Evan (Jake) Waxman MD PhD

Evan (Jake) Waxman MD PhD
Diabetic Eye Disease Evan (Jake) Waxman MD PhD

Diabetic Eye Disease Key Points
Diabetes is a major cause of visual loss If your attention span is already flagging from information overload I really only need your attention for the next 4 slides which go over the key points. Key point number one when considering diabetes and the eye is that diabetes is a major cause of visual loss worldwide, in the US, in PA and specifically in my practice as the general ophthalmologist here at UPMC. It’s the leading cause of blindness in the US for working age adults.

Risk factor control can prevent and slow visual loss Key point number two is You can make a difference. By cooperating with your patients to control their blood glucose, high blood pressure and lipids using medication diet and exercise you can reduce their risk of visual loss and blindness

Key point number three I can make a difference but only if you help me. There are treatments for diabetic retinal disease. They work reasonably well. But they work best if I can get to do them before the patient has visual symptoms and they don’t work at all if you don’t send the patient my way. Treatments exist but work best before vision is lost

Diabetes is a major cause of visual loss Risk factor control can prevent and slow visual loss Treatments exist but work best before vision is lost So … to prevent visual loss Control patient risk factors Insist your patients get yearly dilated eye exams with an ophthalmologist So the bottom line, even before we get to the particulars are If you work with your patients to control their risk factors AND You Insist that your diabetic patients get a yearly dilated exam with an ophthalmologist Then you will reduce their risk of visual disability. We could actually end there but lets look at case.

Diabetic Eye Disease Case Presentation - History
27 year old woman DM I for 16 years poor blood sugar ctrl HgbA1C = 10 c/o spot in L vision for one day Sees “Eye Doctor” every year -- no previous eye disease diagnosed 24 year old Megan Knight Megan’s a type I diabetic diagnosed 16 years ago. Her blood sugar control has been poor and her A1C when I had it checked was 10. She came in urgently because she noticed a spot in the vision of her left eye. She does see an eye doctor each year but he “doesn’t do emergencies”. I want to come back to that a little later. Remind me if I forget.

Diabetic Eye Disease Case Presentation - Exam
Visual Acuity 20/50 OU Normal Pupils Normal Anterior Segment On exam she was a worried but healthy appearing young woman. Her visual acuity was reduced to 20/50 in each eye (That’s below the driving standard by the way) Her pupil exam was normal, as were her extraocular movements. Her visual fields showed a consistent restriction inferiorly in the left eye. The front of her eyes looked normal. We dilated her pupils and performed ophthalmoscopy and…

Diabetic Eye Disease Case Presentation - Exam
We see this. She’s essentially a self-contained atlas of diabetic retinopathy. Here are the dot hemorrhages Here are the blot hemorrhages Here are the cotton wool spots Here’s some intraretinal microvascualar abnormalities or IRMA This area here is swollen. And the pattern of swelling here is consistent with an acute occlusion of this arteriole and infraction of the this section of the retina. That is she’s had a branch retinal arterial occlusion. Which by the way goes along with her symptoms as well the field defect we picked up on exam. All in all not good.

Diabetic Eye Disease Case Presentation Fluoroscein Angiography
I performed a fluoroscein angiogram. Essentially you inject fluorescent dye intravenously and take a rapid series of photos as the dye passes through the retinal circulation. In a normal patient you can see the dye circulate through the arterial system then fill the capillary bed and finally return through the venous system. In a normal patient the dye stays within the vascular tree and doesn’t leak In a normal patient the background fluorescence of the capillary bed is uniform like ground glass. In this unfortunate young woman we see large areas where the dye is leaking out of the circulatory system and into the retina. When you look at the whole series you see that this artery is filling only as a result of retrograde flow after the venous phase And most importantly there are large areas of retina where the capillary bed isn’t filling at all. Some of them within the part of her retina responsible for sharp central vision. Overall not a good situation for her vision. Furthermore this kind of microcirculatory end organ damage is probably going on in her kidneys, heart and brain as well So what’s an eye doc to do. Who can tell me what my first priority for this patient is? Absolutely. Find her a good internist and endocrinologist. Anything else I’m going to do for her pales in comparison to the good that can be done by getting her sugar under control and getting the rest of her systems checked out. After I got off the phone with Dr Rao we started to address what we else we could do for the eyes

