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Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
Diabetes and hga1c
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Diabetes and hga1c

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How does your glucose levels affect your life, sight, and life

How does your glucose levels affect your life, sight, and life

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  • Infections: pneumonia, flu, death Dental disease Almost one-third severe periodontal diseases Complications of pregnancy major birth defects excessively large babies Nervous system disease About 60% to 70% mild to severe forms of nervous system damage Amputations More than 60% of nontraumatic lower-limb amputations. In 2000-2001, about 82,000 lower-limb amputations on DM Heart disease and stroke leading cause of diabetes-related deaths. High blood pressure 73% of adults with diabetes have blood pressure
  • Infections: pneumonia, flu, death Dental disease Almost one-third severe periodontal diseases Complications of pregnancy major birth defects excessively large babies Nervous system disease About 60% to 70% mild to severe forms of nervous system damage Amputations More than 60% of nontraumatic lower-limb amputations. In 2000-2001, about 82,000 lower-limb amputations on DM Heart disease and stroke leading cause of diabetes-related deaths. High blood pressure 73% of adults with diabetes have blood pressure
  • Infections: pneumonia, flu, death Dental disease Almost one-third severe periodontal diseases Complications of pregnancy major birth defects excessively large babies Nervous system disease About 60% to 70% mild to severe forms of nervous system damage Amputations More than 60% of nontraumatic lower-limb amputations. In 2000-2001, about 82,000 lower-limb amputations on DM Heart disease and stroke leading cause of diabetes-related deaths. High blood pressure 73% of adults with diabetes have blood pressure
  • Infections: pneumonia, flu, death Dental disease Almost one-third severe periodontal diseases Complications of pregnancy major birth defects excessively large babies Nervous system disease About 60% to 70% mild to severe forms of nervous system damage Amputations More than 60% of nontraumatic lower-limb amputations. In 2000-2001, about 82,000 lower-limb amputations on DM Heart disease and stroke leading cause of diabetes-related deaths. High blood pressure 73% of adults with diabetes have blood pressure
  • Diabetes mellitus (DM) major medical problem throughout the world. Diabetes causes wide array of long-term systemic complications considerable impact the patient and the society
  • Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.
  • Familial clustering Mutation of aldose reductase gene Increased risk of nephropathy (Type I) Heesom, et al, 1997 Earlier onset of diabetic retinopathy (Type II) Ko, et al, 1995
  • Opening of tight junctions between endothelial cells Endothelial cell fenestration RPE plasma membrane infoldings Endocytic vesicle transport
  • Total prevalence of diabetes among people aged 20 years or older, United States, 2002 Age 20 years or older: 18.0 million; 8.7% of all people in this age group have diabetes. Age 60 years or older: 8.6 million; 18.3% of all people in this age group have diabetes. Men: 8.7 million; 8.7% of all men aged 20 years or older have diabetes. Women: 9.3 million; 8.7% of all women aged 20 years or older have diabetes.
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    • 1. Damien Luviano, MD, FACS
    • 2. <ul><li>What is Diabetes? </li></ul>Damien Luviano, MD, FACS
