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Diabetic eye disease

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Diabetic eye disease

  1. 1. Diabetic Eye Disease Eye Care about My ABCs A Healthy Eyes Healthy People Project Sponsored in part by the AOA and VSP
  2. 2. Diabetic Eye Disease in Indiana <ul><li>Over 112,000 people in Indiana alone have diabetic retinopathy. </li></ul><ul><ul><li>That’s ~20% of diabetics. </li></ul></ul><ul><li>In Indiana, ~60% of diabetics receive an annual eye exam. </li></ul><ul><li>Each year - ~12,000 – 24,000 new cases of blindness. </li></ul>
  3. 3. Diabetes in Indiana
  4. 4. Diabetic Retinopathy in Indiana
  5. 5. Where does it affect the eye? <ul><li>Lens: variations in blood sugar can cause variations in the power of the lens. Uncontrolled diabetics are prone to intermittent blurry vision. </li></ul><ul><li>Retina: Diabetic Retinopathy is when the eye’s blood vessels become leaky and can ultimately bleed profusely. </li></ul>
  6. 6. Ocular Symptoms <ul><li>Blurred Vision- As the power of the lens changes, patients experience unstable blurred vision that fluctuates over weeks to months. </li></ul><ul><li>Diplopia- Retinal (macular) edema can produce a myriad of optical nuances. </li></ul><ul><li>Vision Loss- If retina is damaged, vision can be lost permanently. </li></ul>
  7. 7. When does Diabetes start affecting the Eye? <ul><li>Two determining factors: </li></ul><ul><ul><li>Blood Glucose Control </li></ul></ul><ul><ul><li>Duration of Diabetic Status </li></ul></ul><ul><ul><ul><li>As childhood obesity increases, type 2 diabetes begins earlier. </li></ul></ul></ul>
  8. 8. When does Diabetic Retinopathy arise? <ul><li>Prevalence of Diabetic Retinopathy: </li></ul><ul><ul><li>At Diagnosis: </li></ul></ul><ul><ul><li>10 years after Diagnosis: </li></ul></ul><ul><ul><li>20 years after Diagnosis: </li></ul></ul><ul><ul><ul><ul><ul><li>Type I </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Type II </li></ul></ul></ul></ul></ul><ul><li>20% </li></ul><ul><li>40-50% </li></ul><ul><li>100% </li></ul><ul><li>60% </li></ul>
  9. 9. The Diabetic Eye Exam <ul><li>History </li></ul><ul><li>Visual Acuity </li></ul><ul><li>Eye Movement </li></ul><ul><li>Refraction </li></ul><ul><li>Intraocular Pressure measurement </li></ul><ul><li>Visual Field evaluation </li></ul><ul><li>Dilated Retinal examination </li></ul>
  10. 10. Dilated Retinal Examination Fundus Lens and Slit Lamp Evaluation Binocular Indirect Opthalmoscope
  11. 12. The importance of Dilation Undilated pupil Same Eye-- pupil dilated
  12. 13. Clinical Classification <ul><li>Mild Nonproliferative Diabetic Retinopathy </li></ul><ul><li>Moderate Nonproliferative Diabetic Retinopathy </li></ul><ul><li>Severe Nonproliferative Diabetic Retinopathy </li></ul><ul><li>Proliferative Diabetic Retinopathy </li></ul>
  13. 14. Mild and Moderate Nonproliferative Diabetic Retinopathy <ul><li>Dot and blot hemorrhaging </li></ul><ul><li>Aneurysms </li></ul><ul><li>Hard exudates </li></ul><ul><li>Clinically Significant Macular Edema ( CSME) </li></ul><ul><ul><li>decreased vision </li></ul></ul>
  14. 15. Mild Nonproliferative Diabetic Retinopathy Dot Hemorrhage
  15. 16. Moderate Nonproliferative Diabetic Retinopathy Dot Hemorrhages Blot Hemorrhages Hard Exudates
  16. 17. Severe Nonproliferative Diabetic Retinopathy <ul><li>Intra Retinal Microvascular Abnormalities (IRMA) </li></ul><ul><li>Cotton wool spots- focal retinal ischemia </li></ul><ul><li>Beading and looping of the capillaries </li></ul>
  17. 18. Severe Nonproliferative Diabetic Retinopathy- Early Blot Hemorrhages Cotton Wool Spot Flame Hemorrhages
  18. 19. Severe Nonproliferative Diabetic Retinopathy- “pre-proliferative” Blot Hemorrhages Exudates Venous Beading IRMAs Looping capillaries
  19. 20. Proliferative Diabetic Retinopathy: <ul><li>Neovascularization- New blood vessel growth </li></ul><ul><ul><li>NVI - Rubeosis Iridis </li></ul></ul><ul><ul><li>NVD- optic disk </li></ul></ul><ul><ul><li>NVE- elsewhere in the retina </li></ul></ul>
  20. 21. Proliferative Diabetic Retinopathy: NVI – neovascularization of the iris
  21. 22. NVE – neovascularization elsewhere
  22. 23. NVD – neovascularization of the disk
  23. 24. Serious Diabetic Retinopathy <ul><li>If “neo” goes unnoticed and untreated, it will ultimately bleed . </li></ul><ul><li>Bleeding means Blindness! </li></ul>
  24. 25. New Diagnostic Modalities <ul><li>Ocular Coherence Tomography –OCT is revolutionizing eye care in many instances it can be used in place of IVFA </li></ul><ul><li>OCT is less invasive </li></ul><ul><li>Allows for earlier and more sensitive diagnosis </li></ul><ul><li>Takes less time </li></ul><ul><li>Demonstrates greater anatomical details </li></ul>
