Diabetic Eye DiseaseDr Stuti Misra BOptom PhDDepartment of Ophthalmo - PDF document

Diabetic Eye DiseaseDr Stuti Misra, BOptom, PhDDepartment of OphthalmologyUniversity of Auckland What is diabetes?Disorder of

carbohydrate metabolismLack of effect or production of endogenous insulinType 1 and Type 2Multiple organ involvement Orga

ns affectedLarge blood vessel disease HeartNervous system Peripheral vascular diseaseSmall blood vessel diseaseEyesKidneysNer

vous system Ocular surface: Tear film and CorneaTear film Dry eyeReduced tear quantity Reduced tear film stabilityReduced cor

neal sensitivityGreater risk of viral and fungal infections Kaiserman et al., Ophthalmology2005; Herpetic eye disease in d

iabetic patients. # Gopinathan et al., Cornea2002; The epidemiological features and laboratory results of fungal keratit

is: a 10year review at a referral eye care center in South India. Corneal nerve damage KeratopathySuperficial punctate kerat

itisRecurrent corneal erosionsPersistent epithelial defects Iris, Pupil and Crystalline lensMioticPupilIris neovascularisatio

nLenticular induced myopic shiftCataract (postsubcapsular RetinaDiabetic retinopathy Two main retinal diseases in the o

lder patientDiabetic retinopathyAge related macular degenerationHow to tell the difference????? Diabetic retinopathyAccounts

for �90% blindness under the age of 60Age related macular degenerationAccounts for �90% blindness over the age

of 60. Key differential in retinal macular haemorrhagesPrincipally, either diabetic maculopathy* or age related macular degen

erationLess commonly branch retinal vein occlusion*Differentiate can be tricky:Age ARMD � 60 yrsAge DR60yrsDiabetic ma

culopathy* by itself is uncommonLook for retinopathy beyond macula* Clinical featuresRed bits (small and or large)Blood: micr

oaneurysms, haemorrhages White/yellow bitsCotton wool spots, drusen & exudate Brown/black bitsLaser, pigment Normal Red Bit

s: small Red bits: larger Red Bits: Large Red Bits: LargeAnd Yellow bits Red Bits: LargeAnd Yellow bits Yellow bits= exudate

Red Bits: LargeAnd Yellow bitsAnd brown/black bits More than one vessel involved All the retinal signs accounted for !!Block

ed vessels lead to retinal haemorrhagesCotton wool spotsAbnormal retinal vesselsVenous “sausaging”, irregularity In

traretinal microvascular anomaliesDisc new vesselsRetinal new vessels All the retinal signs accounted for !!Leaking vessels l

ead to Protein (hard exudate)HaemorrhageFluid (diffuse and local)Intraretinal and Subretinal FluidExudate*OCT scan showing fl

uid (oedema) Diabetic retinopathy (DR)How we classify it.Background: bits and bobs but good vision.Preproliferative/ Prolifer

ative: Ischaemic signs of varying degree leading to “new vessel growth”Maculopathy: involvement of the macula Class

ification of retinopathyvessel blockageNo retinopathyProliferativeNon proliferative Background Increasing Ischaemia Classific

ation of retinopathyvessel leakageNo leakageLeakage Focal DiffuseIschaemic Nonproliferative SignsMicroaneurysmsIntraretinalha

emorrhagesHard/Soft exudates Venous changes Proliferative retinopathyNeovascularisation Intraretinal microvascular abnormalit

ies (IRMA) Diabetic Macular oedema Leakage of plasma through vascular abnormalities produces retinal oedema Classification of

maculopathyvessel leakage/blockageMaculopathyFocalFocal area of leakDiffuseGeneral leakIschaemicLoss of blood supply Maculop

athyFocalFluid, lipid and proteins leak from a focal group of microaneurysm often leaving a well defined yellow ring ring or

circinate exudateIschaemiccapillaries underlying the fovea are all occludedDiffuseall the capillaries leak. Normal vasculatu

re Fluorescein angiogram Ischaemic maculopathy Screening Programs in NZWellington (Example)13,000 diabetic in Wn400 patients

screened Social EngineeringHealthy LivingExerciseWeight lossSupport groupsExpensive, difficult to measure outcomes, political

ly unpopular Why should we be interested?Increasing No’s 160,000 diabetics by 2026MOH 2006. in Evidence based Best Pract

ice GuidePersonal costMorbidity, reduced life expectancy etcEconomic cost Lost opportunities,Tx $1,000 million for type 2 by

2021Diabetes Inc 2001 Why are we interested?Retinopathy present in 1/3rd of diabetics8% have retinopathy at diagnosisLeading

cause of blindness in working agegroupPrompt recognition and treatment of sightthreatening eye disease can prevent sightloss

Treatment of retinopathyHistorically no treatment“diabetics died” before chronic complications developedHistoricall

y poor systemic treatmentLaser protocols for blockage e.g. pan retinal photocoagulationLaser protocols for leakage e.g. focal

laser BevacizumabAvastinHelp reducing macular oedema and neovascularisation General managementEducation and supportInstitute

good diabetic controlLifestyle changesWeight lossDietary modificationExerciseCessation of smokingCarbohydrate control DietOr

al hypoglycemicsInsulinControl BP & LipidsMonitor renal functionManagement of the complications of diabetesProgrammes “G

et Checked” . Budget 2006 $76m for obesity. CM “Lets Beat Diabetes” Risk of retinopathyDuration of DMGlycaemic

controlHypertensionLipid statusAnaemiaPregnancyObesitySmokingAlcohol useOther Systemic diseaseEthnicity SummaryBlood and stu

ff in both retinae = diabetic retinopathy if pt 60yrsIf macula involvement = maculopathyIf no macula involvement think “