1. Basic Considerations for Prevention of Blindness in Diabetes Care and EducationProf. Morsi Arab Emeritus Professor of Medicine University of Alexandria

4. Age Group 10 20 30 40 50 60

6. Causes of visual loss and blindness in Diabetes- Diabetic Retinopathy ( DR) is most common - Glucoma less common - Cataract less common - Vitreous hemorrhage

7. The Burden of diabetes on visual abilityThe WHO identifiesDRas the leading causeofpreventable blindnessand visual disabilityin adults ineconomically developedsocieties

8. Significant Observations in DR1- DR takes a long time to become manifest. During this time it is asymptomatic 2- DR. may not be arrested after establishment of normoglycaemia ( bec. glycated subs. can continue to bind to proteins after …) 3- However , glycaemic control at earlystages is effective in controlling progression of DR ( DCCT)

9. Prevalence of Diabetic Retinopathy ( DR)( The Wisconsin Study )all DR Prolif.DRin type 1 (onset of DM >30 ys) 71% 23 %in type 2 (onset after 30ys ) - on insulin 70% 14 % - no insulin 39% 2 %

11. Prevalence of DR in relation to GlycaemiaThe DCCT ( type 1)intensified Rx reduced progression of DR by 76% in primary preven. cohort 54% in secondary preven. cohort 47% progression to severe NPDR 56% necessity for Laser RxDCCT results show importance of both Duration and Glucose exposure ( hyperglyceamia) for the development of DR

12. Preval. of DR in relation to Glycaemia UKPDS ( type 2)intensified Rx with improved metaboliccontrol - risk of worsening DR by 21 % - need for Laser Rx by 29% - Cataract extraction by 24%

13. Prevalence of DR / Duration of DiabetesThe prev. of DR is highly correlated with the duration of DMat 5ysat 25 ysin type 1 : (10 %) ( steep rise) 100 %in type 2 : (25 %) almost 85%

14. Retinopathy in correlation with Duration of DM

15. Hypertension and DRmost studies show a causal association UKPDS :Tight control of B.P. 34 % of progress DR 47 % of moderate loss of Vis. Acuity( N.B. independent on the degree of glycaemic control )No specific type of anti hypertensive medication is superior than other

16. The Genetic factor in DRThere is evidence that severity of DR is influenced by familial , and possibly a genetic factor

17. Dyslipidaemia and DRan association is found between more severe DR and - Total cholesterol - but not with TG (lipid modulation by statins…? not conclusive )

18. Smoking and DRAlthough smoking is a risk factor in albuminuria and nephropathy , its effect on DR is not clear

19. Aspirin in DR- Anti inflam. agents did not show effect in Rx vasc. complications - aspirin failed to prevent dev. of DR - aspirin can be used if indicated ( card) without adverse effect on DR

20. The Risk Factors for DRMostdefinitive:1- Duration of DM 2- High glycaemic levelLess definite: 1- Hypertension 2- Pregnancy 3- Genetic factor 4- Hyperlipidaemia 5- Close assoc. with albuminuria 6- ? Smoking

21. Screening for and follow up of DRin type 1 :screen within 3-5 yrs after diag. ( onset) ( not necessary before age 10 )in type 2 : screen shortly after diagnosis Follow up : - repeat annually if no DR - more frequently if DR is progressing N.B. : In Pregnancy : -- Screen at planning preg. or during first trimest. – Follow up through preg.

22. Education for Prevention of DR ( basic considerations ) 1- knowledge of the Risk factors 2- control of glycaemic level 3- control hypertension 4- screen + follows up , and early intervention 5- close observation in pregnancy 6- control serum lipids 7- discourage smoking 8- no restriction on aspirin ( if required for cardiac )

23. Alexandrie – Palais du Montazah Thank You