    • 3. <ul><li>Diabetes: </li></ul><ul><ul><li>Impaired Insulin </li></ul></ul><ul><ul><li>leads increased glucose </li></ul></ul><ul><ul><li>Increased glucose Damages blood vessels </li></ul></ul><ul><ul><li>Tissues are deprived of blood, thus injured </li></ul></ul><ul><ul><ul><li>Brain-Stroke </li></ul></ul></ul><ul><ul><ul><li>Heart- Myocardial Infarctions </li></ul></ul></ul><ul><ul><ul><li>Dental-Periodontal Disease </li></ul></ul></ul><ul><ul><ul><li>Eye-Retinopathy </li></ul></ul></ul><ul><ul><ul><li>Kidney-Nephropathy </li></ul></ul></ul><ul><ul><ul><li>Nerves-Neuropathy </li></ul></ul></ul>Damien Luviano, MD, FACS
    • 4. <ul><li>How do I know I have it? </li></ul><ul><li>Diagnosis </li></ul>Damien Luviano, MD, FACS
    • 5. <ul><li>DIAGNOSE </li></ul><ul><li>Fasting Plasma Glucose FPG </li></ul><ul><li>HgA1c </li></ul><ul><ul><li>3 month Average </li></ul></ul><ul><li>Oral Glucose Tolerance </li></ul><ul><ul><ul><li>At 2 hrs </li></ul></ul></ul><ul><ul><ul><li>140-199 prediabetes </li></ul></ul></ul><ul><ul><ul><li>200 diabetes </li></ul></ul></ul><ul><li>FASTING PLASMA GLUCOSE FPG </li></ul><ul><ul><ul><li>Easy </li></ul></ul></ul><ul><ul><ul><li>100-125 Pre-Diabetes </li></ul></ul></ul><ul><ul><ul><li>126: Diabetes </li></ul></ul></ul><ul><ul><ul><li>Closer to 126 bad </li></ul></ul></ul><ul><ul><ul><ul><li>Patients with 95 are 50% more likely than 85 FPG </li></ul></ul></ul></ul>Damien Luviano, MD, FACS
    • 6. <ul><li>CONTROLLED </li></ul><ul><ul><li>HemoglobinA1c less 7.0 </li></ul></ul><ul><li>unCONTROLLED </li></ul><ul><li>HemoglobinA1c MORE 6.5 </li></ul><ul><ul><li>Higher incidence </li></ul></ul><ul><ul><li>Strokes </li></ul></ul><ul><ul><li>Blindness </li></ul></ul><ul><ul><li>Tooth Loss </li></ul></ul><ul><ul><li>Heart Attacks </li></ul></ul><ul><ul><li>Kidney Failure </li></ul></ul><ul><ul><li>Leg Loss </li></ul></ul><ul><ul><li>Life Loss </li></ul></ul>Damien Luviano, MD, FACS
    • 7. <ul><li>What is the big deal with a little sugar? </li></ul>Damien Luviano, MD, FACS
    • 8. <ul><li>DEATH (MORTALITY) </li></ul><ul><ul><ul><li>Brain-Stroke </li></ul></ul></ul><ul><ul><ul><li>Heart- Myocardial Infarctions </li></ul></ul></ul><ul><ul><ul><li>Infections </li></ul></ul></ul><ul><li>MISERY (MORBIDITY) </li></ul><ul><ul><ul><li>Dental-Periodontal Disease </li></ul></ul></ul><ul><ul><ul><ul><li>Tooth loss </li></ul></ul></ul></ul><ul><ul><ul><li>Eye-Retinopathy </li></ul></ul></ul><ul><ul><ul><ul><li>blindness </li></ul></ul></ul></ul><ul><ul><ul><li>Kidney-Nephropathy </li></ul></ul></ul><ul><ul><ul><ul><li>Dialysis </li></ul></ul></ul></ul><ul><ul><ul><li>Nerves-Neuropathy </li></ul></ul></ul><ul><ul><ul><ul><li>Pain </li></ul></ul></ul></ul><ul><ul><ul><li>Limb loss </li></ul></ul></ul><ul><ul><ul><ul><li>Wheel Chair </li></ul></ul></ul></ul><ul><ul><ul><li>Erectile dysfunction </li></ul></ul></ul>Damien Luviano, MD, FACS
    • 9. <ul><li>Lets talk about Eyes </li></ul>Damien Luviano, MD, FACS
    • 10. <ul><li>Blindness </li></ul><ul><ul><li>Diabetes is LEADING cause of new cases of blindness among adults aged 20-74 years. </li></ul></ul><ul><ul><li>Can occur from within months </li></ul></ul>Damien Luviano, MD, FACS
    • 11. <ul><li>TWO TYPES </li></ul><ul><ul><li>NON-PROLIFERATIVE (mild, moderate, severe) </li></ul></ul><ul><ul><li>PROLIFERATIVE (Laser) </li></ul></ul><ul><li>MACULAR EDEMA </li></ul><ul><ul><li>Present (LASER) </li></ul></ul><ul><ul><li>Absent </li></ul></ul>Damien Luviano, MD, FACS
    • 12. <ul><li>How does diabetes hurt all these organs? </li></ul><ul><li>Are all these organs connected? </li></ul>Damien Luviano, MD, FACS
    • 13. <ul><li>PATHOPHYSIOLOGY (MECHANISM) </li></ul>Damien Luviano, MD, FACS
