The Goal is in Sight: Eye Care Concerns for Patients with Diabetes Richard Savoy, OD, MPH, FAAO Wilson McGriff, OD, MPH

Workshop Objectives Review the epidemiology of diabetes in the U.S. and Tennessee Discuss the effects and potential impact of diabetes on vision Instruct in the use of the Health Belief Model to promote behavior change Review initiatives and recommendations for preventing and minimizing diabetic complications

Diabetes: A Definition Failure of the pancreas to produce sufficient amounts of insulin -OR- Resistance of the body’s cell to the action of insulin Body either does not make enough insulin (not preventable) or body cannot use insulin properly (preventable)

Epidemiology of Diabetes in the US 29.1 million people have diabetes 1.7 million people 20 years old and older diagnosed in 2012 86 million people have prediabetes 15-30% of people with prediabetes will develop diabetes (Type 2) within 5 years

Complications: Diabetes in the US is… The 6th leading cause of death The LEADING cause of: Kidney failure Non-traumatic lower limb amputation New cases of blindness in adults A MAJOR contributor to: Heart disease (2nd leading cause of death) Stroke (4th leading cause of death)

Some Bad News and Some Good News with Diabetes Medical costs for people with diabetes are twice as high as for people without diabetes Risk of death for adults with diabetes is 50% higher than for adults without diabetes Good: Prediabetics who lose weight by eating healthy and being more active can cut their risk of getting Type 2 diabetes in half

Diabetes by Age (Years) Tennessee, 2005

Diabetes by Gender and Race Tennessee, 2005

Diabetes by Educational Achievement Tennessee, 2005

Diabetes and Cardiovascular Disease Tennessee, 2005

Diabetes and Specific Risk Factors Tennessee, 2005

Types of Diabetes Mellitus 5-10% of cases Loss of ability to produce insulin Type 2 90-95% of cases Loss of ability to use insulin Gestational and other types Hyperglycemia is the defining feature of all types Group of disorders with one feature in common - abnormally high levels of glucose in the blood. This is due to either failure of the pancreas to produce sufficient insulin and/or resistance of the body’s cells to the action of insulin. (American Diabetes Association definition) Insulin resistance or impaired ability of the tissues to use insulin Insufficient insulin in relation to the needs of the body Others: 1-5% of diagnosed cases of diabetes Other more rare forms of the diabetes are secondary to or associated with pancreatic disease, malnutrition, hormonal disease, drug or chemical exposure, insulin receptor abnormalities or certain genetic syndromes. Hyperglycemia or High blood glucose levels are the cause of all diabetic complications

Effects of Chronic Hyperglycemia Microvascular disease Retinopathy Diabetic nephropathy Diabetic neuropathy Over time chronically high levels of glucose in the blood start to affect proteins within the walls of the blood vessels This eventually leads to breakdown of the walls of capillaries throughout the body. Which causes eye disease, kidney disease, nerve disease and heart disease Diabetes-related eye disease predicts these other diseases With large amounts of glucose coursing through the circulatory system, a glycosylation reaction occurs between the sugar and the proteins that make up the vessel walls. Diabetes is a disease of blood vessels. Results in tissue necrosis and loss of function. Under-utilization or overproduction of serum glucose Vascular damage is the primary pathology

Ocular Symptoms of Diabetes Blurry vision at near or far General decline in visual acuity Spots or floaters Straight lines do not look straight Double vision Persistent, red, painful eye Increasing sense of pressure in the eye Diabetes related eye problems can take on many different appearances, and it is often difficult to distinguish between diabetes and other causes of eye disease or vision changes. A good general guideline is to direct patients to an eye care provider if they develop any new problems with their eyes or their vision. It could be something unrelated, but it could be an indication of more severe problems that should be addressed quickly.

