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Diabetes and the Anterior Segment
Amiee Ho, O.D. Pacific University
College of Optometry
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Age-Adjusted Prevalence of Diagnosed Diabetes Among US Adults
<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%
CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data
1994
Age-Adjusted Prevalence of Diagnosed Diabetes Among US Adults
<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%
CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data
2015
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https://www.cdc.gov/diabetes/pdfs/data/DiabetesBelt.pdf
https://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2017-508.pdf
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https://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2017-508.pdf
https://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2017-508.pdf
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https://www.cdc.gov/diabetes/pdfs/library/socialmedia/diabetes-infographic.pdf
https://www.cdc.gov/diabetes/library/socialmedia/infocards.html
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Diabetes is a growing major public health problem
What does this mean for optometrists?
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https://www.cdc.gov/diabetes/library/socialmedia/infocards.html
The Facts •Diabetic ocular complication is the LEADING cause of blindness in developed countries
•Diabetic retinopathy is the MAJOR manifestation • Well understood
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Anterior segment complications from diabetes can potentially
lead to blindness!
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Lids
• Blepharitis • Xanthelasma xanthoma • Cellulitis • Warts • Poliosis• Meibomian gland dysfunction
• Insulin deficiency and hyperglycemia = toxic
• Multiple chalazia• Recurrent stye
Prone to infection!
Conjunctiva
• Vessel distention • Fusiform dilatation • Sludging of blood • Capillary proliferation• Arterole wall thickening• Microanerysm formation • Tortuous and dilated vessels
• Inferior bulbar conj (vessels isolated from surrounding conj, which is not red like inflamed)
• Pinguecula• Pterygium
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Iris, ciliary body, pupil
• Pigment on lens, endo of cornea, TM• Due to glycogen infiltration tissue damage pigment
release
• Iris neo: due to chronic ischemia • Increased accommodative ability • Decreased hippus• Small pupils • Delay dilation of pupil• Iris atrophy (could be aging)• Ectropion uvea
Due to selective diabetic autonomic neuropathySympathic > parasympathic
Lens
• Cataracts (could be aging)• Increase in thickness and curvature myopia
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CorneaHyperglycemia
Advanced Glycation End (AGE) product
Deposits in epithelium
Recurrent corneal erosionSuperficial punctate keratitis
Dry eye disease Slower wound repair
Increased risk of infection Epithelial edema
Cornea
↓ transparencyTransient stromal edemaCorneal lattice degenerationVarious forms of keratitisStromal ulcerationStromal meltingStromal perforationStromal scarring
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Cornea
Hyperglycemia
Aldose Reductase Pathway
Sorbitol
Morphological Permeability Changes Changes(structure) (function)
Cell density ↑cornealPleomorphism thicknessPolymegathism
Nerves
Reactive Oxidative
Stress (ROS)
Advanced glycation end (AGE)products
Sorbitol-aldose Reductase
pathway
ProteinKinase C
Activation
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Nerves
Nerves
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Non-invasive, in-vivo imaging of corneal nerve fibers
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182640/https://www.researchgate.net/figure/A-The-Heidelberg-Retina-Tomograph-HRT-II-combined-with-Rostock-Cornea-Module-The-video_fig22_226008777
Non-invasive, in-vivo imaging of corneal nerve fibers
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182640/
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Non-invasive, in-vivo imaging of corneal nerve fibers
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182640/
• Corneal confocal microscopy (CCM) helps assess:
• Nerve fiber density• Nerve length• Nerve branch density
• Small nerve fiber pathology • Early detection
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182640/
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Normal NeuropathySevere nerve damage
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182640/
Findings: • Rapid, non-invasive, in-vivo, reliable test: Corneal nerve density changes
precede other functional changes detected by clinical and electrophysiology tests of neuropathy
• Correlation: diabetic peripheral neuropathy patients have significant ↓ nerve fibers
• Prediction: ↓ in nerve fiber length predicted development of diabe c peripheral neuropathy
• Prediction: changes in corneal nerves predicted development of diabetic retinopathy!
• Retinal exams are window into systemic vascular changes
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What does this mean??
CCM help assess diabetic peripheral neuropathy• Early detection • Presence of neuropathy • Monitor progression of neuropathy• Assess therapeutic response
CCM help predict retinal changes and systemic vascular changes
↓ Corneal sensitivity
NeuropathySevere nerve damage
Corneal infection/trauma
Wound healingCorneal ulcers
Corneal scarring
Blindness!!
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• Damage to lacrimal gland • ↓ tears
• ↑ glucose in tears• ↓goblet cells ↓mucin ↓ TBUT
https://www.pngkey.com/detail/u2q8q8w7e6q8r5t4_crying-awesome-face-cartoon-sad-face-png/
↓ Corneal sensitivity Chronic hyperglycemia
Treatment Strict glycemic control Artificial tears Bandage contact lens Topical anti-inflammatory: NSAIDs, steroids, cyclosporine Topical autologous serum Topical insulin-like growth factor-1 and substance PTopical nerve growth factor Topical and oral aldose reductase inhibitor Topical naltrexone (opioid antagonist) Oral resolvin D (a docosahexaenoic derivative) Antioxidants: carnosine & ᵝ-caroteneGene, molecular, and stem cell therapy
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Other considerations
Surgical
• Lasik• 2000 FDA: “DM is a relative
contraindication to LASIK”• ↑ risk of corneal
complications • 2005 AAOpthal: “LASIK is
safe in selected group of DM patients”
• Criteria:• Stable, well controlled
fasting glucose with HbA1c<9
• No DM complications • Cataract Surgery
• Worsen nerve damage• Persistent corneal edema• Corneal abrasion
• Trab/Vitrectomy/PRP• Prolong/recurrent
epithelial defects
Trauma
• Corneal abrasion• Deeper damage
• Recurrent corneal erosion
Contact Lens
• ↑ epithelial fragility• ↑ tear film instability• Impair corneal hydration
• Corneal edema • Endothelial polymegathism• ↑ risk of infec on
Delayed wound healing
Take home points
• Diabetes is a major growing public health concern• Diabetes can cause anterior segment disease• Diabetic corneal neuropathy (using CCM)
• Early detection • Presence of neuropathy • Monitoring efficacy of therapy • Predict retinal changes and systemic vascular changes
• Treatment: consider glycemic control • Other considerations: surgical, trauma, CLs