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

2. No financial interests

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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

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

12. 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

13. Diabetic Retinopathy
Proliferative diabetic retinopathy

14. Diabetic Retinopathy
Proliferative diabetic retinopathy with vitreous hemorrhage

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

16. 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

17. Proliferative Diabetic Retinopathy
Panretinal photocoagulation (laser for PDR)

18. 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.

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

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

21. Vitrectomy for Diabetic Retinopathy
Courtesy wikipedia.org

22. Vitrectomy Animation
Courtesy American Academy of Ophthalmology

23. Vitrectomy
Courtesy Federico DiTizio, MD

24. 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

25. 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

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

27. 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

28. 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

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

30. 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

31. 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

32. Mobile Eye Units
Courtesy Carrizo Springs Lions Club

33. Mobile Eye Units