Diabetic Eye Disease Case Presentation - Course
Pan retinal photocoagulation OU Focal photocoagulation OS Vision dropped to 20/200 OD 1 month later Vit heme OS 2 months later Additional PRP Glaucoma surgery x 2 Current Acuity 20/400 OD 20/200 OS Prognosis Poor Due to the severe ischemia I designated her to be at high risk for growth of abnormal blood vessels (proliferative diabetic retinopathy) and vitreous bleeding with visual loss. So I performed panretinal laser in both eyes to try to reduce the amount of retina screaming for oxygen. In addition I shot a small amount of laser at the swollen areas of retina on the left to attempt to reduce the swelling. About a month later she noticed that she had dropped her vision on the right. We looked. She had had another arterial occlusion. 2 months later she developed addnl vitreous heme in the left eye and required addnl PRP. Her current vision 20/400 and 20/200. She’s needed an operation for neovascular glaucoma. Megan’s now legally blind, unable to drive and barely able to read the largest print at age 24 Not good.

Diabetic Eye Disease Background
Treatments work best before vision is lost Many patients are diagnosed only after vision is lost Vision loss is a late symptom of diabetic eye disease Risk factor control is essential So what are the lessons to learn from this case. Well I didn’t do a great job of restoring or even maintaining vision for this woman. I can try to comfort myself with the thought that it’d be worse if we hadn’t done anything but the fact is that our treatments work best before there’s vision loss and many patients don’t see an eye doctor and get diagnosed until late in the disease when its sometimes too late. Its also true that either the patient of their PCP or both didn’t take the high blood sugar seriously enough because this woman appeared healthy and neither the patient or the doc were aware of the end organ damage.

Catching disease prior to vision loss requires yearly screening with a dilated eye exam by an MD But you’d say. Dr Waxman – this patient was seen by an eye doctor each year. What happened. Did all that disease occur in the last couple of months. No way. That much retinopathy is years in the making and something should have been clinically apparent years ago. So what happened. Well the PCP dutifully asked the patient if she’d had her eye exam. The patient dutifully told the truth – that she had. What the PCP didn’t know and the patient didn’t understand the importance of was that the patient was seeing an optometrist for her myopia who was prescribing glasses but either wasn’t looking for or didn’t see the retinal disease. The moral of this story is that patients don’t understand the difference between and optom and an ophthalmologist. Unfortunately this makes it incumbent on you to tell them the differnce and to make sure that the eye doc who sees them is an MD AND knows that the patient is diabetic AND ideally gets back to you with the results of the exam.

Diabetes is a major cause of visual loss Risk factor control can prevent and slow visual loss Treatments exist but work best before vision is lost So … to prevent visual loss Control patient risk factors Insist your patients get yearly dilated eye exams with an ophthalmologist So back to our key points before we move forward. Diabetes is a major cause of visual loss and the number one cause is the working age group. Risk factor control can prevent and slow visual loss Treatments exist but work best before vision is lost So … to prevent visual loss Control patient risk factors Insist your patients get yearly dilated eye exams with an ophthalmologist Onward

Diabetic Eye Disease Background – Scary statistics
Leading cause of blindness in Americans aged Accounts for 12% of new blindness Diabetic patients 25 times more likely to go blind Okay we’re getting into the part of the talk that’s mostly of interest to senior residents who are starting to worry about the boards. Statistics and definitions. Diabetes mellitus is a major cause of blindness in the United States and is the leading cause of new blindness in working-aged Americans. Diabetic retinopathy alone accounts for at least 12% of new cases of blindness each year in the United States. People with diabetes are 25 times more at risk for blindness than the general population.

Diabetic Eye Disease Background – More scary statistics
65,000 with new proliferative retinopathy yearly 75,000 with new macular edema yearly 700,000 have PDR 500,000 have macular edema 25% - 50% with high risk disease not receiving care The estimated annual incidence of new cases of proliferative diabetic retinopathy and diabetic macular edema are 65,000 and 75,000, respectively. Approximately 700,000 Americans have proliferative diabetic retinopathy-the most sight-threatening form of retinopathy-and 500,000 have diabetic macular edema the kind that causes the most visual loss. Over a lifetime, 70% of people with insulin-dependent diabetes mellitus (IDDM) will develop proliferative diabetic retinopathy, and 40% will develop macular edema. Both complications, if untreated, frequently lead to serious visual loss and disability.