Refractive Error and Cataracts Excess glucose causes the crystalline lens to swell May alter or delay glasses prescription 40% increase in risk for developing cataracts Another effect of chronic hyperglycemia is swelling of the natural lens in the eye Large refractive changes may be an indicator of undiagnosed or poorly controlled diabetes If the person’s glucose levels are brought back under control, the swelling reduces and the vision can return to normal in a couple of weeks, but eye doctors will not prescribe glasses until the swelling resolves because the final prescription may not be the same. If the high blood glucose and swelling continues over a long period of time, the cells in the lens start to die and the lens starts to cloud, which is the beginning of a cataract. People with diabetes are at an increased risk for developing cataracts, but this can be reduced with good blood glucose control Diabetes raises the risk for senile cataract about 40%. Duration of diabetes Degree of hyperglycemia

Glaucoma Twice as likely in persons with diabetes Gradual destruction of optic nerve More likely to cause vision loss Glaucoma is another disease that can be caused by diabetes. Diabetes can contribute to a gradual increase in the pressure inside a person’s eye This increase in pressure is painless, but it is still causing gradual destruction of the optic nerve which connects the eye and the brain. Over time, the nerve fibers that make up the optic nerve will be destroyed and the nerve will go from a healthy appearance to a glaucomatous appearance This destruction will first affect your peripheral vision and gradually move in toward your central vision People with diabetes are at a higher risk for vision loss if they do develop glaucoma, but if it is detected early, much if not all of the vision loss can be prevented http://webeye.ophth.uiowa.edu/dept/iih/pc_4.htm on 9/1/2014 More likely to cause vision loss in persons with diabetes Gradual, painless loss of vision that starts peripheral

Diabetic Retinopathy Most significant ocular complication Leading cause of blindness: ages 20-74 Slow progression in the beginning Incidence increases with duration of diabetes >10 years: >50% incidence of retinopathy >15 years: ~90% incidence of retinopathy The most significant ocular complication of diabetes is diabetic retinopathy, and it is the leading cause of blindness in the 20-74 year old age group. In most patients, there is a very gradual progression of the disease in the beginning. The speed that it worsens depends largely on a person’s level of Because vessel damage accumulates over time, the most accurate predictor of retinopathy is duration of diabetes. After 10 years, more than half of patients will show signs of retinopathy, and after 15 years this number increases to nearly 90%.

Diabetic Retinopathy http://www.nei.nih.gov/health/diabetic/retinopathy.asp Photos: National Eye Institute / National Institutes of Health

Severity of Diabetic Retinopathy Depends on Disease Duration High Blood Pressure Smoking status Hemoglobin A1c level (HbA1c) Once you’re diagnosed, the duration of the disease cannot be altered, but all of the other factors that contribute to the severity of diabetic retinopathy are modifiable. One of the key factors is an individual’s hemoglobin A1c level, or HbA1c level

Hemoglobin A1c (HbA1c) AVERAGE blood sugar level over 3 months Normal HbA1c is below 5.7% Average patient with diabetes is around 8.5% Goal is <6.5% for newly diagnosed Predicts likelihood of disability and death Only 24% of persons with diabetes can remember their last HbA1c value Regular testing of HbA1c values is now the principal way to measure and track glycemic control in diabetes. Subunit of the hemoglobin molecules in red blood cells that transport oxygen throughout the body Glucose will stick to these subunits and can be measured as a percentage. The percentage of affected HbA1c increases as the blood glucose level rises As opposed to the familiar random blood glucose monitoring that tells you a person’s glucose level at that specific point in time, HbA1c measures the AVERAGE blood sugar level over the preceding 2 to 3 months “Normal” HbA1c is below 5.7% The average patient with diabetes has an HbA1c of 8.5% For most people with diabetes, the HbA1c goal is <6.5% Exceptions are kids and those with established CVD For people who have had diabetes for a while, an HbA1c goal of 7.5% to 8.0%, or even higher, may be more appropriate. HbA1c predicts those people most likely to go blind and/or die from diabetes According to one study “only 24% of those who reported having a test remembered the actual value, and the self-reported values correlated weakly with the last A1C on the medical record. ” Diabetes Educ. 2002 Jan-Feb;28(1):99-105. Do persons with diabetes know their (A1C) number? Harwell TS1, Dettori N,

HbA1c and Retinopathy Studies have shown that patients who maintain lower hemoglobin A1C levels have delayed onset and slower progression of disease. As you can see from this study graphic The lower the HbA1c, the less likely they are to develop retinopathy Adapted from The Diabetes Control and Complications Trial Research Group, Diabetes 44:968, 1995

Healthy Retina Häggström, Mikael. "Medical gallery of Mikael Häggström 2014". Wikiversity Journal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 20018762. To give you an idea of what we see during an exam, I’m going to show you some photos of eyes with different levels of diabetic retinopathy. First, here is a health eye. Note ONH – about the diameter of a standard #2 pencil eraser (6mm) Macula – slightly smaller than ONH and the part of the retina responsible for your central detail vision: reading / color vision / faces Vessels: arteries and veins Color: salmon colored, even, smooth

