Diabetic Eye Disease

Diabetic Eye Disease

Evan (Jake) Waxman MD PhD

• Diabetes is a major cause of visual loss

Diabetic Eye DiseaseKey Points

• Risk factor control can prevent and slow visual loss

Diabetic Eye DiseaseKey Points

• Treatments exist but work best before vision is lost

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

Diabetic Eye DiseaseKey Points

Diabetic Eye Disease

Case 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

Diabetic Eye Disease

Case Presentation - Exam• Visual Acuity 20/50

OU• Normal Pupils• Normal Anterior

Segment

Diabetic Eye Disease

Case Presentation - Exam

Diabetic Eye Disease

Case PresentationFluoroscein Angiography

Diabetic Eye Disease

Case 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

• 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

Diabetic Eye DiseaseBackground

Diabetic Eye DiseaseBackground

• Catching disease prior to vision loss requires yearly screening with a dilated eye exam by an MD

• 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

Diabetic Eye DiseaseKey Points

• Leading cause of blindness in Americans aged 25- 65

• Accounts for 12% of new blindness

• Diabetic patients 25 times more likely to go blind

Diabetic Eye DiseaseBackground – 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

Diabetic Eye DiseaseBackground – More scary statistics

•Duration•Poor Blood Sugar control•HTN•Hyperlipidemia•Barriers to care

Diabetic Eye DiseaseBackgroundRisk Factors

Diabetic Eye DiseaseBackground

• Prevention of eye disease is possible with increased risk factor control

The Effect of Intensive Diabetes TreatmentOn the Progression of Diabetic RetinopathyIn 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

Diabetic Eye DiseaseFramework

• 2 pathways of Visual Loss in DR–Capillary

Leakage–Capillary

Closure

Diabetes

Preclinical Changes

Background DR

Preproliferative DR Macular Edema

ClinicallySignificantMacular Edema

Proliferative DR

Vitreous Hemorrhage

Retinal DetachmentNeovascular Glaucoma

Vision Loss

and/or

and/or

Diabetic Eye DiseasePathophysiology – Capillary Leakage

• Pericyte Loss

• Endothelial Cell loss

• Blood-retina barrier breakdown

High blood sugar levels affect retinal capillariesHigh blood sugar levels affect retinal capillaries

Diabetic Eye DiseasePathophysiology - Capillary Leakage

• Non proliferative diabetic retinopathy– Damaged

capillaries leak– Leakage into the

macula results in vision loss

Diabetic Eye DiseaseSymptoms/Signs - Preclinical

–None on exam–Special techniques

demonstrate• Leakage• VEGF secretion

Diabetic Eye DiseaseSymptoms/Signs – NPDR

• Usually no symptoms

• Dot heme– Microaneurysms– Leakage

• Blot heme– Leakage

• Flame heme

Diabetic Eye DiseaseSymptoms/Signs – NPDR / Macular Edema

• +/- Symptoms• Dot heme

– Microaneurysms– Leakage

• Blot heme– Leakage

• Hard exudates

Diabetic Eye DiseaseSymptoms/Signs – NPDR / Macular Edema

• Hard exudates• Retinal edema• Vision loss

when edema occurs in central visual area

Diabetic Eye DiseaseNPDR / Macular Edema

• Prevalence–5% for pts

with DM for ≤ 5 years

–15% for pts with DM for≥ 15 years

Diabetic Eye DiseaseNPDR – Macular Edema

• Prevalence–Higher for

insulin dependence

–Higher with increased HgbA1C

Diabetic Eye DiseaseTreatment – NPDR – Macular Edema• Fluoroscein Angiography

Diabetic Eye DiseaseTreatment – NPDR – Macular Edema

• Focal Laser

Diabetic Eye DiseaseTreatment – NPDR – Macular Edema

• Focal Laser

Diabetic Eye DiseaseTreatment – NPDR – Macular Edema

Focal Laser reduces risk of visual loss by 50%

Early Photocoagulation forDiabetic Retinopathy

ETDRS Report Number 9

EARLY TREATMENT DIABETIC RETINOPATHY STUDY RESEARCH GROUP

Ophthalmology 1991; 98; 766-785

Diabetic Eye DiseaseFramework

• 2 pathways of Visual Loss in DR–Capillary

Leakage–Capillary

Closure

Diabetes

Preclinical Changes

Background DR

Preproliferative DR Macular Edema

ClinicallySignificantMacular Edema

Proliferative DR

Vitreous Hemorrhage

Retinal DetachmentNeovascular Glaucoma

Vision Loss

and/or

and/or

Diabetic Eye DiseasePathophysiology – Capillary Closure

• Basement membrane thickening

• Increased platelet and erythrocyte adhesion

• Closure of capillaries

High blood sugar levels affect retinal capillariesHigh blood sugar levels affect retinal capillaries

