به نام خداوند جان و خرد

1. به نام خداوند جان و خرد

2. دکتر نادر طاهری متخصص داخلی فوق تخصص غدد Refrence:ADA(2012) and William textbook of endocrinology

3. Global Prevalence of Diabetes

4. An epidemic of T2DM is under way in both developed and developing countries. • The number of people with diabetes will rise • from 171 million in 2000 to 366 million in 2030.

6. Classification of diabetes

7. The classification of diabetes includes four clinical classes: • Type 1 diabetes: results from beta -cell destruction, usually leading to absolute insulin deficiency • Type 2 diabetes (90% of diabetic cases globally): results from a progressive insulin secretory defect on the background of insulin resistance.

8. genetic defects in beta-cell function, or in insulin action, • diseases of the exocrine pancreas (such as cystic fibrosis), • and drug- induced (such as in the treatment of HIV/AIDS or after organ transplantation • Gestational diabetes mellitus (GDM: diabetes diagnosed during pregnancy)

9. Diagnosis of diabetes • For decades, the diagnosis of diabetes was based on • the fasting plasma glucose (FPG) • or the 2-h value in the 75-g oral glucose tolerance test (OGTT).

10. Diagnosis of diabetes • In 2009, an International Committee that included representatives of • the ADA, • the International Diabetes Federation (IDF), • and the European Association for the Study of Diabetes (EASD) • recommended the use of the A1C test to diagnose diabetes.

11. Diagnosis of diabetes • The A1C has several advantages to the FPG and OGTT, including • greater convenience, • and less day-to-day perturbations • But, these advantages must be balanced by • greater cost, • and the limited availability of A1C testing in certain regions of the developing world,

12. Diagnosis of diabetes • The diagnosis of diabetes must employ glucose criteria exclusively, • in conditions with abnormal red cell turnover, such as pregnancy, recent blood loss or transfusion, or some anemias.

13. Criteria for the diagnosis of Diabetes • FPG > or = 126 mg/dl, • or 2-h plasma glucose > or = 200 mg/dl, during an the 75-g OGTT. • or In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, A random plasma glucose > or = 200 mg/dl. • Or A1C > or = 6.5% .

14. Criteria for the diagnosis of Prediabetes • Prediabetes definded as • FPG > or = 100–125 mg/dl (IFG) • Or 2-h plasma glucose in the 75-g OGTT > or = 140–199 mg/dl (IGT) • Or A1C > or = 5.7–6.4%.

15. Prediabetes • Individuals with IFG and/or IGT have the relatively high risk for • the future development of diabetes • and cardiovascular disease (CVD).

16. Prediabetes • IFG and IGT are associated • with obesity (especially abdominal or visceral obesity) • high triglycerides and/or low HDL cholesterol, • and hypertension.

17. Screening in asymptomatic patients • Testing for type 2 diabetes in asymptomatic people, considered in • adults of any age, who are overweight or obese • and have one additional risk factor for diabetes. • In those without these risk factors, testing begin at age 45 years.

18. Risk factors of type 2 diabetes • physical inactivity • first-degree relative with diabetes • high-risk race/ethnicity • women who delivered a baby weighing 9 lb or past history of GDM • women with polycystic ovarian syndrome • Hypertension • A1C > or = 5.7%,

19. Risk factors of type 2 diabetes • HDL cholesterol level < 35 mg/dl • Triglyceride level > 250mg/dl • clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) • History of CVD

20. Screening in asymptomatic patients • If tests are normal, repeat testing carried out at least at 3-year intervals . • Monitoring for the development of diabetes in those with prediabetes performed every year. • To test for diabetes • A1C, • FPG, • or 2-h 75-g OGTT can be used.

21. Diabetes Complications • diabetes associated with microvascular pathology in: • the retina (retinopathy) • renal glomerulus (nephropathy), • peripheral nerve (neuropathy). • and accelerated atherosclerotic macrovascular disease in the heart, brain, and lower extremities.

