Prof A E OMOTI MBBS FWACS FMC Oph PROFESSOR amp HEAD DEPT OF OPHTHALMOLOGY UBTH INTRODUCTION Diabetes Mellitus DM is a metabolic disorder characterised by chronic hyperglycaemia due to absolute or relative insulin deficiency or resistance or both ID: 1041951
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1. DIABETES MELLITUS AND THE EYEProf A E OMOTIMBBS, FWACS, FMC (Oph),PROFESSOR & HEADDEPT OF OPHTHALMOLOGYUBTH
2. INTRODUCTIONDiabetes Mellitus (DM) is a metabolic disorder characterised by chronic hyperglycaemia due to absolute or relative insulin deficiency or resistance or both.Type 1 and Type 2. Type 2 more prominent
3. Diabetes Mellitus is a multisystem disease which affects the heart, kidneys, nervous system and the eyes. The overall manifestation of Diabetes Mellitus in the eye is referred to as Diabetic Eye Disease. The effects are seen in every part of the eye
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5. ADNEXADiabetic patients may manifest Xanthelasma Palpebrum (XP). These are yellow plaques that occur most commonly near the inner canthus of the eyelid. They may be unilateral or bilateral. In a study by Dey et al, 18.03% of all the patients with xanthelasma palpebrum were observed to be diabetic.
6. Xanthelasma PalpebrumYellowish, subcutaneous plaques containing cholesterol and lipid Usually bilateral and located medially
7. Adnexal manifestationsDiabetics have an increased incidence of styes and chronic blepharitis. More likely to be colonized by bacteria such as Staphylococcus Aureous and Staphylococcus Epidermidis that commonly cause these disorders
8. External hordeolum
9. ConjunctivaThere is a loss of capillaries and macrovascular dilatation and tortuosity of conjunctival vessels. The macrovessel dilatation may result in vessel engorgement and straightening, especially among those with longer duration of diabetes.Diabetics have a greater frequency of conjunctival microaneurysms
10. Conjunctiva There is increased risk of acute infective conjunctivitis in individuals with diabetes in both sexes and all age groups.
11. Dry eye syndrome has been associated with diabetes. Manaviat et al found the prevalence of dry eye syndrome among type 2 diabetics to be 54.3% There was significant association with dry eyes and the duration of diabetes. Using impression cytology analysis, the average grade of squamous cell metaplasia is significantly higher in the diabetics and goblet cell density is significantly lower in the diabetics
12. CorneaIncreased incidence of bacterial keratitis especially uncontrolled DMCorneal ulcers due to Moraxella liquefaciens more common in diabeticsDiabetics more prone to recurrent corneal erosions and to slow healing of corneal wounds
13. Keratoepitheliopathy Corneal sensitivity is reduced in diabetic patients. Epithelial basement membrane in diabetic eyes is poorly adherent to stroma, in part due to decreased numbers of hemidesmosomes, leading to sloughing of entire layer when traumatized.Diabetic corneas do not recover from edema as quickly as normal corneas
14. CorneaThe central corneal thickness (CCT) has been found to be thicker in diabetics than in non-diabetics. significantly lower corneal endothelial function in non-insulin dependent diabetes mellitus.Reduced corneal endothelial cell density, endothelial polymegathism, pleomorphism, increased corneal thickness and increased corneal autoflourescence have been reported in diabetics
15. Cornea – normal cell morphology
16. Cornea – Diabetic Patient
17. AQUEOUS HUMOR Though the dynamics of aqueous flow are not affected to any clinically significant extent in the early or middle stages of diabetic retinopathy , there is a tendency toward lower aqueous humor flow in advanced stages. The aqueous levels of angiogenic and anti-angiogenic growth factors are altered in diabetes. The aqueous fluid content of vascular endothelial growth factor (VEGF) is increased in diabeticsPigment epithelial derived factor (PEDF) is decreased in DM patients
18. Pupils and IrisPupils are miosed in DM especially in patients with diabetic retinopathy (DR)Reduced fluctuations in pupil size and difficulty with dilatationPionter to diabetic autonomic neuropathy (DAN)
19. Rubeosis Iridis
20. RUBEOSIS IRIDISIris neovascularisation {NVI} was first characterized by Salus in 1928Incidence is 1-10% in all diabetics but 64% among patients with DRIt precedes neovascular glaucoma (NVG)Without therapy NVI progresses to NVG in 41.4% within 12months
21. Ocular neovascularisation is due to ocular ischaemia / hypoxiaHypoxia leads to increase VEGF elaboration which in turn causes NVI and DRProliferative DR causes 8.3- 56% of NVG