Diabetic Eye Disease Background Risk Factors
Duration Poor Blood Sugar control HTN Hyperlipidemia Barriers to care A rather large number of well done epidemiologic studies have supported what was pretty well known by practicing eye docs ie that diabetic eye disease happened more often with longer duration of diabetes and worse blood sugar control. Most studies and shown that poor blood pressure control is associated with worse retinopathy and some studies strongly suggest that some kinds of retinopathy are more common in patients with poorly maintained blood lipids. Its also pretty apparent to the practitioner that socioeconomic and other barriers to care are associated with all of the above as well as late arrival to the eye doc and are also associated with poor outcomes.

Prevention of eye disease is possible with increased risk factor control The Effect of Intensive Diabetes Treatment On the Progression of Diabetic Retinopathy In Insulin-Dependent Diabetes Mellitus The Diabetes Control and Complications Trial The Diabetes Control and Complications Trial Research Group CLINICAL SCIENCES Knwoing that worse sugar control is associated with worse retinopathy is not quite the same as knowing that good sugar control can alter the natural history of retinal disease. And so the Diabetes Control and Complications Trial Research Group set out to answer this question prospectively. They looked at over 700 diabetic pts with no retinopathy and over 700 pts with mild to moderate retinopathy and treated some with conventional therapy bid shots and some with intensive control qid shots or a pump and found that intensive control reduced risk of developing retinoapthy by 75% and reduced the risk of progression by 54% and that neuropathy and nephropathy were reduced as well. Risk factor control is key. Arch Ophthalmol. 1995; 113:36-51

Diabetic Eye Disease Framework
2 pathways of Visual Loss in DR Capillary Leakage Capillary Closure There are two major pathways to losing your sight from diabetes. Both involve hyperglycemic damage to capillaries Capillary damage that results in capillary leakage takes you down the pathway of retinal edema Capillary damage that results in capillary closure takes you down the pathway of retinal ischemia Many patients head down both paths simultaneously.

Diabetic Eye Disease Pathophysiology – Capillary Leakage
High blood sugar levels affect retinal capillaries Pericyte Loss Endothelial Cell loss Blood-retina barrier breakdown In the capillary leakage pathway you can see histologically the loss of capillary pericytes at first. This causes increased capillary permeability. Later, Endothelial cells are lost and capillary outpouchings, micro aneurysms form. These are very leaky.

Diabetic Eye Disease Pathophysiology - Capillary Leakage
Non proliferative diabetic retinopathy Damaged capillaries leak Leakage into the macula results in vision loss At first the retina can pump the excess fluid out. Eventually the pump mechanisms are overcome and the retina swells When the swelling occurs in the central visual areas the fovea and the macula the patient notices decreased vision.

Diabetic Eye Disease Symptoms/Signs - Preclinical
None on exam Special techniques demonstrate Leakage VEGF secretion Lets go through the signs and symptoms of the stages of retinopathy along the capillary leakage and retinal edema pathway. Initially the retina appears normal. The patient sees well. Healthy looking nerve vessels and retina. All the blood is where its supposed to be. In the blood vesssels. Within several years of the beginning of hyperglycemia though special techniques demonstrate that invisible damage is occuring. Fluoroscein can be detected within the vitreous cavity in diabetic patients injected with this dye using fluorophotometry before retinopathy can be seen. Vascular endothelial growth factor can be detected within the vitreous long before proliferative retinopathy can be seen. So damage starts before we can see it.

Diabetic Eye Disease Symptoms/Signs – NPDR
Usually no symptoms Dot heme Microaneurysms Leakage Blot heme Flame heme Next stage is early nonproliferative retinopathy Its rare that the patient has symptoms at this stage. Here you see the dot heme, micro aneurysms, blot heme, maybe some flame heme A little hard exudate which is leftover from resorbed edema is present in this retina as well. These are the first clinical signs of retinopathy. At this point I’m telling our patient that if they control their risk factors they can turn this around and that I’ll see them in 6 months to a year.