22. Diabetic retinopathy • A highly specific vascular complication of both type 1 and type 2 diabetes, • The most frequent cause of new cases of blindness among adults, aged 20–74 years. • All patients with T1DM and more than 60% of patients with T2DM develop some degree of retinopathy after 20 years.

23. The primary end-point to evaluate the relationship between glucose levels and diabetic complications is retinopathy.

27. International Classification of Diabetic Retinopathy • no apparent retinopathy (no abnormalities), • mild NPDR (microaneurysms only), • moderate NPDR (more than microaneurysms only but less than severe NPDR),

28. International Classification of Diabetic Retinopathy • severe NPDR (any of the following: • more than 20 intraretinal hemorrhages in each of four quadrants, • definite venous beading in two or more quadrants, • prominent intraretinal microvascular abnormalities in one or more quadrants, • and no PDR

29. International Classification of Diabetic Retinopathy • and PDR : • one or more of retinal neovascularization, • vitreous hemorrhage, • or preretinal hemorrhage

31. Risk factor for retinopathy • Duration of diabetes • Quality of Glycemic control • Hypertesion • Renal disease • Anemia • Elevated serum lipid levels

32. Risk factor for retinopathy • Duration of diabetes: • closely associated with the onset and severity of diabetic retinopathy. • Diabetic retinopathy is rare in prepubescent patients with T1DM, • but all patients with T1DM and more than 60% of patients with T2DM develop some degree of retinopathy after 20 years.

33. Quality of diabetes control • The DCCT showed: Tight glucose control • reduced the development of retinopathy by 27%. • Also, reduced the progression of retinopathy by 76%, • But not prevent retinopathy completely.

34. Hypertension • Patients with DM and hypertension are • more likely to develop retinopathy and diffuse macular edema, • and more severe levels of retinopathy (PDR) • and more rapid progression of retinopathy • when compared with diabetic patients who do not have hypertension.

35. Renal Disease ( proteinuria ) • The presence and severity of diabetic retinopathy • are indicators of the risk of gross proteinuria, • and, conversely, proteinuria predicts PDR.

36. Renal Disease ( proteinuria ) • In a patient with long history of DM • and where retinopathy has been previously stable, • Rapidly progressive retinopathy • Suggest the need for renal evaluation .

37. conclusion • To reduce the risk or slow the progression of retinopathy: • optimize glycemic control. • and optimize blood pressure control.

38. Vision loss • results from: • persistent vitreous hemorrhage, • traction retinal detachment, • or severe macular edema. • The most common cause of vision loss from diabetes, is macular disease and macular edema.

39. Other Ocular Manifestations of Diabetes • Mononeuropathies of the third, fourth, or sixth cranial nerves can arise in association with diabetes; • Mononeuropathies may be the initial presenting sign of new-onset diabetes, • even in patients not claim a history of diabetes

40. Other Ocular Manifestations of Diabetes • Diabetes-induced third-, fourth-, and sixth-nerve palsies are • usually self-limited • and resolve spontaneously in 2 to 6 months. • Palsies can recur or subsequently develop in the contralateral eye .

41. Other Ocular Manifestations of Diabetes • Diabetic papilleddema must distinguished from other causes of disc swelling such as • increased intracranial pressure, • pseudopapilledema, • toxic optic neuropathies, • neoplasms of the optic nerve, • and hypertension.

42. Other Ocular Manifestations of Diabetes • Optic disc pallor can occur • following spontaneous remission of proliferative retinopathy or • remission of panretinal laser photocoagulation • Neovascularization of the iris • neovascular glaucoma

43. Other Ocular Manifestations of Diabetes • The cornea of the diabetic person is • more susceptible to injury • slower to heal after injury • and more prone to infectious corneal ulcers,

44. Other Ocular Manifestations of Diabetes • Open-angle glaucoma is 1.4 times more common in the diabetic population • Cataracts are 1.6 times more common in people with diabetes • Cataracts can occur earlier in life and progress more rapidly in the presence of diabetes.

46. All patients with diabetes should have • dilated ocular examinations by an experienced ophthalmologist • and diabetic patients should be under the direct care of an ophthalmologist • at least by the time severe diabetic retinopathy or diabetic macular edema is present.