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Disclosures. The content of this COPE Accredited CE activity was prepared independently without input from members of the ophthalmic community.I have no direct financial or proprietary interest in any companies, products or services mentioned in this presentation. The content and format of this course is presented without commercial bias and does not claim superiority of any commercial product or service..
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1. Diabetic Retinopathy: The 5 Findings You Can Not Afford to Overlook! Kyle Cheatham, OD, FAAO
Heartland Eye Consultants, Omaha, NE.
FCO Student Chapter Coordinator
2. Disclosures The content of this COPE Accredited CE activity was prepared independently without input from members of the ophthalmic community.
I have no direct financial or proprietary interest in any companies, products or services mentioned in this presentation.
The content and format of this course is presented without commercial bias and does not claim superiority of any commercial product or service.
Heartland Eye Consultants
3. Understanding the Fundamentals for DM is Important for …..
Our patients…. Diabetes is the leading cause of blindness in the U.S. for patients within the ages of 20-74.
Our practice…. Thoroughly understanding this condition gives you confidence on when and why to refer for consultation.
The profession…. No other systemic health condition allows us a better opportunity to coordinate care with primary care physicians.
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4. Goals of This Course Quickly overview epidemiology, pathophysiology and terminology associated with the condition.
Discuss diabetic findings with an emphasis on “threats to vision” associated with the condition.
Utilize evidence based medicine to understand how to properly monitor and manage the threats to vision.
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5. Pathophysiology of Retinopathy
Diabetes leads to microvascular disease and damage to pericytes of the blood retinal barrier.
Theories:
Hyperglycemia causes production of toxic metabolites
Byproducts of glucose metabolism cause alteration in cell signaling pathways
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6. Overview of Terminology Nonproliferative diabetic retinopathy (NPDR) is also called background diabetic retinopathy (BDR).
Proliferative diabetic retinopathy (PDR) indicates the presence of neovascularization; it is always associated with a worse prognosis.
Clinically significant macular edema (CSME) is the leading cause of legal blindness in diabetes. Do not confuse CSME with cystoid macular edema (CME). Heartland Eye Consultants
7. Epidemiology of Diabetic Retinopathy
Overview of Type 1 DM:
Believed to be autoimmune in nature (pancreatic destruction); weak genetic component, strong concern for diabetic ketoacidosis.
At diagnosis: no BDR is expected
After 5 years duration - 25% have retinopathy, PDR is rare.
After 20 years duration: 98% have BDR, 60% have PDR, 30% have CSME.
Duration is disease is strongest risk factor for determining what IDDM patients will have retinopathy.
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8. Epidemiology of Diabetic Retinopathy
Overview of Type 2 DM:
Results from insulin-resistant receptor cells or abnormal B-cell production of insulin; strong genetic component, high association with obesity.
Statistics for NIDDM Type 2 Diabetics:
At diagnosis: 20% have BDR
After 5 years duration: 30% have BDR, 2% have PDR.
After 20 years duration: 50% have BDR, 10% have PDR, 20% have CSME.
15-19 year duration: 84% on insulin, 53% non-insulin dependent have retinopathy
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9. Epidemiology of Diabetic Retinopathy
Statistics for IDDM Type 2 Diabetics:
At diagnosis: 30% have BDR
After 5 years duration: 40% have BDR, 2% have PDR.
After 20 years duration: 90% have BDR, 25% have PDR, 40% have CSME.
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10. ADA Guidelines for DM Exams
Type 1 should have a DFE within 5 years of diagnosis
Type 2 shortly after diagnosis
Exams should be done annually unless retinopathy is progressing then they should be more frequent. Less frequent exams (q2- 3 years) at the discretion of the doctor if exams are normal and HA1C is controlled.
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11. What are Our Best Predictors for Vision Loss in DM Retinopathy?
Overview of mild, moderate, severe NPDR.
Determining risk of progression from NPDR to PDR (The 4-2-1 rule):
Severe retinal hemorrhages in 4 quadrants
Venous beading in 2 quadrants
IRMA in 1 quadrant
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12. Threats to Vision in DM Macular Disease
Macular Ischemia
Macular Edema
Proliferative Disease
Tractional Retinal Detachment
Neovascular Glaucoma
Preretinal/Vitreous Hemorrhage
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13. Macular Disease
Key points regarding Macular Ischemia:
Macular can appear normal or thickened
Also referred to as macular non-perfusion
Fluorescein angiography will reveal capillary non-perfusion larger than normal area of approximately 1 disc diameter in size.
