1. Diagnosis & Management of Diabetic Eye Disease A. Paul Chous, M.A., O.D., F.A.A.O. Tacoma, WA Specializing in Diabetes Eye Care & Education Part 5

2. Diabetic Retinopathy Chronic hyperglycemia unleashes a progressive cascade of events Chronic hyperglycemia unleashes a progressive cascade of events Endothelial pericyte loss Endothelial pericyte loss RGC death RGC death Increased vascular permeability Increased vascular permeability Capillary closure Capillary closure Release of vasoproliferative factors Release of vasoproliferative factors Neovascularization, fibrovascular vitreo-retinal adhesions, vitreous hemorrhage Neovascularization, fibrovascular vitreo-retinal adhesions, vitreous hemorrhage

3. Diabetic Retinopathy Hypertension and increased retinal blood flow accelerate DR Hypertension and increased retinal blood flow accelerate DR Dyslipidemia aggravates diabetic macular edema Dyslipidemia aggravates diabetic macular edema Most (60%) of patients have some DR after ten years Most (60%) of patients have some DR after ten years Electrophysiologic abnormalities are present within the first year (mfERG) Electrophysiologic abnormalities are present within the first year (mfERG)

4. Retinopathy - Management Improve blood glucose, blood pressure & blood lipids Improve blood glucose, blood pressure & blood lipids HbA1c < 6.5% HbA1c < 6.5% BP < 130/80 (ideally, < 120/75) BP < 130/80 (ideally, < 120/75) LDL-C < 100 & TGs < 150 LDL-C < 100 & TGs < 150 Limit glycemic variability Limit glycemic variability Mean Blood Gluose > 2 X Standard Deviation Mean Blood Gluose > 2 X Standard Deviation Photocoagulation for PDR, CSME or severe NPDR in T2DM Photocoagulation for PDR, CSME or severe NPDR in T2DM

5. In the DCCT, “Intensive” Blood Glucose Control (less glycemic fluctuation) Decreased the Risk of Developing DR by 60% compared with “Conventional” Control (more fluctuation) For Patients Having IDENTICAL HbA1c

6. Staging of Diabetic Retinopathy New proposed international standard New proposed international standard No Apparent DR no retinal findings Mild NPDR microaneurysms only Moderate NPDR > ‘mild’ but < ‘severe’ Severe NPDR > 20 hemorrhages in 4 quads or definite vein beading in 2+ quads or IRMA in 1+ quads (4-2-1 rule) PDR definite NVD or NVE and/or VH/PRH Ophthalmology, 2003 Sept: 110(9): 1677-82

9. DR - Pearls For HbA1c values between 5% and 8%, each 10% reduction (e.g. from 8% to 7.2%) lowers the risk of DR progression by 43% For HbA1c values between 5% and 8%, each 10% reduction (e.g. from 8% to 7.2%) lowers the risk of DR progression by 43% In the UKPDS, a 10/5 mm drop in BP cut the risk of severe vision loss in half In the UKPDS, a 10/5 mm drop in BP cut the risk of severe vision loss in half Patients with two or more findings of Severe NPDR have a 45% chance of PDR within 1 year Patients with two or more findings of Severe NPDR have a 45% chance of PDR within 1 year ‘High Risk’ PDR if NVD > ½ DD, or NVD/NVE with VH/PRH ‘High Risk’ PDR if NVD > ½ DD, or NVD/NVE with VH/PRH Untreated, 50% of patients with PDR are blind within 5 years Untreated, 50% of patients with PDR are blind within 5 years