  25. 26. IVFA
  26. 27. IVFA
  27. 28. IVFA
  28. 29. Normal OCT
  29. 30. Diabetic Retinopathy OCT
  30. 31. OCT-Printout
  31. 32. How is neovascularization treated? <ul><li>Focal laser treatment is used to ablate neo before bleeding occurs. </li></ul><ul><li>If bleeding has occurred, lasers can be used to attempt to stop the bleeding and minimize loss of vision. </li></ul><ul><li>Laser surgery does not usually improve vision, it tries to stop vision from worsening. </li></ul>
  32. 33. Laser treatment strategies
  33. 34. Pan retinal laser <ul><li>Laser treatment is used to destroy peripheral retina and decrease the chance of neo by decreasing the need for blood supply. </li></ul>
  34. 35. New Treament Options for PDR <ul><li>Oral Angiogenic agents are being developed to be used in conjunction with laser treatment </li></ul><ul><li>There are two categories of oral angiogenic treatment-one is for the prevention of PDR and the other for early PDR-PKC inhibition </li></ul><ul><li>Currently on the market-Arxxant (Eli-Lilly)-a protein kinase C beta(PKC beta) inhibitor </li></ul>
  35. 36. Other surgical treatment <ul><li>Vitrectomy- </li></ul><ul><ul><li>Non-clearing vitreal bleeds may need to be removed. </li></ul></ul>
  36. 37. Diabetic Macular Edema <ul><li>Can occur at any stage of diabetic retinopathy </li></ul><ul><li>Is caused by the leakage of microaneurysms </li></ul><ul><li>Is the main cause of visual impairment in patients with Diabetic retinopathy </li></ul>
  37. 38. Classification of Diabetic Macular Edema <ul><li>Presents as hard yellow exudates (HYE) or thickening in the posterior pole </li></ul><ul><li>Mild-some thickening or HYE in the posterior pole but distant from the center </li></ul><ul><li>Moderate-approaching the center, but not involving the center </li></ul><ul><li>Severe-Involving the center of the macula </li></ul>
  38. 39. Diabetic Macular Edema Hard Exudates and Macular Edema (CSME) Intraocular steroid injections attempt to reduce edema
  39. 40. Treatment Options for Macular Edema <ul><li>Laser Treatment </li></ul><ul><li>Steroid Implants and devices to the posterior segment </li></ul><ul><li>New Treatment options for Macular edema </li></ul><ul><li>Intravitreal injection of triamcinolone acetonide-for diffuse diabetic macular edema </li></ul><ul><li>Fluocinolone acetonide intravitreal implants </li></ul>
  40. 41. Vision Loss from Diabetic Retinopathy Normal or Mild Diabetic Retinopathy Severe Diabetic Retinopathy
  41. 42. Additional effects on the eyes <ul><li>In addition to the damaging effects of diabetes on the retina, diabetic eye disease also increases the risk for developing: </li></ul><ul><ul><li>Cataracts- </li></ul></ul><ul><ul><li>Glaucoma- </li></ul></ul><ul><ul><ul><li>NVI can lead to elevated intraocular pressure </li></ul></ul></ul>
  42. 43. How is Diabetic Eye Disease avoided? <ul><li>Eye Care About My ABCs </li></ul><ul><ul><li>Hg A 1c, B lood pressure, C holesterol </li></ul></ul><ul><ul><li>Eye Exams </li></ul></ul><ul><li>Annual dilated eye exams! </li></ul><ul><ul><li>Diabetics with excellent control of blood sugar. </li></ul></ul><ul><li>Uncontrolled diabetics… </li></ul><ul><ul><li>Diabetics who have fluctuating blood sugar or who have shown signs of diabetic retinopathy may require more frequent exams. </li></ul></ul>
  43. 44. How to find an Optometrist <ul><li>Medicare beneficiaries can receive assistance: </li></ul><ul><ul><li>“ Diabetes Hotline” 800-826-3947 </li></ul></ul><ul><li>Eye Care Community Outreach (ECCO) </li></ul><ul><ul><li>Helping Hoosiers find and afford eye care. </li></ul></ul><ul><ul><li>Dewana-317-321-1413 </li></ul></ul><ul><ul><li>Kelli-317-321-1424 </li></ul></ul><ul><li>Indiana Optometric Association </li></ul><ul><ul><li>317-237-3560 </li></ul></ul><ul><li>American Optometric Association </li></ul><ul><ul><li>www.aoa.org “Doctor Locator” </li></ul></ul>
  44. 45. Thanks and Credits <ul><li>American Optometric Association - www.aoa.org </li></ul><ul><li>Vision Service Plan (VSP) – www.vsp.com </li></ul><ul><li>Eye Care Community Outreach (ECCO)— </li></ul><ul><ul><li>Kelli Barker, MSW and Dewana Allen, MPH </li></ul></ul><ul><ul><li>Helping Hoosiers find and afford eye care. </li></ul></ul><ul><li>Vic Malinovsky, OD, FAAO - photography </li></ul><ul><ul><li>Chief of Ophthalmic Disease Services at Indiana University School of Optometry </li></ul></ul><ul><li>Edwin C. Marshall, OD, MS, MPH- design </li></ul><ul><ul><li>Indiana University - Associate Dean for Academic Affairs and Student Administration, Professor of Optometry, and Adjunct Professor of Public Health, School of Medicine </li></ul></ul><ul><li>Jack Downey, OD- Consultant </li></ul><ul><ul><li>Indianapolis Eye Care Center </li></ul></ul><ul><li>Andrew Anderson, OD- design </li></ul><ul><ul><li>Gabriele Eye Institute- (574)-254-0700 </li></ul></ul>