    • 14. <ul><ul><ul><li>Genetic </li></ul></ul></ul><ul><ul><ul><li>Environmental </li></ul></ul></ul><ul><ul><ul><li>Immunological </li></ul></ul></ul><ul><ul><ul><ul><li>HLA-DR4+ and DR3 </li></ul></ul></ul></ul><ul><ul><ul><li>Long term hyperglycemia </li></ul></ul></ul><ul><ul><ul><ul><li>Most important factor at present </li></ul></ul></ul></ul>Frank RN: Etiologic mechanisms in diabetic retinopathy. In Ryan SJ, ed: Retina, Schachat AP and Murphy RP, eds vol. 2 Medical Retina,, St. Louis, 1994, Mosby, p. 1245-1246 Damien Luviano, MD, FACS
    • 15. Frank RN: Etiologic mechanisms in diabetic retinopathy. In Ryan SJ, ed: Retina, Schachat AP and Murphy RP, eds vol. 2 Medical Retina,, St. Louis, 1994, Mosby, p. 1263 Damien Luviano, MD, FACS
    • 16. <ul><li>NUMBERS </li></ul><ul><li>STATISTICS </li></ul><ul><li>DEMOGRAPHICS </li></ul><ul><li>RISK FACTORS </li></ul>Damien Luviano, MD, FACS
    • 17. Damien Luviano, MD, FACS
    • 18. Damien Luviano, MD, FACS
    • 19. Damien Luviano, MD, FACS
    • 20. <ul><li>HGA1C </li></ul><ul><li>1% REDUCES 50% RISK </li></ul>Damien Luviano, MD, FACS
    • 21. <ul><li>WHAT MAKES DISEASE WORSE? </li></ul>Damien Luviano, MD, FACS
    • 22. Adverse Risk Factors 1. Long duration of diabetes <ul><li>Obesity </li></ul><ul><li>Hyperlipidaemia </li></ul>2. Poor metabolic control 3. Pregnancy 4. Hypertension 5. Renal disease 6. Other <ul><li>Smoking </li></ul><ul><li>Anemia </li></ul>Damien Luviano, MD, FACS
    • 23. <ul><li>I SEE FINE, I HAVE NO SYMPTOMS MY DOCTOR SAYS I HAVE DIABETES DAMAGE, CAN THAT BE TRUE? </li></ul>Damien Luviano, MD, FACS
    • 24. <ul><li>SYMPTOMS </li></ul>Damien Luviano, MD, FACS
    • 25. <ul><li>In the initial stages </li></ul><ul><ul><li>NO Symptoms </li></ul></ul><ul><li>Advanced stages of the disease </li></ul><ul><ul><li>experience floaters </li></ul></ul><ul><ul><li>blurred vision </li></ul></ul><ul><ul><li>progressive visual acuity loss </li></ul></ul><ul><ul><li>Red eye </li></ul></ul><ul><ul><li>Pain </li></ul></ul>Damien Luviano, MD, FACS
    • 26. <ul><li>What does the Doctor Actually see? </li></ul>Damien Luviano, MD, FACS
    • 27. <ul><li>CLINICAL FINDINGS (DOCTOR EXAM) </li></ul>Damien Luviano, MD, FACS
    • 28. Damien Luviano, MD, FACS
    • 29. Preproliferative diabetic retinopathy Treatment - not required but watch for proliferative disease <ul><li>Cotton-wool spots </li></ul><ul><li>Venous irregularities </li></ul><ul><li>Dark blot haemorrhages </li></ul><ul><li>Intraretinal microvascular </li></ul><ul><li>abnormalities (IRMA) </li></ul>Signs Damien Luviano, MD, FACS
    • 30. Proliferative diabetic retinopathy <ul><li>Flat or elevated </li></ul><ul><li>Severity determined by comparing with area of disc </li></ul>Neovascularization Neovascularization of disc = NVD <ul><li>Affects 5-10% of diabetics </li></ul><ul><li>IDD at increased risk (60% after 30 years) </li></ul>Neovascularization elsewhere = NVE Damien Luviano, MD, FACS
    • 31. Indications for treatment of proliferative diabetic retinopathy NVD &gt; 1/3 disc in area Less extensive NVD + haemorrhage NVE &gt; 1/2 disc in area + haemorrhage Damien Luviano, MD, FACS
    • 32. <ul><li>How is the Doctor Going to Fix my eyes? </li></ul>Damien Luviano, MD, FACS
    • 33. <ul><li>TREATMENT </li></ul><ul><ul><li>NONPROLIFERATIVE </li></ul></ul><ul><ul><ul><li>Glucose Control </li></ul></ul></ul><ul><ul><li>PROLIFERATIVE </li></ul></ul><ul><ul><ul><li>Glucose Control </li></ul></ul></ul><ul><ul><ul><li>Laser of retina outside macula </li></ul></ul></ul><ul><ul><ul><li>Surgery to remove vitreous and scars (jelly) </li></ul></ul></ul><ul><ul><li>MACULAR EDEMA </li></ul></ul><ul><ul><ul><li>Glucose Control </li></ul></ul></ul><ul><ul><ul><li>Laser of Macula </li></ul></ul></ul><ul><ul><ul><li>Steroids and Avastin not FDA approved </li></ul></ul></ul><ul><ul><ul><li>Lucentis in Clinical Trials </li></ul></ul></ul>Damien Luviano, MD, FACS