Diabetic Eye Disease Symptoms/Signs – NPDR / Macular Edema
Dot heme Microaneurysms Leakage Blot heme Hard exudates Eventually the pumping mechanisms in the retina are overcome and retina becomes edematous. Here you see dot and blot heme and this ring of hard exudate surrounding a large area of retinal swelling. This patients soon to be in trouble but as long as the edema hasn’t spread to the fovea then they might not yet notice a vision change. Ideally this is the time to intervene with laser treatment. I’ll get to that. Of course, increased attention to risk control would be useful here as well.

Diabetic Eye Disease Symptoms/Signs – NPDR / Macular Edema
Hard exudates Retinal edema Vision loss when edema occurs in central visual area At some point the edema gets into the fovea and the patient notices decreased vision. This star pattern of edema tells me that the fovea itself is swollen. Vision from edema can be reduced all the way to 20/200 or legally blind and this is the major cause of visual loss in diabetics. I’ll do focal laser treatment at this stage but the result are usually to stabilize the vision. It doesn’t usually result in improvement even when I can get the swelling to go away.

Diabetic Eye Disease NPDR / Macular Edema
Prevalence 5% for pts with DM for ≤ 5 years 15% for pts with DM for ≥ 15 years Again here you see hard exudate and retinal swelling Here are some cotton wool spots. We’re coming to that. 15% of patients have visually significant macular edema by 15 years Interestingly, 5% of newly diagnosed type II’s will have macular edema on their intial eye exam.

Diabetic Eye Disease NPDR – Macular Edema
Prevalence Higher for insulin dependence Higher with increased HgbA1C Risk factor control Macular edema is more prevalent in insulin dependent type I than type II’s and is more Prevalent in patients with higher A1C’s Another ring around the fovea, Exudate, precipitated lipids and proteins surrounding a large area of edema

Diabetic Eye Disease Treatment – NPDR – Macular Edema
Fluoroscein Angiography Treatment of diabetic retinal edema begins by mapping out the areas of leakage using fluoroscein angiography. In the color photo you can see heme and hard exudate and swelling in the fovea. In the fluoroscein photo you can see the leakage from the capillaries and the specific areas where the dye is leaking from.

Focal Laser The procedure for focal laser is as follows. The patient sits at a slit lamp microscope. They receive topical anesthesia A contact lens is placed on the eye Laser is delivered to each of the areas of leakage to change their color. The theory is that this results in a sealing of a leaking capillary and gives the retina a fighting chance to pump out the fluid. It doesn’t hurt. It takes about 10 minutes When we’re done the patient goes home without change in their vision. We check back in 4 to 6 weeks to see if there is less edema.

Focal Laser Here’s an example of a success Before laser Exudate and swelling, just outside the fovea. After laser, a retinal scar but the exudate and swelling are gone and the fovea is spared.

Focal Laser reduces risk of visual loss by 50% Early Photocoagulation for Diabetic Retinopathy ETDRS Report Number 9 EARLY TREATMENT DIABETIC RETINOPATHY STUDY RESEARCH GROUP A large prospective study, the ETDRS, Early treatment of diabetic retinopathy demonstrated that focal laser reduces the risk of visual loss by half for patients that meet particular critera. Ophthalmology 1991; 98;

Diabetic Eye Disease Framework
2 pathways of Visual Loss in DR Capillary Leakage Capillary Closure Again, there are two major pathways to losing your sight from diabetes. Both involved hyperglycemic damage to capillaries Capillary damage that results in capillary leakage takes you down the pathway of retinal edema Capillary damage that results in capillary closure takes you down the pathway of retinal ischemia Many patients head down both paths simultaneously.

Diabetic Eye Disease Pathophysiology – Capillary Closure
High blood sugar levels affect retinal capillaries Basement membrane thickening Increased platelet and erythrocyte adhesion Closure of capillaries On the capillary closure arm of visual loss, hyperglycemia results in a variety of changes which might be etiologic in closing capillary lumens. Here you large areas of capillary bed drop-out again

Diabetic Eye Disease Pathophysiology – Capillary Closure
Proliferative diabetic retinopathy Damaged capillaries close off Ischemic retina secretes VEGF New vessels form in response to VEGF The capillary closure results in retinal ischemia and infarction. Ischemic retina screams for oxygen by secreting vascular endothelial growth factor and other things. New vessels form in response to the ischemic signal.

