Eyes on Diabetics: How to Avoid Blindness in Diabetic Patient

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1 Eyes on Diabetics: How to Avoid Blindness in Diabetic Patient Rova Virgana FK Unpad Pusat Mata Nasional RS Mata Cicendo Bandung Eye Center (Hospital and Clinic) PIT IDI Jabar 2018

3 Keys Facts from WHO The number of people with diabetes has risen from 108 million in 1980 to 422 million in 2014 The global prevalence of diabetes* among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014 Diabetes prevalence has been rising more rapidly in middle- and low-income countries Diabetes is a major cause of BLINDNESS, kidney failure, heart attacks, stroke and lower limb amputation

5 What are effects of Diabetes Mellitus on Eyes

$Effects of DM on Eyes Dry eyes Refraction$ disturbances Glaucoma Figure 3: Normal Vision

6 Effects of DM on Eyes Dry eyes Refraction changes Cataract Retinopathy Papilopathy CN disturbances Glaucoma Figure 3: Normal Vision Figure 4: How vision may be affected by diabetic retinopathy

7 Diabetic Retinopathy (DR) Definition Progressive dysfunction of the retinal blood vessels caused by chronic hyperglycemia. DR can be a complication of diabetes type 1 or diabetes type 2. Initially, DR is asymptomatic, if not treated though it can cause low vision and blindness.

8 Anatomy of The Eye The retina senses light & transmits images to the brain The macula central part of the retina used to read and see fine details clearly The vitreous clear gel fills the back of the eye and sits in front of the retina

9 RETINA

10 Healthy Retina Diabetic Retinopathy

11 Diabetic Retinopathy Epidemiology The total number of people with diabetes is projected to rise from 285 million in 2010 to 439 million in Diabetic retinopathy is responsible for 1.8 million of the 37 million cases of blindness throughout the world. Diabetic retinopathy (DR) is the leading cause of blindness in people of working age in industrialized countries.

13 Prevalence Blindness is 25 more common in diabetics than non diabetics. Prevalence of PDR is much more in type I than type II. Diabetic retinopathy more sever in type I than type II.

14 Prevalence Macular edema : NPDR : 2-6 % PDR : % Macular edema : 20.1 % in younger onset group % in older onset group taking insulin 13.9 % in older onset group not taking insulin

15 Prevalence The 25-year cumulative rate of progression of DR in Type I was: - progression of DR was 83%. - progression to PDR was 42%. - macular edema was 26%. ( WESDR Ophthalmology Nov;115(11): (

16 RISK FACTORS 1. The duration of diabetes : is the most important factor. In patients diagnosed as having diabetes before the age of 30 years, the incidence of DR : - after 10 years is 50% - after 30 years is 90%

17 RISK FACTORS It is extremely rare for DR to develop within 5 years of the onset of diabetes. about 5% of Type II have NPDR at presentation perhaps due to the lag between onset and diagnosis.

18 RISK FACTORS 2. Glycemic control : Good metabolic control of diabetes will not prevent DR, although it may delay its development by a few years. increased severity of diabetic retinopathy is associated with poorer glucose control. insulin treatment is associated with a decreased risk of either the development or progression of diabetic retinopathy in patients with type 1 diabetes.

19 RISK FACTORS With strict control of DM: - risk of developing retinopathy was reduced by 75%. - 50% reduction in the rate of progression of retinopathy in existing retinopathy - early worsening of retinopathy is unlikely to threaten vision. Diabetes Control and Complications Trial Research Group N Engl J Med 1993; 329:

20 RISK FACTORS 3. Miscellaneous factors : - pregnancy (Hormonal changes ) - systemic hypertension - renal disease - anaemia ( oxygen ) - elevated serum lipid - carotid artery occlusive disease - obesity - barriers to care

21 Ocular Risk Factors PVD : due to degenerative changes in the vitreous. significantly more common in diabetic subjects. complete PVD may prevent the development of PDR because the hyaloid is needed as a scaffold for retinal neovascularization. attached posterior hyaloid has also been associated with an increased risk for DME

22 Ocular Risk Factors High myopia : choroidal degeneration and extensive old chorioretinopathy protect against DR. believed to act in the same manner as pan retinal photocoagulation by reducing the metabolic needs of the retina

23 Ocular Risk Factors Removal of cataract : DR may progress after cataract surgery. Patient who have CSME, SNPDR or PDR should undergo photocoagulation if the media is sufficiently clear. If the cataract preclude retina evaluation and treatment, prompt postoperative retinal evaluation and treatment should considered.

