1. Ocular Manifestations of Diabetes
Joobin Khadamy. MD
5/5/2018
Ocular Manifestations of Diabetes
Diabetes and Insuline Conference
2nd Feb/2017
Birjand University of Medical Science (BIUMS)
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline
Source; American Academy of Ophthalmology Guidelines for Diabetic Retinopathy

2. Ocular Manifestations
Neuropathy(RGC)
Ischemic Optic Neuropathy
Glaucoma
Corneal Edema
Corneal Nerve Alterations
Cataract
Retinopathy
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

3. How Often Diabetic Retinopathy is?
Among leading cause of adults blindness in general population
In Diabetics:
Type1/95%
Type2/60%
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

4. Genetic or Environmental Factors
Not All diabetics develope to DR!
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

5. Who Is at Risk for Diabetic Retinopathy?
Simple answer; Every diabetics!
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

6. Diabetic retinopathy risk factors
Blood sugar levels
Blood pressure (<130/80 mmHg)
Duration of diabetes
Type 1/15 years/80 %
Type 2/19 years/84 %
Blood lipid levels
greater accumulation of exudates, protein deposits
higher risk of moderate visual loss.
Ethnicity
Pregnancy
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

7. Other RF investigations is needed
Common RF with Diabetic Nephropathy
Elevated Cystatin C can predict DR ?
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

8. How does non-proliferative diabetic retinopathy affect your vision?
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

9. How does proliferative diabetic retinopathy affect your vision?
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

10. Examination Schedule Type 2 Diabetes
The patient should be referred for ophthalmologic evaluation at the time of diagnosis.
The time of onset of Type 2 diabetes is often difficult to determine and may precede the diagnosis by a number of years.
Up to 3% of patients whose diabetes is first diagnosed at age 30 or later will have CSME or high-risk features at the time of the initial diagnosis of diabetes. 
About 30% of patients will have some manifestation of diabetic retinopathy at diagnosis.
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

11. Examination Schedule Type 1 Diabetes
Ophthalmic examinations are recommended beginning 5 years after the diagnosis of Type 1 diabetes and annually thereafter, which will detect the vast majority of Type 1 patients who require therapy.
Adirect relationship between the prevalence and severity of retinopathy and the duration of diabetes.
 The development of vision-threatening retinopathy is rare in children prior to puberty.
Among patients with Type 1 diabetes, substantial retinopathy may become apparent as early as 6 to 7 years after onset of the disease.
Patient education about the visual impact of early glucose control is important and should begin with the onset of disease.
for ophthalmologic evaluation at the time of diagnosis.
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

12. Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

13. Diabetes Associated with Pregnancy
diabetics > an examination prior to pregnancy
During the first trimester, with follow-up visits
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

14. Women who develop gestational diabetes do not require an eye examination during pregnancy and do not appear to be at increased risk for diabetic retinopathy during pregnancy.
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

15. Physical Examination Visual acuity Slit-lamp biomicroscopy
Intraocular pressure (IOP)
Gonioscopy before dilation, when indicated. Iris neovascularization is best recognized prior to dilation. When neovascularization of the iris is present or suspected, or if the IOP is elevated, undilated gonioscopy can be used to detect neovascularization in the anterior chamber angle.
Pupillary assessment for optic nerve dysfunction
funduscopy
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

16. Importance of Dilated Fundus exam
A dilated pupil is preferred to ensure optimal examination of the retina, because only 50% of eyes are correctly classified for the presence and severity of retinopathy through undilated pupils.
Slit-lamp biomicroscopy is the recommended method to evaluate retinopathy in the posterior pole and midperipheral retina.
Examination of the peripheral retina is best performed using indirect ophthalmoscopy or slit-lamp biomicroscopy.
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

17. Imagings FA OCT OCTA WFI UWFI Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

18. FA Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

19. OCT Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

20. OCTA Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

21. Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

22. Type Of Diabetic Retinopathy
NPDR :
Microaneurysms
Retinal hemorrhages
Hard exudates
Macular edema
Macular ischemia
PDR:
Neovascularization:
NVD/NVE> Fibrovascular>Vitreous Hx> TRD
Angle/Iris > NV glaucoma
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

23. NPDR Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

24. PDR Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

25. Grading Shortages! Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

26. Treatments AntiVEGF + Laser therapy Surgery Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

27. Combined Slow Release Implants
Novel Treatments
Beta Blockers
Steroid implants
MTX
Fenofibrate
……..
Combined Slow Release Implants
Future:
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

28. Exercise Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

29. Effects Related to Other Treatments
There have been case reports of idiosyncratic macular edema that is temporally associated with use of the glitazone class of oral antihyperglycemic agents.
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; AAO Guideline

30. Eye and Diabetes Novelties
Joobin Khadamy. MD
5/5/2018
Eye and Diabetes Novelties
Insulin Eye Drops
Blood Sugar Contact Lenses
Subconjunctival Glucose Sensors
Source; AAO Guideline
Joobin Khadamy. MD; Diabetes & Insuline conferece
Source; American Academy of Ophthalmology Guidelines for Diabetic Retinopathy