Diabetic Eye Disease Eye Care about My ABCs A Healthy Eyes Healthy People Project Sponsored in part by the AOA and VSP

Diabetic Eye Disease in Indiana Over 112,000 people in Indiana alone have diabetic retinopathy. That’s ~20% of diabetics. In Indiana, ~60% of diabetics receive an annual eye exam. Each year - ~12,000 – 24,000 new cases of blindness.

Over 112,000 people in Indiana alone have diabetic retinopathy.

That’s ~20% of diabetics.

In Indiana, ~60% of diabetics receive an annual eye exam.

Each year - ~12,000 – 24,000 new cases of blindness.

Diabetes in Indiana

Diabetic Retinopathy in Indiana

Where does it affect the eye? Lens: variations in blood sugar can cause variations in the power of the lens. Uncontrolled diabetics are prone to intermittent blurry vision. Retina: Diabetic Retinopathy is when the eye’s blood vessels become leaky and can ultimately bleed profusely.

Lens: variations in blood sugar can cause variations in the power of the lens. Uncontrolled diabetics are prone to intermittent blurry vision.

Retina: Diabetic Retinopathy is when the eye’s blood vessels become leaky and can ultimately bleed profusely.

Ocular Symptoms Blurred Vision- As the power of the lens changes, patients experience unstable blurred vision that fluctuates over weeks to months. Diplopia- Retinal (macular) edema can produce a myriad of optical nuances. Vision Loss- If retina is damaged, vision can be lost permanently.

Blurred Vision- As the power of the lens changes, patients experience unstable blurred vision that fluctuates over weeks to months.

Diplopia- Retinal (macular) edema can produce a myriad of optical nuances.

Vision Loss- If retina is damaged, vision can be lost permanently.

When does Diabetes start affecting the Eye? Two determining factors: Blood Glucose Control Duration of Diabetic Status As childhood obesity increases, type 2 diabetes begins earlier.

Two determining factors:

Blood Glucose Control

Duration of Diabetic Status

As childhood obesity increases, type 2 diabetes begins earlier.

When does Diabetic Retinopathy arise? Prevalence of Diabetic Retinopathy: At Diagnosis: 10 years after Diagnosis: 20 years after Diagnosis: Type I Type II 20% 40-50% 100% 60%

Prevalence of Diabetic Retinopathy:

At Diagnosis:

10 years after Diagnosis:

20 years after Diagnosis:

Type I

Type II

20%

40-50%

100%

60%

The Diabetic Eye Exam History Visual Acuity Eye Movement Refraction Intraocular Pressure measurement Visual Field evaluation Dilated Retinal examination

History

Visual Acuity

Eye Movement

Refraction

Intraocular Pressure measurement

Visual Field evaluation

Dilated Retinal examination

Dilated Retinal Examination Fundus Lens and Slit Lamp Evaluation Binocular Indirect Opthalmoscope

The importance of Dilation Undilated pupil Same Eye-- pupil dilated

Clinical Classification Mild Nonproliferative Diabetic Retinopathy Moderate Nonproliferative Diabetic Retinopathy Severe Nonproliferative Diabetic Retinopathy Proliferative Diabetic Retinopathy

Mild Nonproliferative Diabetic Retinopathy

Moderate Nonproliferative Diabetic Retinopathy

Severe Nonproliferative Diabetic Retinopathy

Proliferative Diabetic Retinopathy

Mild and Moderate Nonproliferative Diabetic Retinopathy Dot and blot hemorrhaging Aneurysms Hard exudates Clinically Significant Macular Edema ( CSME) decreased vision

Dot and blot hemorrhaging

Aneurysms

Hard exudates

Clinically Significant Macular Edema ( CSME)

decreased vision

Mild Nonproliferative Diabetic Retinopathy Dot Hemorrhage

Moderate Nonproliferative Diabetic Retinopathy Dot Hemorrhages Blot Hemorrhages Hard Exudates

Severe Nonproliferative Diabetic Retinopathy Intra Retinal Microvascular Abnormalities (IRMA) Cotton wool spots- focal retinal ischemia Beading and looping of the capillaries

Intra Retinal Microvascular Abnormalities (IRMA)

Cotton wool spots- focal retinal ischemia

Beading and looping of the capillaries

Severe Nonproliferative Diabetic Retinopathy- Early Blot Hemorrhages Cotton Wool Spot Flame Hemorrhages

Severe Nonproliferative Diabetic Retinopathy- “pre-proliferative” Blot Hemorrhages Exudates Venous Beading IRMAs Looping capillaries

Proliferative Diabetic Retinopathy: Neovascularization- New blood vessel growth NVI - Rubeosis Iridis NVD- optic disk NVE- elsewhere in the retina

Neovascularization- New blood vessel growth

NVI - Rubeosis Iridis

NVD- optic disk

NVE- elsewhere in the retina

Proliferative Diabetic Retinopathy: NVI – neovascularization of the iris

NVE – neovascularization elsewhere

NVD – neovascularization of the disk

Serious Diabetic Retinopathy If “neo” goes unnoticed and untreated, it will ultimately bleed . Bleeding means Blindness!

