How Diabetes Steals Vision from Your Patients The Sight Thief How Diabetes Steals Vision from Your Patients Jennifer Somers Weizer, MD June 14, 2016

No financial interests

Agenda Pathophysiology of DM Types of diabetic retinopathy Treatment options Screening and exam schedule Future directions

Diabetes Mellitus in the USA 25 million with DM 1/3 unaware that they have DM 28% ages 40+ have retinopathy 79 million with impaired glucose tolerance Prevalence of DM expected to continue to grow rapidly Courtesy American Academy of Ophthalmology

Diabetic Retinopathy Diabetes is the leading cause of blindness in US in ages 20-64 The longer you have diabetes, the more likely you are to have diabetic retinopathy After 20 years: 99% of type 1, 60% of type 2 Studies suggest that rates are higher in African Americans and Hispanics Wisconsin Epidemiologic Study of DR National Health and Nutrition Exam Survey

How does Diabetes Affect the Eyes? Diabetes affects cells that line blood vessels When these endothelial cells die, blood vessels become leaky Target tissues that rely on blood for oxygen and nutrients become damaged due to lack of blood flow Courtesy Bill Walsh Cancer Research Lab

Diabetic Retinopathy Two types of diabetic retinopathy Non-proliferative Mild Moderate Severe Proliferative

Diabetic Retinopathy Non-proliferative diabetic retinopathy Signs of diabetic damage to the retina Dot-blot hemorrhages, cotton wool spots, blood vessel abnormalities Normal retina Severe NPDR

Diabetic Retinopathy Non-proliferative diabetic retinopathy May not yet affect vision Does not require specific treatment beyond blood sugar and blood pressure control Numerous studies show that tighter blood sugar and blood pressure control slow the development and progression of diabetic retinopathy Diabetes Control and Complications Trial United Kingdom Prospective Diabetes Study

Diabetic Retinopathy Macular edema – swelling in center of the retina Affects vision Can be treated by laser New therapy – injections of new medicines (anti-vascular endothelial growth factor) into the eye Studies are being done to compare these medicines to traditional laser treatment

Diabetic Retinopathy Macular edema Macular edema on OCT Normal macula on OCT

Diabetic Retinopathy Proliferative diabetic retinopathy Retinal ischemia induces growth factors that cause abnormal blood vessels to grow (neovascularization) These blood vessels can bleed, cause retinal detachment and glaucoma, cause severe vision loss Needs treatment as well as BS/BP control

Diabetic Retinopathy Proliferative diabetic retinopathy

Diabetic Retinopathy Proliferative diabetic retinopathy with vitreous hemorrhage

Diabetic Retinopathy Proliferative diabetic retinopathy causing iris neovascularization Can cause neovascular glaucoma

Proliferative Diabetic Retinopathy Panretinal photocoagulation Laser treatment to peripheral retina to reduce demand for nutrients, thus decreasing stimulation for abnormal blood vessels to grow Studies being done to compare intravitreal anti-VEGF and steroid injections to laser treatment Vitrectomy surgery

Proliferative Diabetic Retinopathy Panretinal photocoagulation (laser for PDR)

Factoid: Optical Illusion Many people think of laser refractive surgery when hearing about laser treatment for diabetic retinopathy. These laser treatments are different. Laser for diabetic retinopathy is designed to preserve your vision rather than improve it, and will not reduce your need for glasses or contact lenses.

Intravitreal Injection of anti-VEGF Agent for Macular Edema Courtesy Spencer Perry

Vitrectomy for Diabetic Retinopathy Surgery to remove gel that fills vitreous cavity Removes blood, can repair retinal detachments, removes scar tissue Courtesy carolinaretinadoc.com

Vitrectomy for Diabetic Retinopathy Courtesy wikipedia.org

Vitrectomy Animation Courtesy American Academy of Ophthalmology

Vitrectomy Courtesy Federico DiTizio, MD

Screening for Diabetic Retinopathy Unlikely to develop retinopathy within first 5 years of diagnosis of type 1 For type 2, diagnosis may be late, so need eye exam at time of diagnosis May progress more rapidly during pregnancy Anyone with retinopathy needs to see an ophthalmologist regularly

Dilated Exams for Diabetic Retinopathy Age of onset of DM/pregnancy Recommended time of first eye exam Routine minimum follow-up Type 1 Within 5 yrs of dx Yearly Type 2 Upon diagnosis Prior to pregnancy Before conception or early in 1st trimester Every 3 mos or per ophthalmologist’s discretion Courtesy American Academy of Ophthalmology

Gestational Diabetes No need for screening eye exam in patient who develops gestational diabetes No apparent increased risk of retinopathy

Controlling Diabetic Retinopathy Tight blood sugar control can decrease the development and progression of diabetic retinopathy by 50-75% Managing blood pressure and serum lipids also helps control retinopathy Treating diabetic retinopathy may be 90% effective at preventing severe vision loss Diabetes Control and Complications Trial

Controlling Diabetic Retinopathy Diabetic retinopathy is end-organ damage, just like damage to: Kidneys Peripheral nerves (neuropathy) Heart and blood vessels Keeping hemoglobin A1C as close to normal as possible prevents damage to these organs Epidemiology of Diabetes Interventions and Complications Trial

Aspirin Usage No increased risk of bleeding in retinopathy with ASA use ASA is OK from an eye standpoint

We need to do more Only 50-60% of diabetic Medicare beneficiaries had an eye exam in a 15-month period Diabetic patients need to see an eye doctor regularly! Better communication between eye physicians and PCPs Courtesy American Academy of Ophthalmology

Controlling Diabetic Retinopathy Future steps Telemedicine with retinal photos may help screen diabetic patients who do not have easy access to an eye doctor Courtesy university-eyecare.org.au

Mobile Eye Units Courtesy Carrizo Springs Lions Club

Mobile Eye Units