1. Basic Considerations for Prevention of Blindness in Diabetes Care and Education Prof. Morsi Arab Emeritus Professor of Medicine University of Alexandria

4. Age Group 10 20 30 40 50 60

6. Causes of visual loss and blindness in Diabetes - Diabetic Retinopathy ( DR) is most common - Glucoma less common - Cataract less common - Vitreous hemorrhage

7. The Burden of diabetes on visual ability The WHO identifies DR as the leading cause of preventable blindness and visual disability in adults in economically developed societies

8. Significant Observations in DR 1- DR takes a long time to become manifest. During this time it is asymptomatic 2- DR. may not be arrested after establishment of normoglycaemia ( bec. glycated subs. can continue to bind to proteins after …) 3- However, glycaemic control at early stages is effective in controlling progression of DR ( DCCT)

9. Prevalence of Diabetic Retinopathy ( DR) ( The Wisconsin Study ) all DR Prolif.DR in type 1 (onset of DM >30 ys) 71% 23 % in type 2 (onset after 30ys ) - on insulin 70% 14 % - no insulin 39% 2 %

11. Prevalence of DR in relation to Glycaemia The DCCT ( type 1) intensified Rx reduced progression of DR by 76% in primary preven. cohort 54% in secondary preven. cohort 47% progression to severe NPDR 56% necessity for Laser Rx DCCT results show importance of both Duration and Glucose exposure ( hyperglyceamia) for the development of DR

12. Preval. of DR in relation to Glycaemia UKPDS ( type 2) intensified Rx with improved metabolic control - risk of worsening DR by 21 % - need for Laser Rx by 29% - Cataract extraction by 24%

13. Prevalence of DR / Duration of Diabetes The prev. of DR is highly correlated with the duration of DM at 5ys at 25 ys in type 1 : (10 %) ( steep rise) 100 % in type 2 : (25 %) almost 85% Prevalence of DR / Duration of Diabetes The prev. of DR is highly correlated with the duration of DM at 5ys at 25 ys in type 1 : (10 %) ( steep rise) 100 % in type 2 : (25 %) almost 85%

14. Retinopathy in correlation with Duration of DM

15. Hypertension and DR most studies show a causal association UKPDS : Tight control of B.P. 34 % of progress DR 47 % of moderate loss of Vis. Acuity ( N.B. independent on the degree of glycaemic control ) No specific type of anti hypertensive medication is superior than other

16. The Genetic factor in DR There is evidence that severity of DR is influenced by familial, and possibly a genetic factor

17. Dyslipidaemia and DR an association is found between more severe DR and - Total cholesterol - but not with TG (lipid modulation by statins…? not conclusive )

18. Smoking and DR Although smoking is a risk factor in albuminuria and nephropathy, its effect on DR is not clear

19. Aspirin in DR - Anti inflam. agents did not show effect in Rx vasc. complications - aspirin failed to prevent dev. of DR - aspirin can be used if indicated ( card) without adverse effect on DR

20. The Risk Factors for DR Most definitive: 1- Duration of DM 2- High glycaemic level Less definite: 1- Hypertension 2- Pregnancy 3- Genetic factor 4- Hyperlipidaemia 5- Close assoc. with albuminuria 6- ? Smoking The Risk Factors for DR Most definitive: 1- Duration of DM 2- High glycaemic level Less definite: 1- Hypertension 2- Pregnancy 3- Genetic factor 4- Hyperlipidaemia 5- Close assoc. with albuminuria 6- ? Smoking

21. Screening for and follow up of DR in type 1 : screen within 3-5 yrs after diag. ( onset) ( not necessary before age 10 ) in type 2 : screen shortly after diagnosis Follow up : - repeat annually if no DR - more frequently if DR is progressing N.B. : In Pregnancy : -- Screen at planning preg. or during first trimest. – Follow up through preg.

22. Education for Prevention of DR ( basic considerations ) 1- knowledge of the Risk factors 2- control of glycaemic level 3- control hypertension 4- screen + follows up, and early intervention 5- close observation in pregnancy 6- control serum lipids 7- discourage smoking 8- no restriction on aspirin ( if required for cardiac )

23. Alexandrie – Palais du Montazah Thank You