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Diagnosis & Management of Diabetic Eye Disease

Diagnosis & Management of Diabetic Eye Disease. Part 4. A. Paul Chous, M.A., O.D., F.A.A.O. Tacoma, WA Specializing in Diabetes Eye Care & Education. Efferent Cranial Neuropathy. Microvascular infarct commonly leads to short-lived IIIrd, IVth, VIth and VIIth CN palsies 2-6 month duration

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Diagnosis & Management of Diabetic Eye Disease

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  1. Diagnosis & Management of Diabetic Eye Disease Part 4 A. Paul Chous, M.A., O.D., F.A.A.O. Tacoma, WA Specializing in Diabetes Eye Care & Education

  2. Efferent Cranial Neuropathy • Microvascular infarct commonly leads to short-lived IIIrd, IVth, VIth and VIIth CN palsies • 2-6 month duration • Isolated CN palsy as a rule • Autonomic neuropathy leads to diminished pupillary reflexes and accommodative response

  3. 30 minutes Later

  4. Cranial Neuropathy- Management • Improve blood glucose control • Patch/use prism as necessary • Consider earlier use of bifocal correction

  5. Glaucoma • Controversy regarding DM as a risk factor for POAG; undisputed risk for NVG • The Nurses Health Study (n = 76,3180) and meta-analysis of 12 studies (1987-2001) reveal a 50-80% increased risk of POAG in DM Ophthalmology 2006 Jul;113(7): 1081-6 Diabet Med 2004 Jun;21(6): 609-14 • Basic science has shown that AGEs ‘harden’ laminar collagen leading to shear stress • There may be a strong detection bias

  6. Iris Rubeosis aNVG (IOP= 68mm)

  7. Glaucoma - Management • Avoid unnecessarily treating OHTN in patients with diabetes • Increased risk of sight-threatening retinopathy with lower IOP and increased blood flow • Avoid beta blockers in pts on insulin • Increase blood glucose and may cause ‘hypoglycemia unawareness’ • Refer NVI for immediate PRP • Anti-VEGF agents successfully used in 2 cases

  8. AION • Two-thirds of patients with non-arteritic AION have DM, HTN, or both • Younger patients with T1DM often have good recovery of vision (‘diabetic papillopathy’) – not always the case • PREVENTION: strongly consider ASA therapy for patients with DM and small cups & hyperemic discs (‘disc at-risk’) • Aggresively treat HTN & dyslipidemia Optic disc on Fluorescein Angiography

  9. Retinal Vascular Occlusion • Retinal venous and arterial occlusions are more common in diabetes (especially BRVO) • Increased probability of predisposing factors: • Hypertension • Dyslipidemia • Hypercoagulability Especially in Type 2 Diabetes

  10. BRVO Sticky Platelets + HTN = Venous Occlusion

  11. Major risk factors for RAOs are hypertension, atherosclerosis & cardiac valve disease – Two of which are more common in diabetes CRAO

  12. Retinal Vascular Occlusion – Prevention & Management • Improve & stabilize blood glucose • Aggressively treat HTN and dyslipidemia • Monitor closely for neovascularization in all venous occlusions associated with diabetes • ‘Double Whammy’ of ischemia from hyperglycemic capillary closure and venous stasis

  13. Macrovasculopathy & Diabetic Eye Disease • DRT, Retinal Vascular Occlusion and AION strongly correlated with systemic CV disease • -Sticky Platelets from hPAI-1 • -Reactive Oxygen Species injure • blood vessel wall • -Embolic Events from rupture of vulnerable plaque due to hCRP

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