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Diabetic Eye Disease Evan (Jake) Waxman MD PhD. Diabetes is a major cause of visual loss Diabetic Eye Disease Key Points.

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Presentation on theme: "Diabetic Eye Disease Evan (Jake) Waxman MD PhD. Diabetes is a major cause of visual loss Diabetic Eye Disease Key Points."— Presentation transcript:

1 Diabetic Eye Disease Evan (Jake) Waxman MD PhD

2 Diabetes is a major cause of visual loss Diabetic Eye Disease Key Points

3 Risk factor control can prevent and slow visual loss Diabetic Eye Disease Key Points

4 Treatments exist but work best before vision is lost Diabetic Eye Disease Key Points

5 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 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 Diabetic Eye Disease Key Points

6 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 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 Disease Case Presentation - Exam Visual Acuity 20/50 OU Normal Pupils Normal Anterior Segment Visual Acuity 20/50 OU Normal Pupils Normal Anterior Segment

8 Diabetic Eye Disease Case Presentation - Exam

9 Diabetic Eye Disease Case Presentation Fluoroscein Angiography

10 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 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 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 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 Diabetic Eye Disease Background

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

13 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 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 Diabetic Eye Disease Key Points

14 Leading cause of blindness in Americans aged Accounts for 12% of new blindness Diabetic patients 25 times more likely to go blind Leading cause of blindness in Americans aged Accounts for 12% of new blindness Diabetic patients 25 times more likely to go blind Diabetic Eye Disease Background – Scary statistics

15 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 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 Diabetic Eye Disease Background – More scary statistics

16 Duration Poor Blood Sugar control HTN Hyperlipidemia Barriers to care Duration Poor Blood Sugar control HTN Hyperlipidemia Barriers to care Diabetic Eye Disease Background Risk Factors

17 Diabetic Eye Disease Background 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 Disease Framework 2 pathways of Visual Loss in DR –Capillary Leakage –Capillary Closure 2 pathways of Visual Loss in DR –Capillary Leakage –Capillary Closure

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

20 Diabetic Eye Disease Pathophysiology - Capillary Leakage Non proliferative diabetic retinopathy –Damaged capillaries leak –Leakage into the macula results in vision loss Non proliferative diabetic retinopathy –Damaged capillaries leak –Leakage into the macula results in vision loss

21 Diabetic Eye Disease Symptoms/Signs - Preclinical –None on exam –Special techniques demonstrate Leakage VEGF secretion

22 Diabetic Eye Disease Symptoms/Signs – NPDR Usually no symptoms Dot heme –Microaneurysms –Leakage Blot heme –Leakage Flame heme

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

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

25 Diabetic Eye Disease NPDR / Macular Edema Prevalence –5% for pts with DM for ≤ 5 years –15% for pts with DM for ≥ 15 years

26 Diabetic Eye Disease NPDR – Macular Edema Prevalence –Higher for insulin dependence –Higher with increased HgbA1C

27 Diabetic Eye Disease Treatment – NPDR – Macular Edema Fluoroscein Angiography

28 Diabetic Eye Disease Treatment – NPDR – Macular Edema Focal Laser

29 Diabetic Eye Disease Treatment – NPDR – Macular Edema Focal Laser

30 Diabetic Eye Disease Treatment – 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;

31 Diabetic Eye Disease Framework 2 pathways of Visual Loss in DR –Capillary Leakage –Capillary Closure 2 pathways of Visual Loss in DR –Capillary Leakage –Capillary Closure

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

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

34 Proliferative diabetic retinopathy –Neovascularization Fibrous Proliferation Traction with vitreous hemorrhage Traction retinal detachment Neovascular glaucoma Proliferative diabetic retinopathy –Neovascularization Fibrous Proliferation Traction with vitreous hemorrhage Traction retinal detachment Neovascular glaucoma Diabetic Eye Disease Pathophysiology

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

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

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

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

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

40 Diabetic Eye Disease Signs – Proliferative Retinopathy Prevalence ≤ 5 years – 0% ≥ 15 yrs – 25% ≥ 20 yrs – 55%

41 Diabetic Eye Disease Treatment – PDR Panretinal photocoagulation (PRP)

42 Diabetic Eye Disease Treatment – PDR Panretinal photocoagulation (PRP) Before After

43 Diabetic Eye Disease Treatment – PDR Panretinal photocoagulation (PRP) Before After

44 Diabetic Eye Disease Treatment – 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;

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

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

47 Diabetic Eye Disease Treatment – Vitreous Heme Panretinal photocoagulation (PRP) Vitrectomy –Removes blood –Removes Traction –Allows addnl PRP Panretinal photocoagulation (PRP) Vitrectomy –Removes blood –Removes Traction –Allows addnl PRP

48 Diabetic Eye Disease Treatment – Vitreous Heme Vitrectomy

49 Diabetic Eye Disease Treatment – 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;

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

51 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

52 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

53 Diabetic Eye Disease What’s new and cool Intraocular steroid –Injection –Sustained release device Stabilizes blood-retina barrier Reduces Macular Edema

54 Diabetic Eye Disease What’s new and cool Anti VEGF drugs Protein Kinase C beta inhibitors Intravitreal hyaluronidase

55 Diabetic Eye Disease What’s new and cool Ocular Coherence Tomography –Noninvasive imaging of retina –Can detect subtle retinal thickening

56 Diabetes is a major cause of visual loss Diabetic Eye Disease Key Points

57 Risk factor control can prevent and slow visual loss Diabetic Eye Disease Key Points

58 Treatments exist but work best before vision is lost Diabetic Eye Disease Key Points

59 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 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 Diabetic Eye Disease Key Points


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