Diabetes and pills
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Diabetes and pills

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How can pills help prevent blindness and loss of organs in diabetes patients

How can pills help prevent blindness and loss of organs in diabetes patients

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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
  • 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.
  • Opening of tight junctions between endothelial cells Endothelial cell fenestration RPE plasma membrane infoldings Endocytic vesicle transport
  • WESDR

Diabetes and pills Diabetes and pills Presentation Transcript

  • Damien Luviano, MD, FACS
    • Diabetes:
      • Impaired Insulin
      • leads increased glucose
      • Increased glucose Damages blood vessels
      • Tissues are deprived of blood, thus injured
        • Brain-Stroke
        • Heart- Myocardial Infarctions
        • Dental-Periodontal Disease
        • Eye-Retinopathy
        • Kidney-Nephropathy
        • Nerves-Neuropathy
    Damien Luviano, MD, FACS
    • DEATH (MORTALITY)
        • Brain-Stroke
        • Heart- Myocardial Infarctions
        • Infections
    • MISERY (MORBIDITY)
        • Dental-Periodontal Disease
          • Tooth loss
        • Eye-Retinopathy
          • blindness
        • Kidney-Nephropathy
          • Dialysis
        • Nerves-Neuropathy
          • Pain
        • Limb loss
          • Wheel Chair
        • Erectile dysfunction
    Damien Luviano, MD, FACS
    • Lets talk about Eyes
    Damien Luviano, MD, FACS
    • Blindness
      • Diabetes is LEADING cause of new cases of blindness among adults aged 20-74 years.
      • Can occur from within months
    Damien Luviano, MD, FACS
    • TWO TYPES
      • NON-PROLIFERATIVE (mild, moderate, severe)
      • PROLIFERATIVE (Laser)
    • MACULAR EDEMA
      • Present (LASER)
      • Absent
    Damien Luviano, MD, FACS
    • How does diabetes hurt all these organs?
    • Are all these organs connected?
    Damien Luviano, MD, FACS
  • 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
  • Damien Luviano, MD, FACS
  • Damien Luviano, MD, FACS
    • HGA1C
    • 1% REDUCES 50% RISK
    Damien Luviano, MD, FACS
    • What does the Doctor Actually see?
    Damien Luviano, MD, FACS
  • Damien Luviano, MD, FACS
  • Preproliferative diabetic retinopathy Treatment - not required but watch for proliferative disease
    • Cotton-wool spots
    • Venous irregularities
    • Dark blot haemorrhages
    • Intraretinal microvascular
    • abnormalities (IRMA)
    Signs Damien Luviano, MD, FACS
  • Proliferative diabetic retinopathy
    • Flat or elevated
    • Severity determined by comparing with area of disc
    Neovascularization Neovascularization of disc = NVD
    • Affects 5-10% of diabetics
    • IDD at increased risk (60% after 30 years)
    Neovascularization elsewhere = NVE Damien Luviano, MD, FACS
  • Indications for treatment of proliferative diabetic retinopathy NVD > 1/3 disc in area Less extensive NVD + haemorrhage NVE > 1/2 disc in area + haemorrhage Damien Luviano, MD, FACS
    • How is the Doctor Going to Fix my eyes?
    Damien Luviano, MD, FACS
    • TREATMENT
      • NONPROLIFERATIVE
        • Glucose Control
      • PROLIFERATIVE
        • Glucose Control
        • Laser of retina outside macula
        • Surgery to remove vitreous and scars (jelly)
      • MACULAR EDEMA
        • Glucose Control
        • Laser of Macula
        • Steroids and Avastin not FDA approved
        • Lucentis in Clinical Trials
    Damien Luviano, MD, FACS
    • Spot size (200-500  m ) depends
    • on contact lens magnification
    • Gentle intensity burn (0.10-0.05 sec)
    • Follow-up 4 to 8 weeks
    • Area covered by complete PRP
    • Initial treatment is 2000-3000 burns
    Laser panretinal photocoagulation Damien Luviano, MD, FACS
  • Assessment after photocoagulation
    • Persistent neovascularization
    • Hemorrhage
    Poor involution
    • Re-treatment required
    • Regression of neovascularization
    • Residual ‘ghost’ vessels or
    • fibrous tissue
    Good involution
    • Disc pallor
    Damien Luviano, MD, FACS
  • Treatment of clinically significant macular oedema
    • For microaneurysms in centre of hard
    • exudate rings located 500-3000  m
    • from centre of fovea
    Focal treatment
    • Gentle whitening or darkening of
    • microaneurysm (100-200  m , 0.10 sec)
    • For diffuse retinal thickening located more
    • than 500  m from centre of fovea and
    • 500  m from temporal margin of disc
    Grid treatment
    • Gentle burns (100-200  m , 0.10 sec),
    • one burn width apart
    Damien Luviano, MD, FACS
  • 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
    • DOCTOR
    • Glucose Control
      • Goal less HgA1c 7.0
    • Hypertension Control
    • Lipid Control
    • Lasers (temporary)
    • Injections (temporary)
    • PATIENT
    • Weight Control
    • Smoking Control
    • Exercise
    • Alcohol Control
    Damien Luviano, MD, FACS
  • Damien Luviano, MD, FACS
  • Damien Luviano, MD
    • 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  
    Damien Luviano, MD, FACS
    • 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
    Damien Luviano, MD, FACS
    • Aspirin has no benefit Only patients with high-risk PDR and possibly severe NPDR in both eyes should receive immediate PRP in nasal and inferior quadrants All patients with CSME should be treated regardless of vision In NPDR focal macular laser is performed before scatter PRP
    • Results Immediate focal macular laser decreased moderate vision loss by 50% in patients with macular edema Early PRP reduced the development of high-risk PDR in patients with NPDR and early PDR. Immediate focal macular laser and deferred scatter PRP reduced moderate visual loss by 50% in patients with mild, moderate, or severe NPDR,  and early PDR with macular edema.
    Damien Luviano, MD, FACS
    • 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.
    Damien Luviano, MD, FACS
    • 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.
    Damien Luviano, MD, FACS
    • 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
    Damien Luviano, MD, FACS
    • 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.
    Damien Luviano, MD, FACS
    • 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.
    Damien Luviano, MD, FACS
    • 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.
    Damien Luviano, MD, FACS
    • This article reviews our current understanding of the ocular-specific effects of systemic medications commonly used by patients with diabetes mellitus, including those directed at control of hyperglycemia, dyslipidemia, hypertension, cardiac disease, anemia, inflammation and cancer. Current clinical evidence is strongest for the use of angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers in preventing the onset or slowing the progression of early diabetic retinopathy. To a more limited extent, evidence of a benefit of fibrates for diabetic macular edema exists
    Damien Luviano, MD, FACS
    • 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.)
    Damien Luviano, MD, FACS
    • In a cross-sectional analysis of data from the largest study to date, no association was observed between thiazolidinedione exposure and DME in patients with type 2 diabetes; however, we cannot exclude a modest protective or harmful association.
    Damien Luviano, MD, FACS
    • CONCLUSIONS: Diabetic patients undergoing phacoemulsification cataract surgery appear to have a doubling of DR progression rates 12 months after surgery. This outcome, however, represents less progression than was previously documented with intracapsular and extracapsular cataract surgical techniques
    Damien Luviano, MD, FACS
    • Ask Questions
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      • Avvo.com
    • Statistics and information
      • CDC.gov
    • Find Board Certified Physicians
      • certificationmatters.org/
    Damien Luviano, MD, FACS
    • THE END
    • QUESTIONS
    Damien Luviano, MD, FACS