    • 34. <ul><li>Spot size (200-500  m ) depends </li></ul><ul><li>on contact lens magnification </li></ul><ul><li>Gentle intensity burn (0.10-0.05 sec) </li></ul><ul><li>Follow-up 4 to 8 weeks </li></ul><ul><li>Area covered by complete PRP </li></ul><ul><li>Initial treatment is 2000-3000 burns </li></ul>Laser panretinal photocoagulation Damien Luviano, MD, FACS
    • 35. Assessment after photocoagulation <ul><li>Persistent neovascularization </li></ul><ul><li>Hemorrhage </li></ul>Poor involution <ul><li>Re-treatment required </li></ul><ul><li>Regression of neovascularization </li></ul><ul><li>Residual ‘ghost’ vessels or </li></ul><ul><li>fibrous tissue </li></ul>Good involution <ul><li>Disc pallor </li></ul>Damien Luviano, MD, FACS
    • 36. Treatment of clinically significant macular oedema <ul><li>For microaneurysms in centre of hard </li></ul><ul><li>exudate rings located 500-3000  m </li></ul><ul><li>from centre of fovea </li></ul>Focal treatment <ul><li>Gentle whitening or darkening of </li></ul><ul><li>microaneurysm (100-200  m , 0.10 sec) </li></ul><ul><li>For diffuse retinal thickening located more </li></ul><ul><li>than 500  m from centre of fovea and </li></ul><ul><li>500  m from temporal margin of disc </li></ul>Grid treatment <ul><li>Gentle burns (100-200  m , 0.10 sec), </li></ul><ul><li>one burn width apart </li></ul>Damien Luviano, MD, FACS
    • 37. Indications for vitreoretinal surgery Retinal detachment involving macula Severe persistent vitreous haemorrhage Dense, persistent premacular haemorrhage Progressive proliferation despite laser therapy Damien Luviano, MD, FACS
    • 38. <ul><li>DOCTOR </li></ul><ul><li>Glucose Control </li></ul><ul><ul><li>Goal less HgA1c 7.0 </li></ul></ul><ul><li>Hypertension Control </li></ul><ul><li>Lipid Control </li></ul><ul><li>Lasers (temporary) </li></ul><ul><li>Injections (temporary) </li></ul><ul><li>PATIENT </li></ul><ul><li>Weight Control </li></ul><ul><li>Smoking Control </li></ul><ul><li>Exercise </li></ul><ul><li>Alcohol Control </li></ul>Damien Luviano, MD, FACS
    • 39. <ul><li>How often should I see the Eye Doctor? </li></ul>Damien Luviano, MD, FACS
    • 40. <ul><li>FOLLOW UP </li></ul><ul><ul><li>Controlled Diabetes </li></ul></ul><ul><ul><ul><li>12 months </li></ul></ul></ul><ul><ul><li>Diabetic Retinopathy Present </li></ul></ul><ul><ul><ul><li>1-16 weeks </li></ul></ul></ul>Damien Luviano, MD, FACS
    • 41. <ul><li>How many kinds of eye doctors are there? </li></ul>Damien Luviano, MD, FACS
    • 42. <ul><li>PHYSICIANS </li></ul><ul><li>M.D </li></ul><ul><li>Surgeons </li></ul><ul><ul><li>Laser </li></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Eyeglasses prescription </li></ul></ul><ul><li>Medical School </li></ul><ul><ul><li>Manage medical problems </li></ul></ul><ul><li>12-14 years of Training </li></ul><ul><li>Mandatory Dilation </li></ul><ul><li>EYE GLASS DOCTORS </li></ul><ul><li>O.D </li></ul><ul><li>Optometrist </li></ul><ul><ul><li>Eyeglasses prescription </li></ul></ul><ul><ul><li>Optical Service (optician) </li></ul></ul><ul><li>Optometry School </li></ul><ul><li>6-8 years of Training </li></ul><ul><li>Optional Dilation (cost extra) </li></ul>Damien Luviano, MD, FACS
    • 43. <ul><li>PROBLEMS </li></ul><ul><li>DIABETES IS SERIOUS </li></ul><ul><li>HURT MANY ORGANS </li></ul><ul><li>PREVENTABLE </li></ul><ul><li>SOLUTIONS </li></ul><ul><li>GLUCOSE CONTROL </li></ul><ul><li>FOLLOW PHYSICIANS ADVICE </li></ul>Damien Luviano, MD, FACS