22. GLAUCOMA DM has been associated with POAG in many studies such asBlue Mountain Eye StudyWinsconsin epidemiological survey of diabetic retinopathy (WESDR)Los Angeles Latino Eye Study (LALES)Ibadan Glaucoma studyGlaucoma is commoner in diabetics than non-diabetics
23. In the Blue Mountain Eye study in Australia, the prevalence of glaucoma was higher in diabetics (5.5%) compared with non-diabetics (2.8%) Diabetes was present in 13% of people with glaucoma compared with 6.9% of those without glaucoma
24. The risk of developing glaucoma among diabetics increases with duration of disease and the age of the patientGlaucoma was found to be commoner in older diabetics using insulinIn Nigeria, the Ibadan Glaucoma Study, found the presence of chronic diseases such as DM as a factor associated with glaucoma
25. Refractive error changesDM has been associated with changes in refractive error. The direction of the shift in refractive state is dependent on the glycemic stateRefractive power of the eye varies directly as the sugar content of the blood; with a tendency to hypermetropia with decreased sugar and myopia with increased sugar
26. Ciliary BodyIn diabetes, increased glucose in aqueous is deposited in ciliary body, decreasing mobility and thus accomodationResults in early presbyopia in diabetics
27. CataractsA cataract is an opacity of the crystalline lensVarious studies have associated cataracts with DMPoor glycaemic control and duration of disease are significant independent predictors of development of cataract in diabetics DM is risk factor for senile cataractDiabetics are more likely do develop pre-senile cataract than non-diabetics
28. Posterior subcapsular cataract (PSC) have been associated with DMThe Lens Opacity study found that DM increased the risk of having PSC, cortical, nuclear and mixed cataracts
29. Sugar cataract
30. Infection - EndophthalmitisSeveral studies have shown increased risk of post-operative endophthalmitis in diabeticsNot surprising since diabetics have been shown to have impaired cellular and humoral immunity as well as delayed wound healing after surgeryMay also be because diabetics often have more complicated surgeries and longer operative time (although this was controlled for in some trials)
31. Infection - MucormycosisOver 50% of mucor cases occur in diabetics, especially in patients with ketoacidosisUsually originates in sinusesComplete internal and external ophthalmoplegia, decreased vision, proptosis, ptosis, chemosis, black eschars and dischargeVascular invasion and tissue necrosisMortality over 50%
32. Mucormycosis
33. Diabetic PapillopathyDiabetic papillopathy is a unilateral or bilateral transient swelling of the optic disc with minimal deterioration of the vision It is seen in both type 1 and type 2 DM. It may be distinguished from anterior ischaemic optic neuropathy by the young age, minimal optic nerve dysfunction and remission
34. Diabetic Papillopathy
35. Non-Arteritic Anterior Ischemic Optic NeuropathySudden onset, non-progressive monocular visual loss, usually in elderly patients, often noticed upon wakingSwollen optic nerve, RAPD, dyschromatopsia, inferior altitudinal visual field defect
36. Non-arteritic anterior ischaemic optic neuropathyDiabetes Mellitus is one of the vasculopathic risk factors cited for the development of Non-arteritic anterior ischaemic optic neuropathy (NAION). Lee et al found that having DM was associated with a 43% risk of having NAION.Occurs 2.7 to 5 times more commonly in diabetics than non-diabetics, especially with co-morbid hypertension
37. Superior Segmental Optic Nerve HypoplasiaChildren born to mothers with Type 1 DM may have superior segmental optic nerve hypoplasiaOften asymptomatic with inferior visual field defects or have long history of tripping or running into things at their feetRates as high as 8.8% of children of Type I diabetics have been reported in small studiesPathogenesis unknown
38. Retinal vascular occlusions (RVO)Retinal vascular occlusions are infrequent in the general population. DM, hypertension and peripheral arterial disease increased the risk of developing retinal vascular occlusions. RVO is commoner in type 2 DM In DM patients with RVO, hypertension and hyperlipidaemia were the main underlying conditions.
39. BRVO
40. CRVO
41. Cranial nerve abnormalitiesIn 25-30% of patients above the age of 45 years with acute extraocular muscle palsy, diabetes is the underlying cause. Isolated third, fourth and sixth nerve palsies are due to small vessel occlusion. Third nerve palsies may be painful in up to 20% of cases and the pupil is spared in 80%. If the pupil is involved (20%), the effect is usually subtle with an anisocoria of <1 mm rather than the fully dilated unreactive pupil found in compressive lesions. Most patients recover after weeks or months but the condition may recur.
