2/28/19 1 New Fron)ers in the Detec)on & Management of Diabe)c Re)nopathy A . Paul Chous, MA, OD, FAAO, CDE Chous Eye Care Associates Tacoma, Washington These affiliaCons will not affect the content of this presentaCon Financial Disclosures • Bausch & Lomb • Genentech • Konan • Regeneron • ZeaVision • Zeiss A. Paul Chous, OD Objec)ves • Epidemiology & Demographic Trends • What IS Diabe)c Re)nopathy • What’s New for Detec)ng Diabe)c Re)nopathy • Assaul)ng Diabe)c Retnopathy • Preven)on & Optometry’s Role Worldwide Sta)s)cs n 1 billion will have diabetes by 2050 n Highest increases in diabetes & prediabetes in Asia and Sub- Saharan Africa InternaConal Diabetes FederaCon, 2015; www.diabetesatlas.org 2017 CDC Diabetes Sta)s)cs • 30.3 million Americans • 7.2 million undiagnosed • 84.1 million have prediabetes • 1.4 million legally blind from DR NaConal Diabetes StaCsCcs Report 2017 US Centers for Disease Control & PrevenCon Accessed at h]ps://www.cdc.gov/diabetes/pdfs/data/staCsCcs/ naConal-diabetes-staCsCcs-report.pdf Increasing Prevalence of Diabetes Over Time Improvements in therapies and medical management over 3me are factored in 7-8% 11-12% 19-20% 13-14% 17-18% Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16% Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics Increasing Prevalence of Diabetes Over Time Improvements in therapies and medical management over 3me are factored in 7-8% 11-12% 19-20% 13-14% 17-18% Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16% Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics Increasing Prevalence of Diabetes Over Time Improvements in therapies and medical management over 3me are factored in 7-8% 11-12% 19-20% 13-14% 17-18% Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16% Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics Increasing Prevalence of Diabetes Over Time Improvements in therapies and medical management over 3me are factored in 7-8% 11-12% 19-20% 13-14% 17-18% Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16% Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics 2030
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Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics
Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics
Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics
Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics
Early Detection of Diabetes-Induced Retinal Vascular & Neural Dysfunction
n Careful dilated fundus exam, including the periphery
n OCT and OCTA n Multi-spectral Imaging/FAF n Widefield Retinal Imaging n Macular pigment optical density n ERG/VEP n Contrast sensitvity n Threshold Color Contrast Vision n Threshold perimetry (FDT)
Retinal Vasculopathy
Retinal Neuropathy
Peripheral DR n Predominantly peripheral diabetic
retinopathy lesions (PPL) significantly associated with increased non-perfusion, risk of progression and 50% more Hm/ma detected with UWF imaging than SSFP
n DRCR.net Proocol AA is attempting to confirm the predictive value of PPL and association with other diabetes comorbidities
Superficial capillary plexus Deep capillary plexus
OCTAshowsDRNOTseenonclinicalexam
OCTA Findings Linked to DR Progression
n 57 eyes with mild/moderate/severe NPDR and PDR
– retrospective analysis
n Increased FAZ, and both decreased vessel density and flow area in the DCP were highly associated with worsening DR severity (p < 0.01) ARVO 2017
OCTA Identifies Pre-Clinical DR
n Parafoveal vessel density in the choriocapillaris, superficial and deep capillary plexi of diabetes subjects is significantly reduced compared to controls
n Density normals > DM sans DR > DM with DR
n OCTA showed ma and nonperfusion in 11%/25% of patients without clinical DR
Licensed, developed, and produced under CRADA by Konan Medical USAin collaboration with the United States Air Force School of AerospaceMedicine OBVA (Operational Based Vision Assessment Laboratory).Copyright 2017. All rights reserved.
KonanMedical.com/ColorDx
nameVickie Saugen
test methodCCT HD (8bit)
scoring methodUSAFOBVA160701
ID test IDS | OD - OS
test date | time13 Dec 2017 | 14:16:40
age63
eye(s)OD, OS
app version0.1.92
genderFemale
distance2 feet
last calibration01 Sep 2017 | 10:10:17
PsiCone Threshold Trials
AveTime Score Category¹
OD Blue S 33.1% 30 6.4 68 Color Deficient (Tritan)
OS Blue S 75.0% 30 5.6 33 Color Deficient (Tritan)
¹Cut-off criteria are physician-selected from USAF, or user input score method ranges and corresponding assigned categories.
D A
T A
R E
S U
L T
S
Chous Eye Care Associates
Licensed, developed, and produced under CRADA by Konan Medical USAin collaboration with the United States Air Force School of AerospaceMedicine OBVA (Operational Based Vision Assessment Laboratory).Copyright 2017. All rights reserved.