Diabetic Eye Disease Pathophysiology
Proliferative diabetic retinopathy Neovascularization Fibrous Proliferation Traction with vitreous hemorrhage Traction retinal detachment Neovascular glaucoma New blood vessel growth seems like a reasonable response to ischemia. Unfortunately the new vessels that grow are fragile and are easily broken. In addition they grow off the retina into the vitreous. They get pulled on they break, they bleed – the patient loses vision from blood in the eye They get pulled on they contract and become fibrous , they detach the retina – the patient loses vision from a retinal detachment. They grow into the plumbing of the eyes aqueous drainage system and clog it up and can cause glaucoma. I’m sure you all recognized this as standard photo 10A from the Diabetic Retinopathy Study

Diabetic Eye Disease Symptoms/Signs – Preproliferative DR
Symptoms - None Cotton Wool Spots Nerve fiber layer ischemia & infarction Just like the leakage and edema pathway, the ischemic pathway starts with a normal looking eye and then with dot and blot heme. One of the first specific signs for ischemia is the cotton wool spot. Full professors with bowties may remember being taught to call these soft exudates. But they aren’t exudates. They represent areas of infarcted and ischemic retinal nerve fibers. Unless they are smack in the fovea they don’t cause symptoms.

Symptoms - None Cotton Wool Spots Nerve fiber layer ischemia & infarction Venous beading Intraretinal microvascular abnormalities (IRMA) Ischemia can result in changes to the venules and arterioles as well. Venules become beaded and tortuous. In this preproliferative stage Arterioles form into abnormal looped and leaky structures called IRMA or Intraretinal microvascular abnormalities These are bad signs of things to come. This patient doesn’t get treatment but they do get another examine in a couple of months and their PCP gets a phone call. Again no vision symptoms

Symptoms - None Cotton Wool Spots Nerve fiber layer ischemia & infarction Venous beading IRMA More heme Another dire sign of ischemia 4 quadrants of retinal heme. This can sometimes be difficult to distinguish from a central retinal vein occlusion. Unless there’s associated macular edema even at this stage there’s no vision loss but this patient gets watched closely and their PCP gets a page from me.

Diabetic Eye Disease Symptoms/Signs – Proliferative Retinopathy
Symptoms - None Optic Nerve Neovascularization (NVD) As I mentioned, at some point the ischemic drive becomes strong enough that new blood vessel growth occurs. Here’s an example of neovascular growth on the optic nerve or NVD. The pt is asymptomatic. The risk for vitreous bleeding and/or retinal detachment is so high for this pt that we don’t let them leave until they’ve scheduled laser.

Diabetic Eye Disease Symptoms/Signs – Proliferative Retinopathy
Symptoms - None Optic Nerve Neovascularization (NVD) Peripheral Neovascularization (NVE) More neovascularization. Any neo vascularization of the retina not on or near the optic nerve is called oddly enough NVE or neovascularization elsewhere. Again the risk of vitreous hemorrhage or detachment are high enough to warrant laser treatment in this case Again no symptoms at this point

Diabetic Eye Disease Signs – Proliferative Retinopathy
Prevalence ≤ 5 years – 0% ≥ 15 yrs – 25% ≥ 20 yrs – 55% 55% of pts who are diabetic for 20 or more years have high risk proliferative disease.

Diabetic Eye Disease Treatment – PDR
Panretinal photocoagulation (PRP) Prevention of visual loss at the high risk proliferative disease stage requires pan retinal photocoagulation. A rather crude but effective technique in which the peripheral retina is burnt with a laser to reduce retinal oxygen demand. Essentially peripheral retina is sacrificed for the sake of maintaining good central acuity. The procedure for PRP laser is as follows. The patient sits at a slit lamp microscope. They receive topical anesthesia A contact lens is placed on the eye About 1000 laser burns are delivered to the peripheral retina It takes about half an hour. Sometimes its split into sessions. It can hurt. This is variable for different pts. When they really can’t tolerate we anesthetize the eye with a retrobulbar block The most common side effect is decreased night vision Its been shown

