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Diabetic Eye Disease

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59 diapositives · 923 Views · Sep 16, 2014

Diabetic Eye Disease. Evan (Jake) Waxman MD PhD. Diabetic Eye Disease Key Points. Diabetes is a major cause of visual loss. Diabetic Eye Disease Key Points. Risk factor control can prevent and slow visual loss. Diabetic Eye Disease Key Points.

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Diabetic Eye Disease
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  1. Diabetic Eye Disease Evan (Jake) Waxman MD PhD

  2. Diabetic Eye DiseaseKey Points • Diabetes is a major cause of visual loss

  3. Diabetic Eye DiseaseKey Points • Risk factor control can prevent and slow visual loss

  4. Diabetic Eye DiseaseKey Points • Treatments exist but work best before vision is lost

  5. Diabetic Eye DiseaseKey Points • Diabetes is a major cause of visual loss • Risk factor control can prevent and slow visual loss • Treatments exist but work best before vision is lost So … to prevent visual loss • Control patient risk factors • Insist your patients get yearly dilated eye exams with an ophthalmologist

  6. Diabetic Eye DiseaseCase Presentation - History • 27 year old woman • DM I for 16 years • poor blood sugar ctrl • HgbA1C = 10 • c/o spot in L vision for one day • Sees “Eye Doctor” every year -- no previous eye disease diagnosed

  7. Diabetic Eye DiseaseCase Presentation - Exam • Visual Acuity 20/50 OU • Normal Pupils • Normal Anterior Segment

  8. Diabetic Eye DiseaseCase Presentation - Exam

  9. Diabetic Eye DiseaseCase PresentationFluoroscein Angiography

  10. Diabetic Eye DiseaseCase Presentation - Course • Pan retinal photocoagulation OU • Focal photocoagulation OS • Vision dropped to 20/200 OD 1 month later • Vit heme OS 2 months later • Additional PRP • Glaucoma surgery x 2 • Current Acuity 20/400 OD 20/200 OS • Prognosis Poor

  11. Diabetic Eye DiseaseBackground • Treatments work best before vision is lost • Many patients are diagnosed only after vision is lost • Vision loss is a late symptom of diabetic eye disease • Risk factor control is essential

  12. Diabetic Eye DiseaseBackground • Catching disease prior to vision loss requires yearly screening with a dilated eye exam by an MD

  13. Diabetic Eye DiseaseKey Points • Diabetes is a major cause of visual loss • Risk factor control can prevent and slow visual loss • Treatments exist but work best before vision is lost So … to prevent visual loss • Control patient risk factors • Insist your patients get yearly dilated eye exams with an ophthalmologist

  14. Diabetic Eye DiseaseBackground – Scary statistics • Leading cause of blindness in Americans aged 25- 65 • Accounts for 12% of new blindness • Diabetic patients 25 times more likely to go blind

  15. Diabetic Eye DiseaseBackground – More scary statistics • 65,000 with new proliferative retinopathy yearly • 75,000 with new macular edema yearly • 700,000 have PDR • 500,000 have macular edema • 25% - 50% with high risk disease not receiving care

  16. Diabetic Eye DiseaseBackgroundRisk Factors • Duration • Poor Blood Sugar control • HTN • Hyperlipidemia • Barriers to care

  17. Diabetic Eye DiseaseBackground • Prevention of eye disease is possible with increased risk factor control The Effect of Intensive Diabetes Treatment On the Progression of Diabetic Retinopathy In Insulin-Dependent Diabetes Mellitus The Diabetes Control and Complications Trial The Diabetes Control and Complications Trial Research Group CLINICAL SCIENCES Arch Ophthalmol. 1995; 113:36-51

  18. Diabetic Eye DiseaseFramework • 2 pathways of Visual Loss in DR • Capillary Leakage • Capillary Closure

  19. Diabetic Eye DiseasePathophysiology – Capillary Leakage High blood sugar levels affect retinal capillaries • Pericyte Loss • Endothelial Cell loss • Blood-retina barrier breakdown

  20. Diabetic Eye DiseasePathophysiology - Capillary Leakage • Non proliferative diabetic retinopathy • Damaged capillaries leak • Leakage into the macula results in vision loss

  21. Diabetic Eye DiseaseSymptoms/Signs - Preclinical • None on exam • Special techniques demonstrate • Leakage • VEGF secretion

  22. Diabetic Eye DiseaseSymptoms/Signs – NPDR • Usually no symptoms • Dot heme • Microaneurysms • Leakage • Blot heme • Leakage • Flame heme

  23. Diabetic Eye DiseaseSymptoms/Signs – NPDR / Macular Edema • +/- Symptoms • Dot heme • Microaneurysms • Leakage • Blot heme • Leakage • Hard exudates

  24. Diabetic Eye DiseaseSymptoms/Signs – NPDR / Macular Edema • Hard exudates • Retinal edema • Vision loss when edema occurs in central visual area

