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, 2012 12:30 1:00 PM Pacific Time Call In Number: 800.747.5150 Access Code: 9438735
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;122:552-63. **Varma R, Torres M, Pena F, et al. Prevalence of diabetic retinopathy in adult Latinos: the Los Angeles Latino eye study. Ophthalmology 2004;111:1298-306. ***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 102:520-526, 1984
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
Anatomy of the eye:
5 Normal Retina Retinal Arcades Macula Optic Nerve
Fluorescein angiogram Normal macula Normal capillaries barely visible
Fluorescein angiogram Diabetic macula Dilated capillaries interspersed with Nonperfused dark spaces and hyperfluorescent dots (microaneurysms)
Normal Retinal Capillaries Trypsin Digest Regular capillary caliber Round dark pericytes; elongated endothelial nuclei
Diabetic Retinal Capillaries Trypsin Digest Acellular (nonperfused) capillaries Hypercellular (dilated) capillaries
Severe Nonproliferative Retinopathy (NPDR) 10 Latin American male, DM II X 12 years, Last eye exam 5 years ago
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
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
Normal Blood Retinal Barrier (BRB) Fluorescein Angiography Inner BRB-retinal capillary endothelium (Outer BRB-retinal pigment epithelium )
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)
Macular Edema Breakdown of BRB Retinal thickening
Increased Retinal Vessel Permeability and Macular Edema:
66 yr old, DM X 14 yrs, HbA1C=5.5 19
60 yr. old, DM X 9yrs, HbA1C=9.1 21
60 yr. old, DM X 9yrs, HbA1C=9.1 22
60 yr. old, DM X 9yrs, HbA1C=9.1 1 yr. later, HbA1C=5.5: 23
26 yr. old Type I African-American HbA1C=9.6 4/27/2005 24
26 yr. old Type I African-American HbA1C=6.1 1/24/2007 25
26 yr. old Type I African-American HbA1C=6.1 1/24/2007 26
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 24-48 hours Patient is at risk for severe vision loss without treatment
Case 2: 24 year old Latin American female
Case 2: 24 year old Latin American female New Blood Vessels
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.
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
43 yr. old Hispanic Male
43 yr. old Hispanic Male 6 months later blind in both eyes
37 yr. old Caucasian female, type I diabetic since age 5
2 days later..
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