1 / 59

Diabetic Eye Disease

Diabetic Eye Disease. Evan (Jake) Waxman MD PhD. Diabetic Eye Disease Key Points. Diabetes is a major cause of visual loss. Diabetic Eye Disease Key Points. Risk factor control can prevent and slow visual loss. Diabetic Eye Disease Key Points.

mircea
Download Presentation

Diabetic Eye Disease

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. 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

  7. Diabetic Eye DiseaseCase Presentation - Exam • Visual Acuity 20/50 OU • Normal Pupils • Normal Anterior Segment

  8. Diabetic Eye DiseaseCase Presentation - Exam

  9. Diabetic Eye DiseaseCase PresentationFluoroscein Angiography

  10. 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

  11. 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

  12. Diabetic Eye DiseaseBackground • Catching disease prior to vision loss requires yearly screening with a dilated eye exam by an MD

  13. 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

  15. 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

  16. Diabetic Eye DiseaseBackgroundRisk Factors • Duration • Poor Blood Sugar control • HTN • Hyperlipidemia • Barriers to care

  17. 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; 113:36-51

  18. Diabetic Eye DiseaseFramework • 2 pathways of Visual Loss in DR • Capillary Leakage • Capillary Closure

  19. Diabetic Eye DiseasePathophysiology – Capillary Leakage High blood sugar levels affect retinal capillaries • Pericyte Loss • Endothelial Cell loss • Blood-retina barrier breakdown

  20. Diabetic Eye DiseasePathophysiology - Capillary Leakage • Non proliferative diabetic retinopathy • Damaged capillaries leak • Leakage into the macula results in vision loss

  21. Diabetic Eye DiseaseSymptoms/Signs - Preclinical • None on exam • Special techniques demonstrate • Leakage • VEGF secretion

  22. Diabetic Eye DiseaseSymptoms/Signs – NPDR • Usually no symptoms • Dot heme • Microaneurysms • Leakage • Blot heme • Leakage • Flame heme

  23. Diabetic Eye DiseaseSymptoms/Signs – NPDR / Macular Edema • +/- Symptoms • Dot heme • Microaneurysms • Leakage • Blot heme • Leakage • Hard exudates

  24. Diabetic Eye DiseaseSymptoms/Signs – NPDR / Macular Edema • Hard exudates • Retinal edema • Vision loss when edema occurs in central visual area

  25. Diabetic Eye DiseaseNPDR / Macular Edema • Prevalence • 5% for pts with DM for ≤ 5 years • 15% for pts with DM for≥ 15 years

  26. Diabetic Eye DiseaseNPDR – Macular Edema • Prevalence • Higher for insulin dependence • Higher with increased HgbA1C

  27. Diabetic Eye DiseaseTreatment – NPDR – Macular Edema • Fluoroscein Angiography

  28. Diabetic Eye DiseaseTreatment – NPDR – Macular Edema • Focal Laser

  29. Diabetic Eye DiseaseTreatment – NPDR – Macular Edema • Focal Laser

  30. 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

  31. Diabetic Eye DiseaseFramework • 2 pathways of Visual Loss in DR • Capillary Leakage • Capillary Closure

  32. Diabetic Eye DiseasePathophysiology – Capillary Closure High blood sugar levels affect retinal capillaries • Basement membrane thickening • Increased platelet and erythrocyte adhesion • Closure of capillaries

  33. Diabetic Eye DiseasePathophysiology – Capillary Closure • Proliferative diabetic retinopathy • Damaged capillaries close off • Ischemic retina secretes VEGF • New vessels form in response to VEGF

  34. Diabetic Eye DiseasePathophysiology • Proliferative diabetic retinopathy • Neovascularization • Fibrous Proliferation • Traction with vitreous hemorrhage • Traction retinal detachment • Neovascular glaucoma

  35. Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR • Symptoms - None • Cotton Wool Spots • Nerve fiber layer ischemia & infarction

  36. Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR • Symptoms - None • Cotton Wool Spots • Nerve fiber layer ischemia & infarction • Venous beading • Intraretinal microvascular abnormalities (IRMA)

  37. Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR • Symptoms - None • Cotton Wool Spots • Nerve fiber layer ischemia & infarction • Venous beading • IRMA • More heme

  38. Diabetic Eye DiseaseSymptoms/Signs – Proliferative Retinopathy • Symptoms - None • Optic Nerve Neovascularization (NVD)

  39. Diabetic Eye DiseaseSymptoms/Signs – Proliferative Retinopathy • Symptoms - None • Optic Nerve Neovascularization (NVD) • Peripheral Neovascularization (NVE)

  40. Diabetic Eye DiseaseSigns – Proliferative Retinopathy • Prevalence ≤ 5 years – 0% ≥ 15 yrs – 25% ≥ 20 yrs – 55%

  41. Diabetic Eye DiseaseTreatment – PDR • Panretinal photocoagulation (PRP)

  42. Diabetic Eye DiseaseTreatment – PDR • Panretinal photocoagulation (PRP) Before After

  43. Diabetic Eye DiseaseTreatment – PDR • Panretinal photocoagulation (PRP) Before After

  44. 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

  45. Diabetic Eye DiseaseSigns/Symptoms – Vitreous Heme • Symptoms • Floaters/Streaks • Loss of vision • Blood in vitreous • Loss of red reflex • No View

  46. Diabetic Eye DiseaseSymptoms/Signs – Retinal Detachment • Symptom • Visual Loss; often severe • Retinal Elevation • Fibrous Proliferation • Loss of red reflex • Marcus/Gunn Pupil

  47. Diabetic Eye DiseaseTreatment – Vitreous Heme • Panretinal photocoagulation (PRP) • Vitrectomy • Removes blood • Removes Traction • Allows addnl PRP

  48. Diabetic Eye DiseaseTreatment – Vitreous Heme Vitrectomy

  49. 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

  50. Diabetic Eye DiseaseSymptoms/ Signs – Neovascular Glaucoma • Symptoms • Loss of Vision • Pain • “Red Eye” • Iris Neovascularization • High Intraocular Pressure • Marcus Gunn pupil

More Related