If “neo” goes unnoticed and untreated, it will ultimately bleed .

Bleeding means Blindness!

New Diagnostic Modalities Ocular Coherence Tomography –OCT is revolutionizing eye care in many instances it can be used in place of IVFA OCT is less invasive Allows for earlier and more sensitive diagnosis Takes less time Demonstrates greater anatomical details

Ocular Coherence Tomography –OCT is revolutionizing eye care in many instances it can be used in place of IVFA

OCT is less invasive

Allows for earlier and more sensitive diagnosis

Takes less time

Demonstrates greater anatomical details

IVFA

IVFA

IVFA

Normal OCT

Diabetic Retinopathy OCT

OCT-Printout

How is neovascularization treated? Focal laser treatment is used to ablate neo before bleeding occurs. If bleeding has occurred, lasers can be used to attempt to stop the bleeding and minimize loss of vision. Laser surgery does not usually improve vision, it tries to stop vision from worsening.

Focal laser treatment is used to ablate neo before bleeding occurs.

If bleeding has occurred, lasers can be used to attempt to stop the bleeding and minimize loss of vision.

Laser surgery does not usually improve vision, it tries to stop vision from worsening.

Laser treatment strategies

Pan retinal laser Laser treatment is used to destroy peripheral retina and decrease the chance of neo by decreasing the need for blood supply.

Laser treatment is used to destroy peripheral retina and decrease the chance of neo by decreasing the need for blood supply.

New Treament Options for PDR Oral Angiogenic agents are being developed to be used in conjunction with laser treatment There are two categories of oral angiogenic treatment-one is for the prevention of PDR and the other for early PDR-PKC inhibition Currently on the market-Arxxant (Eli-Lilly)-a protein kinase C beta(PKC beta) inhibitor

Oral Angiogenic agents are being developed to be used in conjunction with laser treatment

There are two categories of oral angiogenic treatment-one is for the prevention of PDR and the other for early PDR-PKC inhibition

Currently on the market-Arxxant (Eli-Lilly)-a protein kinase C beta(PKC beta) inhibitor

Other surgical treatment Vitrectomy- Non-clearing vitreal bleeds may need to be removed.

Vitrectomy-

Non-clearing vitreal bleeds may need to be removed.

Diabetic Macular Edema Can occur at any stage of diabetic retinopathy Is caused by the leakage of microaneurysms Is the main cause of visual impairment in patients with Diabetic retinopathy

Can occur at any stage of diabetic retinopathy

Is caused by the leakage of microaneurysms

Is the main cause of visual impairment in patients with Diabetic retinopathy

Classification of Diabetic Macular Edema Presents as hard yellow exudates (HYE) or thickening in the posterior pole Mild-some thickening or HYE in the posterior pole but distant from the center Moderate-approaching the center, but not involving the center Severe-Involving the center of the macula

Presents as hard yellow exudates (HYE) or thickening in the posterior pole

Mild-some thickening or HYE in the posterior pole but distant from the center

Moderate-approaching the center, but not involving the center

Severe-Involving the center of the macula

Diabetic Macular Edema Hard Exudates and Macular Edema (CSME) Intraocular steroid injections attempt to reduce edema

Treatment Options for Macular Edema Laser Treatment Steroid Implants and devices to the posterior segment New Treatment options for Macular edema Intravitreal injection of triamcinolone acetonide-for diffuse diabetic macular edema Fluocinolone acetonide intravitreal implants

Laser Treatment

Steroid Implants and devices to the posterior segment

New Treatment options for Macular edema

Intravitreal injection of triamcinolone acetonide-for diffuse diabetic macular edema

Fluocinolone acetonide intravitreal implants

Vision Loss from Diabetic Retinopathy Normal or Mild Diabetic Retinopathy Severe Diabetic Retinopathy

Additional effects on the eyes In addition to the damaging effects of diabetes on the retina, diabetic eye disease also increases the risk for developing: Cataracts- Glaucoma- NVI can lead to elevated intraocular pressure

In addition to the damaging effects of diabetes on the retina, diabetic eye disease also increases the risk for developing:

Cataracts-

Glaucoma-

NVI can lead to elevated intraocular pressure

How is Diabetic Eye Disease avoided? Eye Care About My ABCs Hg A 1c, B lood pressure, C holesterol Eye Exams Annual dilated eye exams! Diabetics with excellent control of blood sugar. Uncontrolled diabetics… Diabetics who have fluctuating blood sugar or who have shown signs of diabetic retinopathy may require more frequent exams.