  25. Diabetic Eye DiseaseNPDR / Macular Edema • Prevalence • 5% for pts with DM for ≤ 5 years • 15% for pts with DM for≥ 15 years

  26. Diabetic Eye DiseaseNPDR – Macular Edema • Prevalence • Higher for insulin dependence • Higher with increased HgbA1C

  27. Diabetic Eye DiseaseTreatment – NPDR – Macular Edema • Fluoroscein Angiography

  28. Diabetic Eye DiseaseTreatment – NPDR – Macular Edema • Focal Laser

  29. Diabetic Eye DiseaseTreatment – NPDR – Macular Edema • Focal Laser

  30. Diabetic Eye DiseaseTreatment – NPDR – Macular Edema Focal Laser reduces risk of visual loss by 50% Early Photocoagulation for Diabetic Retinopathy ETDRS Report Number 9 EARLY TREATMENT DIABETIC RETINOPATHY STUDY RESEARCH GROUP Ophthalmology 1991; 98; 766-785

  31. Diabetic Eye DiseaseFramework • 2 pathways of Visual Loss in DR • Capillary Leakage • Capillary Closure

  32. Diabetic Eye DiseasePathophysiology – Capillary Closure High blood sugar levels affect retinal capillaries • Basement membrane thickening • Increased platelet and erythrocyte adhesion • Closure of capillaries

  33. Diabetic Eye DiseasePathophysiology – Capillary Closure • Proliferative diabetic retinopathy • Damaged capillaries close off • Ischemic retina secretes VEGF • New vessels form in response to VEGF

  34. Diabetic Eye DiseasePathophysiology • Proliferative diabetic retinopathy • Neovascularization • Fibrous Proliferation • Traction with vitreous hemorrhage • Traction retinal detachment • Neovascular glaucoma

  35. Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR • Symptoms - None • Cotton Wool Spots • Nerve fiber layer ischemia & infarction

  36. Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR • Symptoms - None • Cotton Wool Spots • Nerve fiber layer ischemia & infarction • Venous beading • Intraretinal microvascular abnormalities (IRMA)

  37. Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR • Symptoms - None • Cotton Wool Spots • Nerve fiber layer ischemia & infarction • Venous beading • IRMA • More heme

  38. Diabetic Eye DiseaseSymptoms/Signs – Proliferative Retinopathy • Symptoms - None • Optic Nerve Neovascularization (NVD)

  39. Diabetic Eye DiseaseSymptoms/Signs – Proliferative Retinopathy • Symptoms - None • Optic Nerve Neovascularization (NVD) • Peripheral Neovascularization (NVE)

  40. Diabetic Eye DiseaseSigns – Proliferative Retinopathy • Prevalence ≤ 5 years – 0% ≥ 15 yrs – 25% ≥ 20 yrs – 55%

  41. Diabetic Eye DiseaseTreatment – PDR • Panretinal photocoagulation (PRP)

  42. Diabetic Eye DiseaseTreatment – PDR • Panretinal photocoagulation (PRP) Before After

  43. Diabetic Eye DiseaseTreatment – PDR • Panretinal photocoagulation (PRP) Before After

  44. Diabetic Eye DiseaseTreatment – PDR PRP reduces the risk of severe vision loss by more than 50% Photocoagulation Treatment of Proliferative Diabetic Retinopathy Clinical Application of Diabetic Retinopathy Study (DRS) Findings, DRS Report Number 8 THE DIABETIC RETINOPATHY STUDY RESEARCH GROUP Ophthalmology 1991; 88; 583-600

  45. Diabetic Eye DiseaseSigns/Symptoms – Vitreous Heme • Symptoms • Floaters/Streaks • Loss of vision • Blood in vitreous • Loss of red reflex • No View

  46. Diabetic Eye DiseaseSymptoms/Signs – Retinal Detachment • Symptom • Visual Loss; often severe • Retinal Elevation • Fibrous Proliferation • Loss of red reflex • Marcus/Gunn Pupil

  47. Diabetic Eye DiseaseTreatment – Vitreous Heme • Panretinal photocoagulation (PRP) • Vitrectomy • Removes blood • Removes Traction • Allows addnl PRP

  48. Diabetic Eye DiseaseTreatment – Vitreous Heme Vitrectomy

  49. Diabetic Eye DiseaseTreatment – PDR Vitrectomy results in improved vision in patients with persistent vitreous hemorrhage Early Vitrectomy fo Severe Vitreous Hemorrhage in Diabetic Retinopathy Two-Year Results of a Randomized Trial Diabetic Retinopathy Virectomy Report 2 THE DIABETIC RETINOPATHY VITRECTOMY STUDY RESEARCH GROUP Arch Ophthalmol. 1985; 103 1644-1652

  50. Diabetic Eye DiseaseSymptoms/ Signs – Neovascular Glaucoma • Symptoms • Loss of Vision • Pain • “Red Eye” • Iris Neovascularization • High Intraocular Pressure • Marcus Gunn pupil