42. Applied anatomy of pupillomotor nerve fibres
43. Left third nerve palsy
44. Left third nerve palsy
45. Recent right sixth nerve palsy
46. Diabetic RetinopathyDR is a microangiopathic complication of DM with potentially devastating effect on visionIt accounts for 5% of global blindnessLeading cause of blindness in the developed worldIt is now a target disease in Vision 2020
47. Rare in children <10 years oldAbsent within 4 years in type 1Incidence rises after pubertyAfter 20 years: 100% in type1; 60%in type IIRigorous glycemic control delays onset & retards progression of retinopathy (DCCT;UKPDS;WESDR)Presence of retinopathy indicates long standing poorly controlled diabetes
48. Prevalence of DR in Germany is 10.6% and 15.3% in Australia In India the prevalence was 17.6% In the USA, 40.3% of all diabetics over 40 years of age have some form of DR. The prevalence of DR is 45.7% among type 1 DM pts and 25.3% among type 2 DM patients In Singapore the prevalence of DR is 38.1% In sub-Saharan Africa, Glover et al, found the DR prevalence to be 32.5%
49. In Nigeria prevalence levels vary geographically. In Ibadan a prevalence of 42.1% was reported.Magulike et al in the South-East had a value of 12.7% Lawan found the prevalence of DR in Kano to be 36%
50. Risk factors Duration of diabetesPoor controlHypertensionPregnancyNephropathyHyperlipidaemiaAnaemiaSmoking Obesity Cataract surgery
51. Pathogenesis Cellular damage : mechanisms include intracellular sorbitol accumulation, oxidative stress due to free radicals excess, accummulation of advanced glycation end products and excessive activation of several protein kinase C isoforms
52. Capillaropathy characterized by pericyte death, thickening of capillary basement membrane, loss of vascular smooth muscle and proliferation of endothelial cells. This manifests as leakage and occlusion
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54. Consequences of retinal ischaemiaConsequences of retinal ischaemia
55. Consequences of chronic leakageConsequences of chronic leakage
56. Diabetic retinopathy
57. OCT of normal & cystoid macula oedema
58. NeovascularisationCapillary non-perfusion leads to retinal hypoxia which may progress to neovascularisation (pre-retinally and intraretinally). New vessels are due to an imbalance in angiogenic and anti-angiogenic factors in an attempt to revascularize hypoxic retina
59. DR is a microvascular disease characterized bymicroaneurysms, retinal hemorrhage, hard exudates, cotton wool spots, new vessels, vitreous hemorrhage & tractional retinal detachmentFeatures – same in types I & II diabetes
60. Non proliferative diabetic retinopathy
61. Non proliferative diabetic retinopathy
62. Proliferative diabetic retinopathy
63. NON PROLIFERATIVE DIABETIC RETINOPATHY NPDRVERY MILD NPDRMicroaneurysms onlyMILD NPDRAny or all: microaneurysms, hmrges, exudates, cotton wool spotsMODERATE NPDRSevere hmrges (1-3 quadrants), venous beading, cotton wool spotsSEVERE NPDRSevere hmrges (4 quadrants),or severe venous beading(2 quadrants),or IRMA VERY SEVERE NPDRAny two of the features of Severe NPDRPROLIFERATIVE DIABETIC RETINOPATHY PDRMILD-MODERATENVD, NVEHIGH RISKNVD =1/3 disc area, NVD + vitreous hmrge, NVE> ½ disc area + vit. hmrgeADVANCED DIABETIC EYE DISEASEVitreous hmrge, tractional RD
64. MACULAR OEDEMAGENERAL PRACTIONEROPHTHALMOLOGISTMACULAR OEDEMA ABSENTNO EXUDATES OR RETINAL THICKENING IN P.PREVIEW IN 12 MONTHSMILD MACULAR OEDEMA EXUDATES OR RETINAL THICKENING @ PP, >1DD FROM FOVEAREVIEW IN 6 MONTHS.MODERATE MACULAR OEDEMAEXUDATES OR RETINAL THICKENING AT PP,≤ 1DD FROM FOVEAREFER TO EYE CLINIC. ENSURE STRICT BP AND BLOOD SUGAR CONTROLLASER TREATMENT IF CSMO. REVIEW IN 6 MTHS IF NO CSMOSEVERE MACULAR OEDEMAEXUDATES OR RETINAL THICKENING AFFECTING CENTRE OF FOVEAREFER TO RETINAL CLINIC LASER TREATMENT OR INTRAVITREAL ANTI-VEGF
65. High risk retinopathy In defining high risk retinopathy the following characteristics are used:1. Presence of new vessels2. Location of new vessels3. Size of new vessels4. Presence of pre-retinal or vitreous hemorrhage
66. The features of high risk diabetic retinopathy are as follows:- Optic disc new vessels (NVD) greater than or equal to one third to a half of the disc area- NVD in the presence of vitreous or pre-retinal hemorrhage or- New vessels elsewhere (NVE) greater than a half of the disc area in the presence of vitreous or pre-retinal hemorrhageWhere both NVE and NVD coexist, only NVD counts.
67. NVD
68. NVD and NVE
69. Pre-retinal haemorrhage
70. Tractional RD
71. SCREENING Regular fundus exam - dilated ophthalmoscopy - retinal photographyFor those diagnosed <30 years age: examine by 5 years of onsetFor those >30 years examine at diagnosis
72. Treatment optionsLaser therapy- Argon or diode laserIntravitreal anti-vascular endothelial growth factor (anti-VEGF) agent- RanibizumabIntravitreal triamcilononeRetinal detachment surgeryVitrectomy
73. Laser therapy-
74. Laser panretinal photocoagulation
75. Indications for vitreoretinal surgerySevere persistent vitreous haemorrhageDense, persistent premacular haemorrhage
76. Indications for vitreoretinal surgeryProgressive proliferation despite laser therapyRetinal detachment involving the macula
77. PreventionHealth educationTight glycemic controlLife-long regular eye checkAll doctors to do ophthalmoscopy
78. CONCLUSIONThe eyes are significantly affected in DMProper glycemic control and regular eye checks are important in preventing the blinding complications of DM Early referral and treatment is recommended to prevent blindness
79. Thank you for listening