    • 44. Damien Luviano, MD, FACS
    • 45. <ul><li>INTERPRETATION: Treatment with fenofibrate in individuals with type 2 diabetes mellitus reduces the need for laser treatment for diabetic retinopathy, although the mechanism of this effect does not seem to be related to plasma concentrations of lipids. </li></ul>Damien Luviano, MD, FACS
    • 46. <ul><li>CONCLUSIONS: Intensive glycemic control and intensive combination treatment of dyslipidemia, but not intensive blood-pressure control, reduced the rate of progression of diabetic retinopathy. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov numbers, NCT00000620 for the ACCORD study and NCT00542178 for the ACCORD Eye study.) </li></ul>Damien Luviano, MD, FACS
    • 47. <ul><li>CONCLUSIONS: Early blockade of the renin-angiotensin system in patients with type 1 diabetes did not slow nephropathy progression but slowed the progression of retinopathy. </li></ul>Damien Luviano, MD, FACS
    • 48. <ul><li>Regardless of vision, PRP is beneficial (reduced severe vision loss by  50%-60%) in the management of patients with severe NPDR, preproliferative and especially beneficial in high-risk proliferative retinopathy.  PRP is also indicated for NVI   </li></ul>Damien Luviano, MD, FACS
    • 49. <ul><li>Conclusions: Early vitrectomy is recommended for type 1 DM with severe visual loss secondary to vitreous hemorrhage. Earlyvitrectomy is recommended for eyes with useful vision and advancedactive PDR, especially with extensive neovascularization. Endolaser at the time of vitrectomy  was not preformed at the time of vitrectomy </li></ul>Damien Luviano, MD, FACS
    • 50. <ul><li>Aspirin has no benefitOnly patients with high-risk PDR and possibly severe NPDR in both eyes should receive immediate PRP in nasal and inferior quadrantsAll patients with CSME should be treated regardless of visionIn NPDR focal macular laser is performed before scatter PRP </li></ul>Damien Luviano, MD, FACS
    • 51. <ul><li>Results: Tighter BP control decreased diabetes related mortality by 32%.Tighter BP control decreased deterioration of retinopathy and visual acuity by 34% and 47% respectively.  Conclusion: Tighter BP control is beneficial in reducing complications from diabetic retinopathy. </li></ul>Damien Luviano, MD, FACS
    • 52. <ul><li>Result: Intensive treatment group had a 12% reduced risk of diabetes associated complication when compared with the conventional group.Intensive treatment reduced mortality by 10% and morbidity by 6%.Intensive treatment had a significant 25% risk reduction in microvascular endpoints (fewer cases of PRP)  Conclusion: Tighter BS control is beneficial in type 2 DM. </li></ul>Damien Luviano, MD, FACS
    • 53. <ul><li>Results: (6.5 years follow up) Intensive therapy reduced– development of DR by 76% and severe NPDR/PDR by 47%, progression ofDR by 54%, macular edema by 23%, and risk of laser treatment by 56%. HgA1c is strongly related to incidence of diabetic retinopathy Conclusion: Tighter BS control should be recommended. Aim for HgA1c o 7% or less </li></ul>Damien Luviano, MD, FACS
    • 54. <ul><li>Objective: Follow up patients after termination of DCCT Results: (Additional 4 years follow up)Intensive therapy reduced - progression of DR by 75%, macular edema by 58%, risk of laser treatment by 52%. Despite a similar HgA1c of 7.5%-8% in each group. Conclusion: Tighter BS control has long-term benefit. </li></ul>Damien Luviano, MD, FACS
    • 55. <ul><li>THE END </li></ul><ul><li>QUESTIONS </li></ul>Damien Luviano, MD, FACS

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