24 Diabetic retinopathy symptoms Diabetic retinopathy is asymptomatic in early stages of the disease As the disease progresses symptoms may include Blurred vision Floaters Fluctuating vision Distorted vision Dark areas in the vision Poor night vision Impaired color vision Partial or total loss of vision

25 HOW DIABETES CAUSES VISION LOSS How diabetes cause vision loss Macular edema Clinical significant macular edema Diabetes Preclinical changes Background DR Vision loss Preproliferative DR Proliferative DR Vitreous hemorrhage and/or Retinal detachment and/or neovascular glaucoma

Microvascular Occlusion Ischemia Infarction

Tractional retinal detachment Retina in systemic

26 Microvascular Occlusion Ischemia Infarction Increased VEFG Cotton wool spot Neovascularization Vitreous hemorrhage Fibrovascular bands Neovascular glaucoma Tractional retinal detachment Retina in systemic disease : a color manual of ophthalmoscopy / Homayoun Tabandeh, Morton F. Goldberg 2009

27 Microvascular Leakage Edema Hard exudates Retinal hemorrhage Retina in systemic disease : a color manual of ophthalmoscopy / Homayoun Tabandeh, Morton F. Goldberg 2009.

28 RECOMMENDED EYE EXAMINATION SCHEDULE Diabetic Eye Disease Key Points Diabetes Type Recommended Time of First Examination Recommended Followup* Type years after diagnosis Yearly Type 2 At time of diagnosis Yearly Treatments Prior exist to conception but work best Prior to pregnancy (type 1 or type 2) and early in the first before vision trimester is lost No retinopathy to mild moderate NPDR every 3-12 months Severe NPDR or worse every 1-3 months. *Abnormal findings may dictate more frequent follow-up examinations h ttp://one.aao.org/ce/practiceguidelines/ppp_content.aspx?cid=d0c853d3-219f-487b-a ab3cecd9a

29 International Clinical Diabetic Retinopathy Disease Severity Scale Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales Ophthalmology Volume 110, Number 9, September 2003 Proposed Disease Severity Level Findings Observable upon Dilated Ophthalmoscopy Findings Obsd No apparent retinopathy No abnormalities Mild nonproliferative diabetic retinopathy Microaneurysms only Moderate nonproliferative diabetic retinopathy More than just microaneurysms but less than severe NPDR Severe nonproliferative diabetic retinopathy Any of the following: More than 20 intraretinal hemorrhages in each of four quadrants Definite venous beading in two or more quadrants Prominent IRMA in one or more quadrants and no signs of proliferative retinopathy. Proliferative diabetic retinopathy One or both of the following: Neovascularization Vitreous/preretinal hemorrhage

30 No retinopathy

31 MILD NONPROLIFERATIVE DIABETIC RETINOPATHY Microaneurysms

32 Moderate Nonproliferative Diabetic Retinopathy (NPDR) Microaneurysm Hard exudates Flamed shaped hemorrhage

33 Severe Nonproliferative Diabetic Retinopathy (NPDR) Venous beading

34 PROLIFERATIVE DIABETIC RETINOPATHY Cotton-wool spot Neovascularization Neovascularization Hard exudate Blot hemorrhage

35 PREVENTION 90 percent of diabetic eye disease can be prevented simply by proper regular examinations, treatment and by controlling blood sugar.