Panretinal photocoagulation (PRP) We check the pt at about one month. Success is indicated by regression of the neovascular vessels. Here’s the before with florid NVD neovascularization of the disc Here’s the after with regression the vessels. You can see some fibrous remnants as well as some of the laser scars on the nasal retina Before After

Panretinal photocoagulation (PRP) I couldn’t resist throwing in another before and after. It really makes you feel good when you get this kind of result Here you see extensive disc neo and the beginnings of vitreous hemorhage A month or so after laser and you see complete regression and the central visual area is completely spared. Before After

PRP reduces the risk of severe vision loss by more than 50% Photocoagulation Treatment of Proliferative Diabetic Retinopathy Clinical Application of Diabetic Retinopathy Study (DRS) Findings, DRS Report Number 8 THE DIABETIC RETINOPATHY STUDY RESEARCH GROUP Just to add to initials I’m throwing at you I thought I’d let you know that the DRS or dibaetic retinopathy study of 1991 showed that panretinal laser reduces the risk of severe visual loss in patients with high risk proilferative retinopathy by half. My residents need to know about all of these studies for their yearly inservice exams and boards. Ophthalmology 1991; 88;

Diabetic Eye Disease Signs/Symptoms – Vitreous Heme
Floaters/Streaks Loss of vision Blood in vitreous Loss of red reflex No View Here’s what happens when proliferative disease progresses. The fragile neovascularization gets pulled on, breaks and bleeds The patient will notice floaters, streaks, haze, and loss of vision depending on the amont and location of the bleeding. If you look at the eye in your office with a direct ophthalmoscope you may see the vitreous blood, more likely though you’ll just notice loss of the red reflex notice that you can’t see anything at all. There should not be a Marcus Gunn pupil if its just a vitreous hemorrhage. Don’t be too surprised if the ophthalmologist you are working with doesn’t insist you send the pt over immediately if the pt has a good story for vit heme. Initial treatment is observation. I always end up seeing them immediately though just for everyone’s piece of mind.

Diabetic Eye Disease Symptoms/Signs – Retinal Detachment
Visual Loss; often severe Retinal Elevation Fibrous Proliferation Loss of red reflex Marcus/Gunn Pupil If the blood vessels don’t break when there’s vessel contraction then the retina does. This is a traction retinal detachment from diabetes. This pt has severe visual loss Pupil exam would be positive for a Marcus Gunn pupil You might pick up the retinal elevation with a direct or you might just pick up the loss of red reflex and lack of view.

Diabetic Eye Disease Treatment – Vitreous Heme
Panretinal photocoagulation (PRP) Vitrectomy Removes blood Removes Traction Allows addnl PRP Treatment for vitreous hemorrhage is PRP to make the new blood vessels regress. If the blood doesn’t clear enough to allow PRP or if the patient has had very thorough PRP and repeated vit hemorrhage then its time for a vitrectomy. This is an outpt, in the OR procedure done under local or general anesthesia The surgeon makes several small incisions into the sclera and removes the hemorrhage using a technique that still reminds me of laporoscopic abdominal surgery. Vitrectomy helps by removing the blood, Removing the vitreous so that there’s no more traction and allowing PRP out to the edges of the retina that you can’t easily get at with the laser in the office. Its also the only option for patients with tractional retinal detachments. In this case the retinal surgeon dissects off and lyses the traction bands and attempts to lay the retina flat again.

Diabetic Eye Disease Treatment – Vitreous Heme
Vitrectomy Here’s a before and after of vitrectomy for non clearing vitreous hemorrhage You can still see some traction bands on the nasal retina here after the surgery and I don’t see as much laser as I would like. Still the patient definitely seeing better with the blood out of the way.