No treatment for this condition.
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14. Macular Edema
Macular edema is excessive fluid WITHIN the layers of the retina, distinct from the accumulation of fluid under or between the retinal layers (subsensory fluid, serous retinal detachment).
Results from excessive leakage from capillaries within the macular region that overwhelms normal homeostasis mechanisms (i.e. RPE pumps).
Can occur in NPDR or PDR.
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15. Diabetic Macular Edema
Macula will always appear thickened in macular edema.
Tips for finding macular edema….
Is macular edema always treated?
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16. Clinically Significant Macular Edema (CSME)
Criteria for CSME and subsequent treatment with focal/grid laser photocoagulation.
Exudate within 1/3 DD of the fovea with associated retinal thickening.
Retinal thickening within 1/3 DD of the fovea.
Retinal thickening within 1 DD of the fovea that is 1DD in size. Heartland Eye Consultants
17. Cystoid Macular Edema (CME)
Not the same as clinically significant macular edema (CSME)
#1 cause of CME is post-cataract extraction, which is believed to be prostaglandin mediated.
Occasionally, in diabetes, CME can accompany diabetic macular edema.
Classic clinical appearance of fluid-filled, cystoid spaces in the macular region.
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18. Cystoid Macular Edema Heartland Eye Consultants
19. Diabetic Macular Edema Heartland Eye Consultants
20. Proliferative Diabetic Retinopathy
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21. Preretinal / Vitreous Hemorrhage Quick review of various types of hemorrhages (vitreous, preretinal, intraretinal, subretinal hemorrhages) with emphasis on differentiating preretinal and vitreous hemes.
Etiology of preretinal/vitreous hemorrhages – leakage of blood from neovascularization into vitreous (neo vessel breaks due to vitreous traction)
Management – B-scan ultrasonography and considerations of vitrectomy
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22. Tractional Retinal Detachment
Etiology – retinal detachment results from vitreous traction on preretinal neovascularization.
Management –Cryo laser, vitrectomy, scleral buckle
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23. Neovascular Glaucoma
Etiology – VEGF release results from insufficient oxygen supply and can perculate to anterior segment and result in fibrovascularization, thereby blocking the trabecular meshwork and decreasing outflow.
When is gonioscopy appropriate (compare to CRVO).
Management - Standard of care is PRP. Temporary improvements may be possible with intermittent, repeated anti-VEGF medications (i.e. Avastin, Lucentis, Macugen). Heartland Eye Consultants
24. PRP Treatment in Proliferative Disease
Are all cases of neovascularization treated?
Treatment for proliferative disease is recommended when patient has high risk characteristics (HRC’s), which include either of the following criteria:
NVD >1/4 DD
Any NVD/NVE with associated preretinal or vitreous hemorrhage
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25. Effectiveness of PRP Patients with HRC’s:
Treatment Group: 10% reached severe vision loss (SVL) (5/200)
Observation Group: 28% reached SVL
Clinical Significance: 18% absolute risk reduction of SVL, which means approximately 1 out of 5 patients receive benefit from the treatment.
Patients with Proliferative disease, but no HRC’s:
Treatment Group: 5-10% reached SVL
Observation Group: 2-5% reached SVL
Patients with Very severe NPDR, but no HRC’s:
Treatment Group: 3-4% reached SVL
Observation Group: 1-2% reached SVL
Overall Summary Point:
Only patients with HRC’s are treated!
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26. Other Diabetic Findings
Cranial Nerve Palsies
Review of history, signs, symptoms, pathophysiology and diagnosis of CN III, IV and CN VI palsies.
Management: review of when diagnostic imaging is appropriate.
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27. Other Diabetic Findings
NAION
Etiology: Ischemia to anterior portion of optic disc with exact causal mechanism unknown
Epidemiology: most prominent in patients > 50, no gender predilection
Risk factors (HTN, DM, disc at risk)
Prominent symptoms (vision loss classically occurs in morning,
altitudinal visual field defect, etc)
Testing (normal ESR, CRP, etc)
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28. Other Diabetic Findings
Cataracts – review of pathophysiology
Beware of hypertension/diabetic combination leading to increased microvascular damage. Heartland Eye Consultants
29. Lecture Summary Two broad categories (macula and proliferative disease) with five overall concerns:
Macular edema
Macular ischemia
Preretinal/Vitreous hemorrhage
Tractional Retinal Detachment
Neovascular Glaucoma
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30. Thank You!
Any Questions? Heartland Eye Consultants