Eye Care About My ABCs

Hg A 1c, B lood pressure, C holesterol

Eye Exams

Annual dilated eye exams!

Diabetics with excellent control of blood sugar.

Uncontrolled diabetics…

Diabetics who have fluctuating blood sugar or who have shown signs of diabetic retinopathy may require more frequent exams.

How to find an Optometrist Medicare beneficiaries can receive assistance: “ Diabetes Hotline” 800-826-3947 Eye Care Community Outreach (ECCO) Helping Hoosiers find and afford eye care. Dewana-317-321-1413 Kelli-317-321-1424 Indiana Optometric Association 317-237-3560 American Optometric Association www.aoa.org “Doctor Locator”

Medicare beneficiaries can receive assistance:

“ Diabetes Hotline” 800-826-3947

Eye Care Community Outreach (ECCO)

Helping Hoosiers find and afford eye care.

Dewana-317-321-1413

Kelli-317-321-1424

Indiana Optometric Association

317-237-3560

American Optometric Association

www.aoa.org “Doctor Locator”

Thanks and Credits American Optometric Association - www.aoa.org Vision Service Plan (VSP) – www.vsp.com Eye Care Community Outreach (ECCO)— Kelli Barker, MSW and Dewana Allen, MPH Helping Hoosiers find and afford eye care. Vic Malinovsky, OD, FAAO - photography Chief of Ophthalmic Disease Services at Indiana University School of Optometry Edwin C. Marshall, OD, MS, MPH- design Indiana University - Associate Dean for Academic Affairs and Student Administration, Professor of Optometry, and Adjunct Professor of Public Health, School of Medicine Jack Downey, OD- Consultant Indianapolis Eye Care Center Andrew Anderson, OD- design Gabriele Eye Institute- (574)-254-0700

American Optometric Association - www.aoa.org

Vision Service Plan (VSP) – www.vsp.com

Eye Care Community Outreach (ECCO)—

Kelli Barker, MSW and Dewana Allen, MPH

Helping Hoosiers find and afford eye care.

Vic Malinovsky, OD, FAAO - photography

Chief of Ophthalmic Disease Services at Indiana University School of Optometry

Edwin C. Marshall, OD, MS, MPH- design

Indiana University - Associate Dean for Academic Affairs and Student Administration, Professor of Optometry, and Adjunct Professor of Public Health, School of Medicine

Jack Downey, OD- Consultant

Indianapolis Eye Care Center

Andrew Anderson, OD- design

Gabriele Eye Institute- (574)-254-0700

References American Diabetes Association - www.diabetes.org Center for Disease Control – www.cdc.gov Diabetes “Sight for Life” - funded by the AOA and Roche Diagnostics Derek Y. Kunimoto MD, Kunal D. Kanitar MD, Mary S. Makar MD. Editors. Mark A. Friedberg MD, Christopher J. Rapuano MD. Founding Editors: “The Wills Eye Manual.” 4 th ed. Lippincott Williams and Wilkins 2004. Indiana State Department of Health Diabetes Prevention and Control Program. Kaiser MD, Peter, K., Neil J. Friedman MD, Roberto Pineda II MD. “The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology.” 2 nd ed. Saunders 2004. National Eye Institute - www.nei.nih.gov /health/diabetic New Hampshire “Sight for Life”

American Diabetes Association - www.diabetes.org

Center for Disease Control – www.cdc.gov

Diabetes “Sight for Life” - funded by the AOA and Roche Diagnostics

Derek Y. Kunimoto MD, Kunal D. Kanitar MD, Mary S. Makar MD. Editors. Mark A. Friedberg MD, Christopher J. Rapuano MD. Founding Editors: “The Wills Eye Manual.” 4 th ed. Lippincott Williams and Wilkins 2004.

Indiana State Department of Health Diabetes Prevention and Control Program.

Kaiser MD, Peter, K., Neil J. Friedman MD, Roberto Pineda II MD. “The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology.” 2 nd ed. Saunders 2004.