Vitrectomy results in improved vision in patients with persistent vitreous hemorrhage Early Vitrectomy fo Severe Vitreous Hemorrhage in Diabetic Retinopathy Two-Year Results of a Randomized Trial Diabetic Retinopathy Virectomy Report 2 THE DIABETIC RETINOPATHY VITRECTOMY STUDY RESEARCH GROUP DRVS or Diabetic retinopathy vitrectomy study demonstrated that the risks and benefits of vitrectomy fo vitreous hemorrhage weigh out in favor of vitrectomy if the hemorrhage hasn’t cleared on its own in a few months. Arch Ophthalmol. 1985;

Diabetic Eye Disease Symptoms/ Signs – Neovascular Glaucoma
Loss of Vision Pain “Red Eye” Iris Neovascularization High Intraocular Pressure Marcus Gunn pupil Finally, One of the worst manifestions of ischemic diabetic eye disease is proliferation of new vessels on the iris or NVI. The neo tends to grow into the eyes aqueous drainage system clog it up and cause the pressure to go up. The high pressure results in pain, redness, decreased vision and eventually a Marcus Gunn pupil. I have a pt with this who was treated for 3 weeks for conjunctivitis before he made it to me. The eye was at that point lost. But we managed to save the other eye. Treatment is medical therapy to lower the pressure and laser to get the neo to regress.

Diabetic Eye Disease Other Manifestation of Diabetes in the Eye
Branch Retinal Artery Occlusion Central Retinal Artery Occlusion Branch Retinal Vein Occlusion Central Retinal Vein Occlusion Other manifestations of Diabetes in the retina include occlusion of larger vessels Branch and Central Arterial Occlusions Branch and Central Venous Occlusions

Diabetic Eye Disease Other Manifestation of Diabetes in the Eye
Increased risk of cataract Increased risk of glaucoma Diabetic papillitis Acute CN III, IV or VI paresis Other manifestations of Diabetes in the eye outside the retina include Cataract or clouding of the lens of the eye Glaucoma, optic nerve damage from intraocular pressure Acute vision loss from optic nerve swelling Acute double vision or diplopia from paresis of extraocular muscles

Diabetic Eye Disease What’s new and cool
Intraocular steroid Injection Sustained release device Stabilizes blood-retina barrier Reduces Macular Edema I’d feel bad if I didn’t mention some of the upcoming advance for treating diabetic retinopathy. Intraocular steroids are a very active topic of research and development at present. Its been observed that steroid medications stabilize the blood/retinal barrier and reduces macular edema A number of companies are developing inserts that can be placed in the vitreous cavity through a small incision and deliver a sustained release dose of medication. In the meantime many ophthalmologists are using intravitreal injection of Kenalog and getting great results. I’ve had some experience with this lately and have managed to improve vision in patients that I thought had no chance Its really been quite dramatic.

Anti VEGF drugs Protein Kinase C beta inhibitors Intravitreal hyaluronidase VEGF definitely plays a role in the ischemic arm of retinopathy and may play a role in the leakage arm of retinopathy as well. At least one drug company is working on an anti VEGF medication that would be give by injection. Protein Kinase C beta is an enzyme that is activated by hyperglycemia and induces vascular permeability changes. It is likely to play a role in the leakage arm of diabetic retinopathy and Eli Lilly is working on an anti PKC beta medication for retinal disease. Vitrase or intravitreal hyaluronidase is an enzyme that breaks down vitreous gel. It could be give to a pt with a vitreous hemorrhage to allow it to clear more quickly. Studies are underway.

Ocular Coherence Tomography Noninvasive imaging of retina Can detect subtle retinal thickening Ocular Coherence Tomography is a new imaging technique that is non invasive and get demonstrate retinal thickening. It has potential to allow us to detect and monitor diabetic macular edema without injection of fluorescein dye. A lot of the research on this device has been done by Dr Joel Schuman who is the chair for our dept.

Diabetes is a major cause of visual loss Okay time to wake the post call interns and med students back up. Diabetes is a major cause of visual loss.

Risk factor control can prevent and slow visual loss Risk factor control can prevent and slow visual loss.

Treatments exist but work best before vision is lost Treatments exist but work best before vision is lost

Diabetes is a major cause of visual loss Risk factor control can prevent and slow visual loss Treatments exist but work best before vision is lost So … to prevent visual loss Control patient risk factors Insist your patients get yearly dilated eye exams with an ophthalmologist So to prevent visual loss Control patient risk factors and insist and verify that your patient gets a yearly dilated eye exam with an EyeMD. Thanks.

Evan (Jake) Waxman MD PhD

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