  45. 46. References <ul><li>American Diabetes Association - www.diabetes.org </li></ul><ul><li>Center for Disease Control – www.cdc.gov </li></ul><ul><li>Diabetes “Sight for Life” - funded by the AOA and Roche Diagnostics </li></ul><ul><li>Derek Y. Kunimoto MD, Kunal D. Kanitar MD, Mary S. Makar MD. Editors. Mark A. Friedberg MD, Christopher J. Rapuano MD. Founding Editors: “The Wills Eye Manual.” 4 th ed. Lippincott Williams and Wilkins 2004. </li></ul><ul><li>Indiana State Department of Health Diabetes Prevention and Control Program. </li></ul><ul><li>Kaiser MD, Peter, K., Neil J. Friedman MD, Roberto Pineda II MD. “The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology.” 2 nd ed. Saunders 2004. </li></ul><ul><li>National Eye Institute - www.nei.nih.gov /health/diabetic </li></ul><ul><li>New Hampshire “Sight for Life” </li></ul>
  46. 47. Questions??? <ul><li>POP QUIZ!!! </li></ul>
  47. 48. QUIZ #1 True or False <ul><li>People with diabetes are more likely than people without diabetes to develop certain eye diseases. </li></ul><ul><li>True. Diabetic eye disease includes diabetic retinopathy—a leading cause of blindness in adults—cataract, and glaucoma. The longer someone has diabetes, the more likely he or she will develop diabetic eye disease. </li></ul>
  48. 49. #2 True or False <ul><li>Diabetic eye disease usually has early warning signs. </li></ul><ul><li>False. Often there are none in the early stages of the disease. Vision may not change until the disease becomes severe. </li></ul>
  49. 50. #3 True or False <ul><li>People with diabetes should have yearly eye examinations. </li></ul><ul><li>True . Everyone with diabetes should get an eye examination through dilated pupils at least once a year. Because diabetic eye disease usually has no symptoms, regular eye exams are important for early detection and timely treatment. </li></ul>
  50. 51. #4 True or False <ul><li>Diabetic retinopathy is caused by changes in the blood vessels in the eye. </li></ul><ul><li>True . In some people, blood vessels in the retina may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina. </li></ul>
  51. 52. #5 True or False <ul><li>People with diabetes are at low risk for developing glaucoma. </li></ul><ul><li>False. Glaucoma is almost twice as likely to occur in people with diabetes than in those without the disease. Glaucoma can usually be treated with medications or laser or other surgery. </li></ul>
  52. 53. #6 True or False <ul><li>Laser surgery can be used to halt the progression of diabetic retinopathy. </li></ul><ul><li>True. In laser surgery, a special beam of light is used to shrink the abnormal blood vessels or seal leaking blood vessels. Laser surgery has been proved to reduce the five-year risk of vision loss from advanced diabetic retinopathy by more than 90 percent. </li></ul>
  53. 54. #7 True or False <ul><li>People with diabetes should have regular eye examinations through dilated pupils. </li></ul><ul><li>True. An eye examination through dilated pupils is the best way to detect diabetic eye disease, in which drops are used to enlarge the pupils. This allows the eye care professional to see more of the inside of the eye to check for signs of the disease. </li></ul>
  54. 55. #8 True or False <ul><li>Cataracts are common among people with diabetes. </li></ul><ul><li>True. People with diabetes are twice as likely to develop cataracts and to develop them at an earlier age than are those without diabetes. Cataracts can usually be treated with surgery. </li></ul>
  55. 56. #9 True or False <ul><li>People who have good control of their diabetes are not at high risk for diabetic eye disease. </li></ul><ul><li>False. Even with good control of blood glucose, there is still a risk of developing diabetic eye disease. However, studies show that careful management of blood sugar levels slows the onset and progression of diabetic retinopathy. </li></ul>
  56. 57. #10-- True or False <ul><li>The risk of blindness from diabetic eye disease can be reduced. </li></ul><ul><li>True. With early detection and timely treatment, the risk of blindness from diabetic eye disease can be reduced. </li></ul>