Damien Luviano, MD, FACS

What is Diabetes?

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

How do I know I have it?

Diagnosis

Damien Luviano, MD, FACS

DIAGNOSE

Fasting Plasma Glucose FPG HgA1c

• 3 month Average Oral Glucose Tolerance

At 2 hrs 140-199 prediabetes 200 diabetes

FASTING PLASMA GLUCOSE FPG

Easy 100-125 Pre-Diabetes 126: Diabetes Closer to 126 bad

Patients with 95 are 50% more likely than 85 FPG

Damien Luviano, MD, FACS

CONTROLLED• HemoglobinA1c less

7.0

unCONTROLLED HemoglobinA1c

MORE 6.5• Higher incidence• Strokes• Blindness• Tooth Loss• Heart Attacks• Kidney Failure• Leg Loss • Life Loss

Damien Luviano, MD, FACS

What is the big deal with a little sugar?

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

PATHOPHYSIOLOGY (MECHANISM)

Damien Luviano, MD, FACS

GeneticEnvironmental ImmunologicalHLA-DR4+ and DR3

Long term hyperglycemiaMost important factor at present

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

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

NUMBERS

STATISTICS DEMOGRAPHICS RISK FACTORS

Damien Luviano, MD, FACS

Damien Luviano, MD, FACS

Damien Luviano, MD, FACS

Damien Luviano, MD, FACS

HGA1C 1% REDUCES 50% RISK

Damien Luviano, MD, FACS

WHAT MAKES DISEASE WORSE?

Damien Luviano, MD, FACS

Adverse Risk Factors

1. Long duration of diabetes

• Obesity• Hyperlipidaemia

2. Poor metabolic control

3. Pregnancy

4. Hypertension

5. Renal disease

6. Other

• Smoking• Anemia

Damien Luviano, MD, FACS

I SEE FINE, I HAVE NO SYMPTOMS MY DOCTOR SAYS I HAVE DIABETES DAMAGE, CAN THAT BE TRUE?

Damien Luviano, MD, FACS

SYMPTOMS

Damien Luviano, MD, FACS

In the initial stages• NO Symptoms

Advanced stages of the disease• experience floaters• blurred vision• progressive visual acuity loss• Red eye• Pain

Damien Luviano, MD, FACS

What does the Doctor Actually see?

Damien Luviano, MD, FACS

CLINICAL FINDINGS (DOCTOR EXAM)

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 = NVEDamien Luviano, MD, FACS

Indications for treatment of proliferativediabetic 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

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Assessment after photocoagulation

• Persistent neovascularization

• Hemorrhage

Poor involution

• Re-treatment required

• Regression of neovascularization• Residual ‘ghost’ vessels or fibrous tissue

Good involution

• Disc pallorDamien 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

How often should I see the Eye Doctor?

Damien Luviano, MD, FACS

FOLLOW UP• Controlled Diabetes

12 months• Diabetic Retinopathy Present

1-16 weeks

Damien Luviano, MD, FACS

How many kinds of eye doctors are there?

Damien Luviano, MD, FACS

PHYSICIANS

M.D Surgeons

• Laser • Surgery• Eyeglasses prescription

Medical School• Manage medical problems

12-14 years of Training Mandatory Dilation

EYE GLASS DOCTORS

O.D Optometrist

• Eyeglasses prescription• Optical Service (optician)

Optometry School 6-8 years of Training Optional Dilation (cost extra)

Damien Luviano, MD, FACS

PROBLEMS

DIABETES IS SERIOUS HURT MANY ORGANS PREVENTABLE

SOLUTIONS

GLUCOSE CONTROL FOLLOW PHYSICIANS ADVICE

Damien Luviano, MD, FACS

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

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

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

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 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

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 DCCTResults: (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

THE END

QUESTIONS

Damien Luviano, MD, FACS