36 Primary prevention Strict glycemic control Blood pressure control Secondary prevention Annual eye exams Tertiary prevention Retinal Laser photocoagulation Vitrectomy

37 DIABETIC RETINOPATHY TREATMENT The best measure for prevention of loss of vision from diabetic retinopathy is strict glycemic control

38 Laser Photocoagulation Laser Photocoagulation is recommended for eyes with: Clinical significant macular edema CSME High risk Proliferative diabetic retinopathy

vessels (focal laser) Laser therapy to reduce retinal oxygen

39 DIABETIC RETINOPATHY TREATMENT Once DR threatens vision treatments can include: Laser therapy to seal leaking blood vessels (focal laser) Laser therapy to reduce retinal oxygen demand (scatter laser) Surgical removal of blood from the eye (vitrectomy)

DIABETIC RETINOPATHY TREATMENT NEWER DEVELOPMENTS: The use of anti-vascular endothelial growth factor antibodies has been shown to be useful in the treatment of DR Anti-VEGF antibody treatment

40 DIABETIC RETINOPATHY TREATMENT NEWER DEVELOPMENTS: The use of anti-vascular endothelial growth factor antibodies has been shown to be useful in the treatment of DR Anti-VEGF antibody treatment appears to be useful for both macular edema and proliferative retinopathy Studies to determine the exact role of anti-vegf treatment in relation to laser treatment in specific situations are underway.

41 Diabetic Macular Edema Most common cause of decreased VA in DR Can occur in any DR stage Diabetic retinopathy occurs in 1 out of 3 people with diabetes, with reported rates of DME reaching 7% in this group of patients In fact, DME is the leading cause of visual loss and legal blindness in people with diabetes

42 Meta analysis and review on the effect on bevacizumab id diabetic macular edema Graefes Arch Clin Exp Ophthalmol(2011) 249:15-27

43 Why is Diabetic macular edema so important? The macula is responsible for central vision. Diabetic macular edema may be asymptomatic at first. As the edema moves in to the fovea (the center of the macula) the patient will notice blurry central vision. The ability to read and recognize faces will be compromised. Macula Fovea

44 Normal Macular Edema

45 Pathogenesis of DME Vascular endothelial growth factor (VEGF) is believed to be a key mediator It promotes angiogenesis and causes a breakdown in the BRB by damaging the tight junctions between retinal endothelial cells These tight junctions are critical to the function and regulation of the BRB The breakdown of BRB then results in accumulation of plasma proteins such as albumin which exert a high oncotic pressure in the neural interstitium, leading to interstitial edema. Other comorbidities such as chronic hyperglycemia, hypertension, and hyperlipidemia are also implicated in the development of DME

46 Treatment of DME The various treatment modalities for DME can be divided into ocular systemic

47 Ocular Treatment of DME Laser Therapy (focal and grid) Intravitreal anti-vegf therapy Bevacizumab, Ranibizumab, Aflibercept Intravitreal steroid therapy TCA, Dexamethasone, Fluocinolone acetonide Intravitreal NSAID therapy Na Diclofenac Vitrectomy Novel therapy Pharmacological / non pharmacological

48 Systemic Treatment of DME Fenofibric Acid Therapy Addition to simvastatin lower progression of 40% Systemic Erythropoietin Therapy Anemia in ESRF Subcutaneous injection ACE Inhibitor Therapy

49 Negative effects to DME GlitazoneTherapy Insulin Therapy Blood Glucose Levels Anaemia Hypertension Dyslipidaemia Kidney Disease Pregnancy

50 Take home message DR and DME has an increasing prevalence PREVENTION is the KEY (timely diagnosis, early finding, controlling risk factors, regular screening) DO FUNDUSCOPIC EXAMINATION in DM SYSTEMIC PROBLEMS should be closely MONITORED and CONTROLLED PROMT TREATMENT

51 Thank you

Diagnosis and treatment of diabetic retinopathy. Blake Cooper MD Ophthalmologist Vitreoretinal Surgeon Retina Associates Kansas City

Diagnosis and treatment of diabetic retinopathy Blake Cooper MD Ophthalmologist Vitreoretinal Surgeon Retina Associates Kansas City Disclosures Consulted for Novo Nordisk 2017,2018. Will be discussing