of artificial tears is significantly

higher amongst patients with diabetes and with a family Hx of diabetes

Optometry. 2006 Nov;77(11):554-8

Am J Ophthalmol. 2005 Mar;139(3):498-503

Diabetic Neurotrophic Ulcer

Keratopathy - ManagementKeratopathy - Management

Improve & stabilize blood glucoseImprove & stabilize blood glucose Be careful with contact lenses & Be careful with contact lenses &

corneal refractive surgeriescorneal refractive surgeries Avoid vigorous eye rubbingAvoid vigorous eye rubbing NP tears, plugs, immunomodulators, NP tears, plugs, immunomodulators,

bandage SCLs, etc. as indicatedbandage SCLs, etc. as indicated Beware infectionBeware infection

Key PointsKey Points

Diabetes and diabetic eye Diabetes and diabetic eye disease are epidemicdisease are epidemic

Ocular complications are myriad Ocular complications are myriad and associated with large blood and associated with large blood vessel diseasevessel disease

State-of-the-art care is evolving State-of-the-art care is evolving rapidlyrapidly

“The only thing to dowith good advice is topass it on to others…

It is of absolutely nouse to oneself.”

- Oscar Wilde