The Natural History of Diabetic Retinopathy and How Primary Care Makes A Difference

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The Natural History of Diabetic Retinopathy and How Primary Care Makes A Difference We will discuss - How exactly does blood sugar control affect retinopathy?

1 The Natural History of Diabetic Retinopathy and How Primary Care Makes A Difference We will discuss - How exactly does blood sugar control affect retinopathy? - What are other factors that we measure in Primary Care that affect retinopathy? - How long does it take to develop vision impairment from diabetes? Please share your questions, comments, and experiences with us. February 27, :30 1:00 PM Pacific Time Call In Number: Access Code:

2 The Burden of Diabetic Retinopathy: Prevalence of retinopathy in adults > 40 years in the U.S. is 3.4% (4.1 million persons) Prevalence of VISION-THREATENING retinopathy is 0.75% (899,000 persons)* The main cause of blindness among adults 25 to 70 years (12,000 to 24,000 persons per year) Los Angeles Latino Eye Study: 18% with diabetes of more than 15 years' duration had proliferative diabetic retinopathy 21% of patients with type 2 diabetes have retinopathy at the time of first diagnosis*** Kempen JH, O'Colmain BJ, Leske MC, et al. The prevalence of diabetic retinopathy among adults in the United States. Arch Ophthalmol 2004;122: **Varma R, Torres M, Pena F, et al. Prevalence of diabetic retinopathy in adult Latinos: the Los Angeles Latino eye study. Ophthalmology 2004;111: ***Klein R, Klein BE, Moss SE, Davis MD, DeMets DL: The Wisconsin Epidemiologic Study of Diabetic Retinopathy. II. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol 102: , 1984

3 Diabetic Retinopathy in Your Clinics: Data derived from EyePACS cases: 33% + or 14.8% have diabetic retinopathy 9.1% + or 0.7% have sight-threatening retinopathy?? % have vision impairment from diabetes

4 Anatomy of the eye:

5 5 Normal Retina Retinal Arcades Macula Optic Nerve

6 Fluorescein angiogram Normal macula Normal capillaries barely visible

7 Fluorescein angiogram Diabetic macula Dilated capillaries interspersed with Nonperfused dark spaces and hyperfluorescent dots (microaneurysms)

8 Normal Retinal Capillaries Trypsin Digest Regular capillary caliber Round dark pericytes; elongated endothelial nuclei

9 Diabetic Retinal Capillaries Trypsin Digest Acellular (nonperfused) capillaries Hypercellular (dilated) capillaries

10 Severe Nonproliferative Retinopathy (NPDR) 10 Latin American male, DM II X 12 years, Last eye exam 5 years ago

11 11 Neovascularization (New Blood Vessels) 49 year old Caucasian male, DM II X 13 years, IDDM X 10 years, subjective DM control: Good ; last eye exam: more than 5 years

12 Normal Blood-Retinal Barrier Retinal vascular endothelial cells have tight junctions Tight junctions present a physiological barrier to the passage of larger molecules such as albumin Barrier maintains normal retinal thickness

13 Normal Blood Retinal Barrier (BRB) Fluorescein Angiography Inner BRB-retinal capillary endothelium (Outer BRB-retinal pigment epithelium )

14 Increased Retinal Vessel Permeability in Diabetic Retinopathy Breakdown of normal BRB Abnormal (albumin-bound) fluorescein leakage from retinal capillaries Microaneurysms major leakage source Results in retinal edema (swelling)

15 Macular Edema Breakdown of BRB Retinal thickening

16 Increased Retinal Vessel Permeability and Macular Edema:

19 66 yr old, DM X 14 yrs, HbA1C=5.5 19

21 60 yr. old, DM X 9yrs, HbA1C=9.1 21

22 60 yr. old, DM X 9yrs, HbA1C=9.1 22

23 60 yr. old, DM X 9yrs, HbA1C=9.1 1 yr. later, HbA1C=5.5: 23

24 26 yr. old Type I African-American HbA1C=9.6 4/27/

25 26 yr. old Type I African-American HbA1C=6.1 1/24/

26 26 yr. old Type I African-American HbA1C=6.1 1/24/

27 24 yr. old Latin American female - Gail Ellias, OD and Karina Lomeli, MPH Type 1 DM since 2005 HbA1c = 9.5 Meds: prenatal vitamins, humalog/nph insulin Photographed on 9/21/2011 at 12:21 PM Consultation on 9/21/2011 at 5:01 PM: Large areas of neovascularization of the optic disk right eye Neovascularization elsewhere left eye High risk proliferative diabetic retinopathy right eye Refer to Retina Specialist hours Patient is at risk for severe vision loss without treatment

28 Case 2: 24 year old Latin American female

29 Case 2: 24 year old Latin American female New Blood Vessels

30 Case 2: 24 year old Latin American female Image from EyePACS visit on 7/16/2009: HbA1c 9.3 Pregnant Per pt, around July 4th, started seeing "webs" on the right eye. Referred for treatment within one week.

31 Case 2: 24 year old Latin American female Image from EyePACS visit on 1/31/2006: HbA1c 12.6 Pregnant! DM Type 1 since 7 months Advised to have close follow up due to pregnancy. Pregnancy accelerates retinopathy Type 1 DM usually has no retinopathy for first 5 years. Prominent IRMA

32 43 yr. old Hispanic Male

33 43 yr. old Hispanic Male 6 months later blind in both eyes

34 37 yr. old Caucasian female, type I diabetic since age 5

36 2 days later..

37 You Can Make A Difference

EyePACS Grading System (Part 2): Detecting Presence and Severity of Background (Non-Proliferative) Diabetic Retinopathy Lesion

EyePACS Grading System (Part 2): Detecting Presence and Severity of Background (Non-Proliferative) Diabetic Retinopathy Lesion George Bresnick MD MPA Jorge Cuadros OD PhD Anatomy of the eye: 3 Normal Retina