Diagnosis &
Management of
Diabetic Eye Disease
Part 1
A. Paul Chous, M.A., O.D., F.A.A.O.
Tacoma, WA
Specializing in Diabetes Eye Care & Education
Dr. Paul Chous received his undergraduate education at
Brown University and the University of California at Irvine,
where he was elected to Phi Beta Kappa in 1985. He received
his Masters Degree in 1986 and his Doctorate of Optometry in
1991, both with highest honors from the University of
California at Berkeley. Dr. Chous was selected as the
Outstanding Graduating Optometrist in 1991. He has
practiced in Renton, Kent, Auburn and Tacoma, Washington
for the last 15 years, emphasizing diabetic eye disease and
diabetes education. Dr. Chous has been a Type 1 diabetic
since 1968.
Dr. Chous serves as a consultant to dLife - Your Diabetes Life, Children With
Diabetes, the Diabetes Exercise & Sports Association, and the American
Diabetes Association, which honored him with its Distinguished Public Service
Award in 1998. He is an Adjunct Faculty member at NOVA Southeastern
University in Ft. Lauderdale, Florida. Dr. Chous has given numerous invited talks
about diabetes and the eye to both patients and other health care professionals,
a process which led him to write a unique and extremely important book aimed at
diabetic patients, their families and friends: Diabetic Eye Disease: Lessons From
A Diabetic Eye Doctor - How To Avoid Blindness and Get Great Eye Care.
The Problem of Diabetes &
Diabetic Eye Disease
Another American is Dx with DM
every 24 seconds
 1.3 million new cases every year
 Another American dies from a
complication of diabetes every 2
minutes
 More than 250,000 deaths each
year

The Problem
Diabetic Eye Disease



Another American becomes legally
blind from diabetic retinopathy every 30
minutes
No independent tracking of irreparable
vision loss from other eye diseases
commonly associated with diabetes
(retinal vascular occlusion, AION,
glaucoma)
Realistic accounting might increase the
toll from 12-24 thousand to 30,000+
cases per year
The Pathobiology
of Diabetic Eye
Disease
Biochemical &
Hemodynamic
Influences
Biochemical Influences

In small vessels:
 Hyperglycemia
causes mitochondrial
over-production of reactive oxygen
species (ROS)
 This drives four major biochemical
pathways that cause microvascular
disease:
 Polyol
 Hexosamine
Flux
 Advanced Glycation Endproducts
 Protein Kinase C

Each of these 4 pathways
depends upon over-production of
reactive oxygen species
(Superoxide) by mitochondria
Intracellular
Glucose & FFAs
mitochondria
ATP + hSuperoxide (O2-)
Mitochondrian
Glucose Metabolism
Glucose
ROS
Polyol Pathway
Glucose-6-phosphate
Fructose-6-phosphate
Glyceraldehyde-3-phosphate
GAPDH
1,3 Diphosphoglycerate
(harmless metabolite)
Hexosamine Flux
Protein Kinase C
Advanced Glycation
Endproducts
Small Vessel Biochemistry
 Polyol
Pathway
Increased intracellular sorbitol
leads to:
Diabetic Peripheral Neuropathy,
Diabetic Nephropathy, Diabetic
Retinopathy, Keratopathy & Cataract
small vessel biochemistry
 Hexosamine
Pathway
Increased levels of
inflammatory cytokines lead
to:
Diabetic Nephropathy
small vessel biochemistry
 AGE Pathway
Non-enzymatic glycation of
proteins results in advanced
glycation endproducts (AGEs)
AGEs are a “biological cement”
causing altered protein function
and increased oxidative stress
Retinopathy, Nephropathy, Neuropathy,
Alzheimer’s, ED, Pulmonary Fibrosis…..
small vessel biochemistry
 Protein
Kinase C Pathway
Increased Protein Kinase C (PKC)
activates Vascular Endothelial
Growth Factor (VEGF) leading to:
Diabetic Macular Edema,
Proliferative Retinopathy,
Diabetic Kidney Disease