Pre-retinal hemorrhage Diabetic Retinopathy Mild Moderate Severe Two main stages of diabetic retinopathy Nonproliferative Diabetic Retinopathy Leakage of intravascular fluid Bleeding within the retina Loss of blood flow to areas of the retina Mild NPDR Standard Photo 1: Hemorrhages & Microaneurysms LESS THAN Standard Photo 2A Moderate NPDR Standard Photo 2A: H/ MA > Standard Photo 2A and/ or CWE/VB/IRMA to a moderate degree. Severe NPDR Standard Photo 2B: At least one high-risk NPDR characteristic (4-2-1 Rule). Neo of the optic disc Neo elsewhere Pre-retinal hemorrhage Images from the Early Treatment Diabetic Retinopathy Study

Clinically Significant Macular Edema Responsible for nearly HALF of all vision loss in diabetes! Referred for immediate treatment The collection of intraretinal fluid in the macular area disrupts retinal structure With or without lipid exudate or cystoid changes Focal or diffuse Can occur at any stage of retinopathy Only treated when it becomes “clinically significant” Follow-up every 3 to 4 months by a retinal specialist Macular edema is the collection of intraretinal fluid in the macular area with or without lipid exudates or cystoid changes. Plasma fluid and serum lipoproteins accumulate in extracellular spaces of the retina. This disrupts the normal retinal structure and may be focal or diffuse. It can occur at any stage of retinopathy. Visual acuity may be compromised when it becomes “clinically significant”. This may initially occur without involving the fovea. Non-clinically significant macular edema is any macular edema not meeting the criteria for clinical significance. This does not require laser surgery, but these patients should be re-examined wihin 3 to 4 months by a retinal specialist. Risk of progression and vision loss is high for these patients. Images from the Early Treatment Diabetic Retinopathy Study

Other Ocular Manifestations Anterior Ischemic Optic Neuropathy Corneal Ulcers Also at risk for other vascular disorders that affect the optic nerve Corneal ulcers Nerve palsies caused by damage to the blood vessels that supply the nerves that move the eye III most common, also IV, and occassionally VI Double vision Drooping of one eyelid (ptosis) Pain in the head or behind the eye Cranial Nerve Palsies

Prevention and Treatment of Diabetic Eye Disease Annual dilated exams ~75% reduction of diabetic retinopathy with proper control Less than 50% of persons with diabetes get annual dilated eye exams Treatment Laser Injections Invasive surgery Early Diagnosis is the Key ALWAYS preschedule your patients with diabetes for annual (and other) visits Getting an annual dilated eye exam cuts the risk of going blind from diabetes by up to 95% by allowing for early detection of eye complications Laser PRP reduces visual loss by 50% Goals: Prevent further neovascularization Reduce risk of vitreous hemorrhage and/or reduce traction retinal detachment Side Effects (lessened now with injections) Constriction of peripheral vision Decreased night vision Loss of acuity After Diagnosis Annual dilated exam After first diagnosis of diabetic eye changes Every year or six months At pre-proliferative stage Should be referred to retinal specialist

Health Insurance and Diabetes Medicare BlueCare/TennCare/United/AmeriGroup Private insurance Affordable Care Act Many people with medical insurance do not realize that their coverage includes an annual eye exam if they have diabetes Medicare beneficiaries are covered for an annual, dilated eye exam, but it does not include glasses or contact lens coverage. Depending on the plan, some Medicare Advantage plans do include vision services In Tennessee, adults over the age of 21 on one of the Medicaid plans have coverage similar to Medicare, but children under 21 also have coverage that includes glasses. Most every private insurance plan includes annual dilated exams for people with diabetes. The exceptions would be individuals with catastrophic coverage only. Under the Affordable Care Act, primary care providers and eye care providers are financially incentivized to improve their communication for patients with diabetes in an effort to improve their care and prevent complications. For every patient with diabetes that is referred to an eye care provider for an eye exam, we are expected to send reports back to that primary care provider Medicare Benefit for Eye Exams For People with Diabetes -- People with Medicare who have diabetes can get a dilated eye exam to check for diabetic eye disease. Your doctor will decide how often you need this exam.  Patients must pay 20 percent of the Medicare-approved amount after the yearly Part B deductible. Telephone: 1-800-633-4227. Website :http://www.medicare.gov. State Children's Health Insurance Program (SCHIP) For little or no cost, this insurance pays for doctor visits, prescription medicines, hospitalizations, and much more for children 18 years and younger. Most states also cover the cost of dental care, eye care, and medical equipment. Telephone: 1-877-543-7669. Insure Kids Now! Website:http://www.insurekidsnow.gov.

