Diabetic Eye Disease

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Diabetic Eye Disease

• Evan (Jake) Waxman MD PhD

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Diabetic Eye DiseaseKey Points

• Diabetes is a major cause of visual loss

3
Diabetic Eye DiseaseKey Points

• Risk factor control can prevent and slow visual
  loss

4
Diabetic Eye DiseaseKey Points

• Treatments exist but work best before vision is
  lost

5
Diabetic Eye DiseaseKey Points

• 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

6
Diabetic Eye DiseaseCase 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

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Diabetic Eye DiseaseCase Presentation - Exam

• Visual Acuity 20/50 OU
• Normal Pupils
• Normal Anterior Segment

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Diabetic Eye DiseaseCase Presentation - Exam
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Diabetic Eye DiseaseCase PresentationFluoroscein
Angiography
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Diabetic Eye DiseaseCase 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

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Diabetic Eye DiseaseBackground

• 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

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Diabetic Eye DiseaseBackground

• Catching disease prior to vision loss requires
  yearly screening with a dilated eye exam by an MD

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Diabetic Eye DiseaseKey Points

• 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

14
Diabetic Eye DiseaseBackground Scary statistics

• Leading cause of blindness in Americans aged 25-
  65
• Accounts for 12 of new blindness
• Diabetic patients 25 times more likely to go blind

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Diabetic Eye DiseaseBackground 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

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Diabetic Eye DiseaseBackgroundRisk Factors

• Duration
• Poor Blood Sugar control
• HTN
• Hyperlipidemia
• Barriers to care

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Diabetic Eye DiseaseBackground

• 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
Arch Ophthalmol. 1995 11336-51
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Diabetic Eye DiseaseFramework

• 2 pathways of Visual Loss in DR
• Capillary Leakage
• Capillary Closure

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Diabetic Eye DiseasePathophysiology Capillary
Leakage
High blood sugar levels affect retinal capillaries

• Pericyte Loss
• Endothelial Cell loss
• Blood-retina barrier breakdown

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Diabetic Eye DiseasePathophysiology - Capillary
Leakage

• Non proliferative diabetic retinopathy
• Damaged capillaries leak
• Leakage into the macula results in vision loss

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Diabetic Eye DiseaseSymptoms/Signs - Preclinical

• None on exam
• Special techniques demonstrate
• Leakage
• VEGF secretion

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Diabetic Eye DiseaseSymptoms/Signs NPDR

• Usually no symptoms
• Dot heme
• Microaneurysms
• Leakage
• Blot heme
• Leakage
• Flame heme

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Diabetic Eye DiseaseSymptoms/Signs NPDR /
Macular Edema

• /- Symptoms
• Dot heme
• Microaneurysms
• Leakage
• Blot heme
• Leakage
• Hard exudates

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Diabetic Eye DiseaseSymptoms/Signs NPDR /
Macular Edema

• Hard exudates
• Retinal edema
• Vision loss when edema occurs in central visual
  area

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Diabetic Eye DiseaseNPDR / Macular Edema

• Prevalence
• 5 for pts with DM for 5 years
• 15 for pts with DM for 15 years

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Diabetic Eye DiseaseNPDR Macular Edema

• Prevalence
• Higher for insulin dependence
• Higher with increased HgbA1C

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Diabetic Eye DiseaseTreatment NPDR Macular
Edema

• Fluoroscein Angiography

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Diabetic Eye DiseaseTreatment NPDR Macular
Edema

• Focal Laser

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Diabetic Eye DiseaseTreatment NPDR Macular
Edema

• Focal Laser

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Diabetic Eye DiseaseTreatment NPDR Macular
Edema

• 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
Ophthalmology 1991 98 766-785
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Diabetic Eye DiseaseFramework

• 2 pathways of Visual Loss in DR
• Capillary Leakage
• Capillary Closure

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Diabetic Eye DiseasePathophysiology Capillary
Closure
High blood sugar levels affect retinal capillaries

• Basement membrane thickening
• Increased platelet and erythrocyte adhesion
• Closure of capillaries

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Diabetic Eye DiseasePathophysiology Capillary
Closure

• Proliferative diabetic retinopathy
• Damaged capillaries close off
• Ischemic retina secretes VEGF
• New vessels form in response to VEGF

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Diabetic Eye DiseasePathophysiology