National Eye Institute - www.nei.nih.gov /health/diabetic

New Hampshire “Sight for Life”

Questions??? POP QUIZ!!!

POP QUIZ!!!

QUIZ #1 True or False People with diabetes are more likely than people without diabetes to develop certain eye diseases. True. Diabetic eye disease includes diabetic retinopathy—a leading cause of blindness in adults—cataract, and glaucoma. The longer someone has diabetes, the more likely he or she will develop diabetic eye disease.

People with diabetes are more likely than people without diabetes to develop certain eye diseases.

True. Diabetic eye disease includes diabetic retinopathy—a leading cause of blindness in adults—cataract, and glaucoma. The longer someone has diabetes, the more likely he or she will develop diabetic eye disease.

#2 True or False Diabetic eye disease usually has early warning signs. False. Often there are none in the early stages of the disease. Vision may not change until the disease becomes severe.

Diabetic eye disease usually has early warning signs.

False. Often there are none in the early stages of the disease. Vision may not change until the disease becomes severe.

#3 True or False People with diabetes should have yearly eye examinations. True . Everyone with diabetes should get an eye examination through dilated pupils at least once a year. Because diabetic eye disease usually has no symptoms, regular eye exams are important for early detection and timely treatment.

People with diabetes should have yearly eye examinations.

True . Everyone with diabetes should get an eye examination through dilated pupils at least once a year. Because diabetic eye disease usually has no symptoms, regular eye exams are important for early detection and timely treatment.

#4 True or False Diabetic retinopathy is caused by changes in the blood vessels in the eye. True . In some people, blood vessels in the retina may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina.

Diabetic retinopathy is caused by changes in the blood vessels in the eye.

True . In some people, blood vessels in the retina may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina.

#5 True or False People with diabetes are at low risk for developing glaucoma. False. Glaucoma is almost twice as likely to occur in people with diabetes than in those without the disease. Glaucoma can usually be treated with medications or laser or other surgery.

People with diabetes are at low risk for developing glaucoma.

False. Glaucoma is almost twice as likely to occur in people with diabetes than in those without the disease. Glaucoma can usually be treated with medications or laser or other surgery.

#6 True or False Laser surgery can be used to halt the progression of diabetic retinopathy. True. In laser surgery, a special beam of light is used to shrink the abnormal blood vessels or seal leaking blood vessels. Laser surgery has been proved to reduce the five-year risk of vision loss from advanced diabetic retinopathy by more than 90 percent.

Laser surgery can be used to halt the progression of diabetic retinopathy.

True. In laser surgery, a special beam of light is used to shrink the abnormal blood vessels or seal leaking blood vessels. Laser surgery has been proved to reduce the five-year risk of vision loss from advanced diabetic retinopathy by more than 90 percent.

#7 True or False People with diabetes should have regular eye examinations through dilated pupils. True. An eye examination through dilated pupils is the best way to detect diabetic eye disease, in which drops are used to enlarge the pupils. This allows the eye care professional to see more of the inside of the eye to check for signs of the disease.

People with diabetes should have regular eye examinations through dilated pupils.

True. An eye examination through dilated pupils is the best way to detect diabetic eye disease, in which drops are used to enlarge the pupils. This allows the eye care professional to see more of the inside of the eye to check for signs of the disease.

#8 True or False Cataracts are common among people with diabetes. True. People with diabetes are twice as likely to develop cataracts and to develop them at an earlier age than are those without diabetes. Cataracts can usually be treated with surgery.

Cataracts are common among people with diabetes.

True. People with diabetes are twice as likely to develop cataracts and to develop them at an earlier age than are those without diabetes. Cataracts can usually be treated with surgery.

#9 True or False People who have good control of their diabetes are not at high risk for diabetic eye disease. False. Even with good control of blood glucose, there is still a risk of developing diabetic eye disease. However, studies show that careful management of blood sugar levels slows the onset and progression of diabetic retinopathy.

People who have good control of their diabetes are not at high risk for diabetic eye disease.

False. Even with good control of blood glucose, there is still a risk of developing diabetic eye disease. However, studies show that careful management of blood sugar levels slows the onset and progression of diabetic retinopathy.

#10-- True or False The risk of blindness from diabetic eye disease can be reduced. True. With early detection and timely treatment, the risk of blindness from diabetic eye disease can be reduced.

The risk of blindness from diabetic eye disease can be reduced.

True. With early detection and timely treatment, the risk of blindness from diabetic eye disease can be reduced.