Diabetes Health Promotion Programs National Level Initiative: Healthy People 2020

Healthy People 2020 D-1 Reduce the number of new cases of diabetes D-2 Reduce the death rate D-3 Reduce the diabetes death rate D-4 Reduce the rate of lower extremity amputations D-1 Reduce the annual number of new cases of diagnosed diabetes in the population D-2 Reduce the death rate among persons with diabetes D-3 Reduce the diabetes death rate D-4 Reduce the rate of lower extremity amputations in persons with diagnosed diabetes

Healthy People 2020 D-5 Glycemic control D-6 Lipid control D-7 Blood pressure control D-8 Annual dental examination D-9 Annual foot examination D-10 Annual dilated eye examination

Healthy People 2020 D-11 Twice a year glycosylated hemoglobin measurement D-12 Annual urinary microalbumin measurement D-13 Once daily self-blood glucose-monitoring D-14 Formal diabetes education D-15 Diagnosed proportion of persons with diabetes D-16 Prevention behaviors in persons with prediabetes Retrieved from: http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx on 09/02/14

Diabetes Health Promotion Programs State Level Initiative: Project Diabetes

Tennessee’s Project Diabetes Goals: Decrease the prevalence of overweight/obesity across the State and, in turn, prevent or delay the onset of Type 2 diabetes and/or the consequences of this devastating disease. Educate the public about current and emerging health issues linked to diabetes and obesity Promote community, public-private partnerships to identify and solve regional health problems related to obesity and diabetes

Tennessee’s Project Diabetes Goals Advise and recommend policies and programs that support individual and community health improvement efforts Evaluate effectiveness of improvement efforts/programs that address overweight, obesity, prediabetes, and diabetes Disseminate best practices for diabetes prevention and health improvement. Retrieved from: http://health.state.tn.us/projectdiabetes.htm on 09/02/14

Social Ecology of Health Model A. Level I: Intrapersonal B. Level II: Interpersonal C. Level III: Organizational D. Level IV: Community E. Level V: Societal

Diabetes Health Promotion Programs Patient Level Initiative: Intrapersonal/Interpersonal Behavioral Change

Health Belief Model Cue to Action Self-Efficacy BEHAVIOR CHANGE!! Perceived Susceptibility Perceived Benefits BEHAVIOR CHANGE!! Perceived Severity Perceived Barriers Susceptibility – how likely is a person to believe their vision will be affected by diabetes Severity – how likely is a person to believe they will loose vision due to their diabetes Benefits – Good vision for the remainder of their life Survey data indicating populations preference for retaining their vision over other senses Barriers? 1. Coreil, J. (Editor)(2010). Social and Behavioral Foundations of Public Health, 2nd Edition. Thousand Oaks, CA:Sage. 2. Retrieved from: http://www.utwente.nl/cw/theorieenoverzicht/theory%20clusters/health%20communication/health_belief_model/ on 09/02/14

Health Promotion and Social Support “People, unlike fish, are unable to swim upstream for any length of time. When the entire responsibility for health enhancement and risk reduction rests with the individual, independent of the health norms……….the probability for success is very small” Bellingham, 1990 Friends double the pleasure and half the pain

Diabetic “Bullets”

Potential Benefits of Preventing and Treating Diabetes Feel better Fewer symptoms Longer, healthier life Good vision Reduce the risk for complications involving eye, foot, kidney, heart, and nerve disease

Basic Recommendations for Preventing and Minimizing Diabetic Eye Disease In consultation with a physician knowledgeable about diabetes care, and through proper diet, exercise, and medication: Keep blood sugar levels as close to normal as possible Check and control even mild high blood pressure Check and improve blood lipid profile Check blood sugar levels at home on a regular basis, and know HbA1c levels Quit smoking Have a dilated eye examination each year, more often if specifically recommended

Diabetes “Team” Family Physician Optometrist Podiatrist Dentist Retinal Specialist Diabetic Educator Dietician

Additional Acknowledgements Some information courtesy of your American Optometric Association  For More Info: American Optometric Association: aoa.org American Diabetes Association: diabetes.org National Institutes of Health: ndep.nih.gov