• Proliferative diabetic retinopathy
• Neovascularization
• Fibrous Proliferation
• Traction with vitreous hemorrhage
• Traction retinal detachment
• Neovascular glaucoma

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Diabetic Eye DiseaseSymptoms/Signs
Preproliferative DR

• Symptoms - None
• Cotton Wool Spots
• Nerve fiber layer ischemia infarction

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Diabetic Eye DiseaseSymptoms/Signs
Preproliferative DR

• Symptoms - None
• Cotton Wool Spots
• Nerve fiber layer ischemia infarction
• Venous beading
• Intraretinal microvascular abnormalities (IRMA)

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Diabetic Eye DiseaseSymptoms/Signs
Preproliferative DR

• Symptoms - None
• Cotton Wool Spots
• Nerve fiber layer ischemia infarction
• Venous beading
• IRMA
• More heme

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Diabetic Eye DiseaseSymptoms/Signs
Proliferative Retinopathy

• Symptoms - None
• Optic Nerve Neovascularization (NVD)

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Diabetic Eye DiseaseSymptoms/Signs
Proliferative Retinopathy

• Symptoms - None
• Optic Nerve Neovascularization (NVD)
• Peripheral Neovascularization (NVE)

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Diabetic Eye DiseaseSigns Proliferative
Retinopathy

• Prevalence
• 5 years 0
• 15 yrs 25
• 20 yrs 55

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Diabetic Eye DiseaseTreatment PDR

• Panretinal photocoagulation (PRP)

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Diabetic Eye DiseaseTreatment PDR

• Panretinal photocoagulation (PRP)

Before
After
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Diabetic Eye DiseaseTreatment PDR

• Panretinal photocoagulation (PRP)

Before
After
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Diabetic Eye DiseaseTreatment PDR

• 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
Ophthalmology 1991 88 583-600
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Diabetic Eye DiseaseSigns/Symptoms Vitreous
Heme

• Symptoms
• Floaters/Streaks
• Loss of vision
• Blood in vitreous
• Loss of red reflex
• No View

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Diabetic Eye DiseaseSymptoms/Signs Retinal
Detachment

• Symptom
• Visual Loss often severe
• Retinal Elevation
• Fibrous Proliferation
• Loss of red reflex
• Marcus/Gunn Pupil

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Diabetic Eye DiseaseTreatment Vitreous Heme

• Panretinal photocoagulation (PRP)
• Vitrectomy
• Removes blood
• Removes Traction
• Allows addnl PRP

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Diabetic Eye DiseaseTreatment Vitreous Heme

• Vitrectomy

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Diabetic Eye DiseaseTreatment PDR

• 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
Arch Ophthalmol. 1985 103 1644-1652
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Diabetic Eye DiseaseSymptoms/ Signs
Neovascular Glaucoma

• Symptoms
• Loss of Vision
• Pain
• Red Eye
• Iris Neovascularization
• High Intraocular Pressure
• Marcus Gunn pupil

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Diabetic Eye DiseaseOther Manifestation of
Diabetes in the Eye

• Branch Retinal Artery Occlusion
• Central Retinal Artery Occlusion
• Branch Retinal Vein Occlusion
• Central Retinal Vein Occlusion

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Diabetic Eye DiseaseOther Manifestation of
Diabetes in the Eye

• Increased risk of cataract
• Increased risk of glaucoma
• Diabetic papillitis
• Acute CN III, IV or VI paresis

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Diabetic Eye DiseaseWhats new and cool

• Intraocular steroid
• Injection
• Sustained release device
• Stabilizes blood-retina barrier
• Reduces Macular Edema

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Diabetic Eye DiseaseWhats new and cool

• Anti VEGF drugs
• Protein Kinase C beta inhibitors
• Intravitreal hyaluronidase

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Diabetic Eye DiseaseWhats new and cool

• Ocular Coherence Tomography
• Noninvasive imaging of retina
• Can detect subtle retinal thickening

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Diabetic Eye DiseaseKey Points

• Diabetes is a major cause of visual loss

57
Diabetic Eye DiseaseKey Points

• Risk factor control can prevent and slow visual
  loss

58
Diabetic Eye DiseaseKey Points

• Treatments exist but work best before vision is
  lost

59
Diabetic Eye DiseaseKey Points

• 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