Diabetic Eye DiseasePathophysiology – Capillary Closure

• Proliferative diabetic retinopathy– Damaged capillaries

close off– Ischemic retina

secretes VEGF– New vessels form in

response to VEGF

• Proliferative diabetic retinopathy– Neovascularization

• Fibrous Proliferation• Traction with

vitreous hemorrhage• Traction retinal

detachment• Neovascular

glaucoma

Diabetic Eye DiseasePathophysiology

Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR

• Symptoms - None

• Cotton Wool Spots – Nerve fiber

layer ischemia & infarction

Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR

• Symptoms - None• Cotton Wool Spots

– Nerve fiber layer ischemia & infarction

• Venous beading• Intraretinal

microvascular abnormalities (IRMA)

Diabetic Eye DiseaseSymptoms/Signs – Preproliferative DR

• Symptoms - None• Cotton Wool Spots

– Nerve fiber layer ischemia & infarction

• Venous beading• IRMA• More heme

Diabetic Eye DiseaseSymptoms/Signs – Proliferative Retinopathy

• Symptoms - None• Optic Nerve

Neovascularization (NVD)

Diabetic Eye DiseaseSymptoms/Signs – Proliferative Retinopathy

• Symptoms - None• Optic Nerve

Neovascularization (NVD)

• Peripheral Neovascularization (NVE)

Diabetic Eye DiseaseSigns – Proliferative Retinopathy

• Prevalence ≤ 5 years – 0% ≥ 15 yrs – 25% ≥ 20 yrs – 55%

Diabetic Eye DiseaseTreatment – PDR

• Panretinal photocoagulation (PRP)

Diabetic Eye DiseaseTreatment – PDR

• Panretinal photocoagulation (PRP)

Before After

Diabetic Eye DiseaseTreatment – PDR

• Panretinal photocoagulation (PRP)

Before After

Diabetic Eye DiseaseTreatment – PDR

PRP reduces the risk of severe vision loss by more than 50%

Photocoagulation Treatment ofProliferative 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

Diabetic Eye DiseaseSigns/Symptoms – Vitreous Heme

• Symptoms– Floaters/Streaks– Loss of vision

• Blood in vitreous• Loss of red reflex• No View

Diabetic Eye DiseaseSymptoms/Signs – Retinal Detachment

• Symptom– Visual Loss; often

severe• Retinal Elevation• Fibrous Proliferation• Loss of red reflex• Marcus/Gunn Pupil

Diabetic Eye DiseaseTreatment – Vitreous Heme

• Panretinal photocoagulation (PRP)• Vitrectomy

– Removes blood– Removes Traction– Allows addnl PRP

Diabetic Eye DiseaseTreatment – Vitreous Heme

Vitrectomy

Diabetic Eye DiseaseTreatment – PDR

Vitrectomy results in improved vision in patients with persistent vitreous hemorrhage

Early Vitrectomy fo Severe VitreousHemorrhage in Diabetic RetinopathyTwo-Year Results of a Randomized TrialDiabetic Retinopathy Virectomy Report 2

THE DIABETIC RETINOPATHY VITRECTOMY STUDY RESEARCH GROUP

Arch Ophthalmol. 1985; 103 1644-1652

Diabetic Eye DiseaseSymptoms/ Signs – Neovascular Glaucoma

• Symptoms– Loss of Vision– Pain

• “Red Eye”• Iris Neovascularization• High Intraocular

Pressure• Marcus Gunn pupil

Diabetic Eye DiseaseOther Manifestation of Diabetes in the Eye

• Branch Retinal Artery Occlusion

• Central Retinal Artery Occlusion

• Branch Retinal Vein Occlusion

• Central Retinal Vein Occlusion

Diabetic Eye DiseaseOther Manifestation of Diabetes in the Eye

• Increased risk of cataract

• Increased risk of glaucoma

• Diabetic papillitis• Acute CN III, IV or VI

paresis

Diabetic Eye DiseaseWhat’s new and cool

• Intraocular steroid– Injection– Sustained release

device• Stabilizes blood-retina

barrier• Reduces Macular

Edema

Diabetic Eye DiseaseWhat’s new and cool

• Anti VEGF drugs• Protein Kinase C beta

inhibitors• Intravitreal

hyaluronidase

Diabetic Eye DiseaseWhat’s new and cool

• Ocular Coherence Tomography– Noninvasive imaging

of retina– Can detect subtle

retinal thickening

• Diabetes is a major cause of visual loss

Diabetic Eye DiseaseKey Points

• Risk factor control can prevent and slow visual loss

Diabetic Eye DiseaseKey Points

• Treatments exist but work best before vision is lost

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

Diabetic Eye DiseaseKey Points