1. Diagnosis & Management of Diabetic Eye Disease A. Paul Chous, M.A., O.D., F.A.A.O. Tacoma, WA Specializing in Diabetes Eye Care & Education Part 4

2. Efferent Cranial Neuropathy Microvascular infarct commonly leads to short-lived IIIrd, IVth, VIth and VIIth CN palsies Microvascular infarct commonly leads to short-lived IIIrd, IVth, VIth and VIIth CN palsies 2-6 month duration 2-6 month duration Isolated CN palsy as a rule Isolated CN palsy as a rule Autonomic neuropathy leads to diminished pupillary reflexes and accommodative response Autonomic neuropathy leads to diminished pupillary reflexes and accommodative response

3. 30 minutes Later

4. Cranial Neuropathy- Management Improve blood glucose control Improve blood glucose control Patch/use prism as necessary Patch/use prism as necessary Consider earlier use of bifocal correction Consider earlier use of bifocal correction

5. Glaucoma Controversy regarding DM as a risk factor for POAG; undisputed risk for NVG Controversy regarding DM as a risk factor for POAG; undisputed risk for NVG The Nurses Health Study (n = 76,3180) and meta-analysis of 12 studies (1987-2001) reveal a 50-80% increased risk of POAG in DM The Nurses Health Study (n = 76,3180) and meta-analysis of 12 studies (1987-2001) reveal a 50-80% increased risk of POAG in DM Ophthalmology 2006 Jul;113(7): 1081-6 Ophthalmology 2006 Jul;113(7): 1081-6 Diabet Med 2004 Jun;21(6): 609-14 Diabet Med 2004 Jun;21(6): 609-14 Basic science has shown that AGEs ‘harden’ laminar collagen leading to shear stress Basic science has shown that AGEs ‘harden’ laminar collagen leading to shear stress There may be a strong detection bias There may be a strong detection bias

6. Iris Rubeosis  NVG (IOP= 68mm)

7. Glaucoma - Management Avoid unnecessarily treating OHTN in patients with diabetes Avoid unnecessarily treating OHTN in patients with diabetes Increased risk of sight-threatening retinopathy with lower IOP and increased blood flow Increased risk of sight-threatening retinopathy with lower IOP and increased blood flow Avoid beta blockers in pts on insulin Avoid beta blockers in pts on insulin Increase blood glucose and may cause ‘hypoglycemia unawareness’ Increase blood glucose and may cause ‘hypoglycemia unawareness’ Refer NVI for immediate PRP Refer NVI for immediate PRP Anti-VEGF agents successfully used in 2 cases Anti-VEGF agents successfully used in 2 cases

8. AION Two-thirds of patients with non-arteritic AION have DM, HTN, or both Two-thirds of patients with non-arteritic AION have DM, HTN, or both Younger patients with T1DM often have good recovery of vision (‘diabetic papillopathy’) – not always the case Younger patients with T1DM often have good recovery of vision (‘diabetic papillopathy’) – not always the case PREVENTION: strongly consider ASA therapy for patients with DM and small cups & hyperemic discs (‘disc at-risk’) PREVENTION: strongly consider ASA therapy for patients with DM and small cups & hyperemic discs (‘disc at-risk’) Aggresively treat HTN & dyslipidemia Aggresively treat HTN & dyslipidemia Optic disc on Fluorescein Angiography

9. Retinal Vascular Occlusion Retinal venous and arterial occlusions are more common in diabetes (especially BRVO) Retinal venous and arterial occlusions are more common in diabetes (especially BRVO) Increased probability of predisposing factors: Increased probability of predisposing factors: Hypertension Hypertension Dyslipidemia Dyslipidemia Hypercoagulability Hypercoagulability Especially in Type 2 Diabetes

10. Sticky Platelets + HTN = Venous Occlusion BRVO

11. CRAO Major risk factors for RAOs are hypertension, atherosclerosis & cardiac valve disease – Two of which are more common in diabetes

12. Retinal Vascular Occlusion – Prevention & Management Improve & stabilize blood glucose Improve & stabilize blood glucose Aggressively treat HTN and dyslipidemia Aggressively treat HTN and dyslipidemia Monitor closely for neovascularization in all venous occlusions associated with diabetes Monitor closely for neovascularization in all venous occlusions associated with diabetes ‘Double Whammy’ of ischemia from hyperglycemic capillary closure and venous stasis ‘Double Whammy’ of ischemia from hyperglycemic capillary closure and venous stasis

13. Macrovasculopathy & Diabetic Eye Disease DRT, Retinal Vascular Occlusion and AION strongly correlated with systemic CV disease DRT, Retinal Vascular Occlusion and AION strongly correlated with systemic CV disease -Sticky Platelets from  PAI-1 -Reactive Oxygen Species injure blood vessel wall blood vessel wall -Embolic Events from rupture of vulnerable plaque due to  CRP