1. Diabetes and the Eye Presented to DES chapters by the Canadian Association of Optometrists

2. An optometrist knows your eyes inside and out OPTO.CA Diabetes mortality Three million Canadians will be living with diabetes by the end of this decade. Diabetes contributes to the death of 41,500 Canadians each year. Type 2 diabetes shortens life expectancy by 5-10 years.

3. An optometrist knows your eyes inside and out OPTO.CA Diabetes morbidity Diabetes doubles the risk of stroke. Diabetes quadruples the risk of heart disease. Diabetes is the leading cause of non-traumatic lower extremity amputations. Diabetes causes 33% of the new cases of end stage renal disease. Diabetes is the leading cause of blindness in adults aged 25-75.

4. An optometrist knows your eyes inside and out OPTO.CA Components of visual function light energy dioptric system photoreceptors neurological processing visual perception cognitive functions PHYSICALPHYSIOLOGICAL PSYCHOLOGICAL

5. An optometrist knows your eyes inside and out OPTO.CA Ocular effects of diabetes 6 1 3 3 5 8 8 7 7 42 1.Cornea + tears 2.Aqueous 3.Iris 4.Lens 5.Vitreous 6.Retina 7.Internal muscles 8.External muscles

6. An optometrist knows your eyes inside and out OPTO.CA Ocular effects of diabetes Cornea – hypoesthesia, delayed healing, thickness changes Aqueous – glucose concentration, refractive index changes Iris – neovascularization, secondary glaucoma Lens – refractive changes, cataract development Vitreous – lipid deposits, hemorrhage Retina – edema, ischemia, hemorrhage, neovascularization Intraocular muscles – paresis, accommodative dysfunction Extraocular muscles – paresis, sudden onset diplopia

7. An optometrist knows your eyes inside and out OPTO.CA Fluctuating vision Diabetes can cause large shifts in nearsightedness and farsightedness as blood sugar levels fluctuate

8. An optometrist knows your eyes inside and out OPTO.CA Diabetic lens changes Transient hyperopic refractive changes in newly diagnosed juvenile diabetes. Giusti C. Swiss Med Wkly 2003;133:200–205 Transient refractive changes are highly dependent on the magnitude of plasma glucose concentrations Correction of hyperglycemia is strictly correlated with complete recovery of ocular refraction Sorbitol production via the polyol pathway with overhydration of the lens remains the best pathophysiological hypothesis

9. An optometrist knows your eyes inside and out OPTO.CA Cortical cataract

10. An optometrist knows your eyes inside and out OPTO.CA Mature cataract

11. An optometrist knows your eyes inside and out OPTO.CA Cataract surgery – foldable implants

12. An optometrist knows your eyes inside and out OPTO.CA YAG capsulotomy

13. An optometrist knows your eyes inside and out OPTO.CA Diabetic iris changes Ischemia is thought to initiate retinal & iris neovascularization Vascular endothelial growth factor (VEGF) likely plays a central role in neovascularization New vessel growth at the pupillary border, iris surface and iris angle leads to formation of fibrovascular membranes Membranes in the anterior chamber angle block aqueous outflow causing glaucoma

14. An optometrist knows your eyes inside and out OPTO.CA Glaucoma

15. An optometrist knows your eyes inside and out OPTO.CA Canadian Diabetes Association 2008 Clinical Practice Guidelines Retinopathy key messages: Screening is important for the detection of treatable disease. Screening intervals for diabetic retinopathy vary according to the individuals age and type of diabetes. Tight glycemic control reduces the onset and progression of sight- threatening diabetic retinopathy. Laser therapy reduces the risk of significant visual loss.

16. An optometrist knows your eyes inside and out OPTO.CA Normal fundus

17. An optometrist knows your eyes inside and out OPTO.CA Retinopathy Individuals with type 1 diabetes 100% will have some diabetic retinopathy after 15-20 years of diagnosis

18. An optometrist knows your eyes inside and out OPTO.CA Retinopathy Individuals with type 2 diabetes 20% will have some diabetic retinopathy at the time of diagnosis 50% will have some diabetic retinopathy after 7 years of diagnosis 85% will have some diabetic retinopathy after 15 years of diagnosis

19. An optometrist knows your eyes inside and out OPTO.CA Dots, blots, microaneurysms

20. An optometrist knows your eyes inside and out OPTO.CA Retinopathy - macular edema Remains the leading cause of vision loss in people living with diabetes Can occur at any time in type 1 and 2

21. An optometrist knows your eyes inside and out OPTO.CA Macular edema

22. An optometrist knows your eyes inside and out OPTO.CA Moderate background diabetic retinopathy

23. An optometrist knows your eyes inside and out OPTO.CA Hypertensive and diabetic retinopathy

24. An optometrist knows your eyes inside and out OPTO.CA Retinopathy NVD

25. An optometrist knows your eyes inside and out OPTO.CA Retinopathy NVE

26. An optometrist knows your eyes inside and out OPTO.CA Canadian Diabetes Association 2008 Clinical Practice Guidelines Recommendations: 1.In individuals 15 y/o or older with type 1 diabetes, screening and evaluation for retinopathy by an expert professional should be performed annually starting 5 years after the onset of diabetes 2. In individuals with type 2 diabetes, screening and evaluation by an expert professional should be performed at the time of diagnosis of diabetes. The interval for follow-up assessments should be tailored to the severity of the retinopathy. In those with no or minimal retinopathy, the recommended interval is 1-2 years.

27. An optometrist knows your eyes inside and out OPTO.CA Canadian Diabetes Association 2008 Clinical Practice Guidelines 3.Screening for diabetic retinopathy should be performed by experienced professionals, either in person or through interpretation of retinal photographs taken through dilated pupils. 4.To prevent the onset and to delay the progression of diabetic retinopathy, people with diabetes should be treated to achieve optimal control of blood glucose. People with abnormal lipids should be considered at high risk for retinopathy.

28. An optometrist knows your eyes inside and out OPTO.CA Canadian Diabetes Association 2008 Clinical Practice Guidelines 5.Patients with sight threatening diabetic retinopathy should be assessed by a general ophthalmologist or retina specialist. Laser therapy and/or vitrectomy and/or pharmacologic intervention should be considered. 6.Visually disabled people should be referred for low vision evaluation and rehabilitation.

29. An optometrist knows your eyes inside and out OPTO.CA Diet

30. An optometrist knows your eyes inside and out OPTO.CA Laser vision correction

31. An optometrist knows your eyes inside and out OPTO.CA Floaters

32. An optometrist knows your eyes inside and out OPTO.CA Basal cell carcinoma

33. An optometrist knows your eyes inside and out OPTO.CA Subconjunctival hemorrhage

34. An optometrist knows your eyes inside and out OPTO.CA Pteyrgium

35. An optometrist knows your eyes inside and out OPTO.CA Retention cyst

36. An optometrist knows your eyes inside and out OPTO.CA Allergic conjunctivitis

37. An optometrist knows your eyes inside and out OPTO.CA Bacterial conjunctivitis

38. An optometrist knows your eyes inside and out OPTO.CA Viral conjunctivitis – pink eye

39. An optometrist knows your eyes inside and out OPTO.CA ARMD

40. An optometrist knows your eyes inside and out OPTO.CA Early dry ARMD

41. An optometrist knows your eyes inside and out OPTO.CA Dry – geographic ARMD

42. An optometrist knows your eyes inside and out OPTO.CA Wet AMD with fibrosis