1. Diagnosis & Management of Diabetic Eye Disease Paul Chous, M.A., O.D., F.A.A.O. Specializing in Diabetes Eye Care & Education Part 3

2. Cataract Hyperglycemia leads to sorbitol accumulation via aldose reductase (the polyol pathway) Hyperglycemia leads to sorbitol accumulation via aldose reductase (the polyol pathway) True diabetic “snowflake” cataracts True diabetic “snowflake” cataracts Typical age-related cataracts develop prematurely due to AGE formation Typical age-related cataracts develop prematurely due to AGE formation Decreased elasticity of lens proteins causes premature presbyopia and, eventually, loss of tranparency Decreased elasticity of lens proteins causes premature presbyopia and, eventually, loss of tranparency

3. Diabetic “Snowflake” Cortical Cataract

4. Nuclear Sclerotic Cataract – 52 yo diabetic

5. The Maillard Reaction Advanced Glycation Endproducts: AGEs – they’re what’s for dinner

6. Cataract - Management Improve & stabilize blood glucose Improve & stabilize blood glucose A1c < 6.5% (ideally) A1c < 6.5% (ideally) Strive for a low standard deviation Strive for a low standard deviation Phacoemulsification when prudent or necessary Phacoemulsification when prudent or necessary Much higher risk of post-operative CME and worsening retinopathy Much higher risk of post-operative CME and worsening retinopathy Always address retinopathy prior to surgery Always address retinopathy prior to surgery

7. Diabetic Keratopathy Hyperglycemia & corneal sensory neuropathy weaken hemidesmosomal attachments between the basal epithelium and its basement membrane Hyperglycemia & corneal sensory neuropathy weaken hemidesmosomal attachments between the basal epithelium and its basement membrane PEK, Erosions, Neurotrophic Keratitis & Ulceration PEK, Erosions, Neurotrophic Keratitis & Ulceration Increased tear osmolarity and lacrimal autonomic neuropathy result in dry eye Increased tear osmolarity and lacrimal autonomic neuropathy result in dry eye

8. Photonic Colloidal Crystalline Array

9. Diabetic Keratopathy Prevalence of Dry Eye Syndrome and use of artificial tears is significantly higher amongst patients with diabetes and with a family Hx of diabetes Optometry. 2006 Nov;77(11):554-8 Am J Ophthalmol. 2005 Mar;139(3):498-503

10. Diabetic Neurotrophic Ulcer

11. Keratopathy - Management Improve & stabilize blood glucose Improve & stabilize blood glucose Be careful with contact lenses & corneal refractive surgeries Be careful with contact lenses & corneal refractive surgeries Avoid vigorous eye rubbing Avoid vigorous eye rubbing NP tears, plugs, immunomodulators, bandage SCLs, etc. as indicated NP tears, plugs, immunomodulators, bandage SCLs, etc. as indicated Beware infection Beware infection

12. Key Points Diabetes and diabetic eye disease are epidemic Diabetes and diabetic eye disease are epidemic Ocular complications are myriad and associated with large blood vessel disease Ocular complications are myriad and associated with large blood vessel disease State-of-the-art care is evolving rapidly State-of-the-art care is evolving rapidly

13. “The only thing to do with good advice is to pass it on to others… It is of absolutely no use to oneself.” - Oscar Wilde