KonanMedical.com/ColorDx
nameVickie Saugen
test methodCCT HD (8bit)
scoring methodUSAFOBVA160701
ID test IDS | OD - OS
test date | time13 Dec 2017 | 14:16:40
age63
eye(s)OD, OS
app version0.1.92
genderFemale
distance2 feet
last calibration01 Sep 2017 | 10:10:17
PsiCone Threshold Trials
AveTime Score Category¹
OD Blue S 33.1% 30 6.4 68 Color Deficient (Tritan)
OS Blue S 75.0% 30 5.6 33 Color Deficient (Tritan)
¹Cut-off criteria are physician-selected from USAF, or user input score method ranges and corresponding assigned categories.
IMPACT OF INTESIVE THERAPY OF DIABETES: Summary of Major Clinical Trials
Trial Microvascular
UKPDS
DCCT/EDIC*
ACCORD
ADVANCE
VADT
Initial Trial Long-Term Follow-up
*T1DM
UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:854 Holman RR et al. N Engl J Med. 2008;359:1577 DCCT Research Group. N. Engl J Med 1993;329:977 Nathan DM et al. N Engl J Med. 2005;353:2643 Gerstein HC e al. N Engl J Med. 2008; 358:2545 Duckworth W et al. N Engl J Med. 2009; 360;129
Ø United Kingdon Prospective Diabetes Study Ø Diabetes Control & Complication Trial Ø Epidemiology of Diabetes Interventions &
Complications Ø Action to Control Cardiovascular Risk in Diabetes Ø Action in Diabetes and Vascular Disease Ø Veterans Affairs Diabetes Trial
Metabolic Memory
Good Control Does NOT Eliminate Risk of Severe DR � 10 year risk of PDR and/or CSME
in a newly Dx patient with A1c = 6.5% and BP = 120/80 is nearly 4%
� With mild NPDR the 10 yr risk is 8.4%
Diabetologia. 2011 Oct;54(10):2525-32
BloodGlucoseReality
� Many patients never or rarely check their glucose
� Many patients never get A1c < 7% within the first 5 years - when tight glucose control is most effective at preventing DR
n VinegarimprovesinsulinsensiCvityinIRsubjectsDiabetesCare.2004Jan;27(1):281-2
n 2Tbspvinegarconsumedbeforea75gCHOmealpreventedpost-prandialglucosespikesinptswithT1DMandreducedAUCBGby20%• AceCcaciddelaysgastricemptyingandenhancesglycogenrepleCon
Mean Change/SD in visual function measures, serum lipids, hsCRP, TNF-α, glycohemoglobin, foveal thickness and symptoms of diabetic peripheral neuropathy with 95% p-Values
Evidence-Based Tips To Avoid Diabetes n Exercise 30 minutes each day (soon after waking) &
minimize added sugars n Eat a predominantly plant based diet including a variety
of fruits and vegetables and more vegetables n Minimize processed meats n Drink coffee or tea n Sleep > 6 hours per night and < 9 hours n Get your serum vitamin D > 40 ng/ml n Don’t smoke n Live away from smog n Breast Feed n Turn down the thermostat n Reduce Light at Night n Fast if you’re obese
Am J Med. 2013 Jul;126(7):583-9
2014 US Surgeon General’s Report
Am J Med. 2013 Jul;126(7):583-9
Am J Med. 2013 Jul;126(7):583-9 Am J Med. 2013 Jul;126(7):583-9
Am J Med. 2013 Jul;126(7):583-9
Sleep Med Rev. 2015 Oct 21;30:11-24 PLoS One. 2015; 10(11): e0141724.
Curr Nutr Rep. 2014 Dec 1; 3(4): 364–378. Environ Health Perspect. 2015 May; 123(5): 381–389
ReversingT2DM
Patient PK
n 52yomale-T2DMx2years–noDRn Me}ormin+Januvia®(sitaglip)n)
n A1c6.6%atDx,loweredonmedsbutnow7.4%andplacedoninsulin(Lantus®)QHS
n BMI38atDxandnow40kg/m2
n Wediscussedop)ons,includingalternatedailyfas)ng(ADF)combinedwithPaleo-typelowcarbdieton‘feedingdays’
PK6monthslatern 35lbsweightloss(BMI=30Kg/m2)
n A1cnow5.4%andhasdiscon)nuedinsulinandJanuvia
n PKreportsincreasedenergy,libidoandclearerthinking
n “ThiswasthebestthingI’veeverdone”
2/28/19
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Why ODs Should Be on The Diabetes Care Team
n We are often gate keepers into the health care system for many patients
n Diabetes and diabetic retinopathy are largely preventable conditions and ODs do a fabulous job educating our patients
n DM an DR cases continue to climb
n Our countries, communities, other HCPs and patients need us