Diabetic Eye Disease
Evan (Jake) Waxman MD PhD
Diabetic Eye Disease
Key Points
• Diabetes is a major cause of
visual loss
Diabetic Eye Disease
Key Points
• Risk factor control can prevent
and slow visual loss
Diabetic Eye Disease
Key Points
• Treatments exist but work best
before vision is lost
Diabetic Eye Disease
Key Points
• Diabetes is a major cause of visual loss
• Risk factor control can prevent and slow visual loss
• Treatments exist but work best before vision is lost
So … to prevent visual loss
• Control patient risk factors
• Insist your patients get yearly dilated eye
exams with an ophthalmologist
Diabetic Eye Disease
Case Presentation - History
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27 year old woman
DM I for 16 years
poor blood sugar ctrl
HgbA1C = 10
c/o spot in L vision for
one day
• Sees “Eye Doctor” every
year -- no previous eye
disease diagnosed
Diabetic Eye Disease
Case Presentation - Exam
• Visual Acuity 20/50
OU
• Normal Pupils
• Normal Anterior
Segment
Diabetic Eye Disease
Case Presentation - Exam
Diabetic Eye Disease
Case Presentation
Fluoroscein Angiography
Diabetic Eye Disease
Case Presentation - Course
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Pan retinal photocoagulation OU
Focal photocoagulation OS
Vision dropped to 20/200 OD 1 month later
Vit heme OS 2 months later
Additional PRP
Glaucoma surgery x 2
Current Acuity 20/400 OD 20/200 OS
Prognosis Poor
Diabetic Eye Disease
Background
• Treatments work best before
vision is lost
• Many patients are diagnosed
only after vision is lost
• Vision loss is a late symptom of
diabetic eye disease
• Risk factor control is essential
Diabetic Eye Disease
Background
• Catching disease
prior to vision loss
requires yearly
screening with a
dilated eye exam
by an MD
Diabetic Eye Disease
Key Points
• Diabetes is a major cause of visual loss
• Risk factor control can prevent and slow visual loss
• Treatments exist but work best before vision is lost
So … to prevent visual loss
• Control patient risk factors
• Insist your patients get yearly dilated eye
exams with an ophthalmologist
Diabetic Eye Disease
Background – Scary statistics
• Leading cause of blindness in
Americans aged 25- 65
• Accounts for 12% of new
blindness
• Diabetic patients 25 times more
likely to go blind
Diabetic Eye Disease
Background – More scary statistics
• 65,000 with new proliferative
retinopathy yearly
• 75,000 with new macular edema
yearly
• 700,000 have PDR
• 500,000 have macular edema
• 25% - 50% with high risk disease not
receiving care
Diabetic Eye Disease
Background
Risk Factors
• Duration
• Poor Blood Sugar control
• HTN
• Hyperlipidemia
• Barriers to care
Diabetic Eye Disease
Background
• Prevention of eye disease is possible with
increased risk factor control
CLINICAL SCIENCES
The Effect of Intensive Diabetes Treatment
On the Progression of Diabetic Retinopathy
In Insulin-Dependent Diabetes Mellitus
The Diabetes Control and Complications Trial
The Diabetes Control and Complications Trial Research Group
Arch Ophthalmol. 1995; 113:36-51
Diabetic Eye Disease
Framework
• 2 pathways of Visual
Loss in DR
–Capillary
Leakage
–Capillary
Closure
Diabetes
Preclinical Changes
Background DR
Preproliferative DR
Proliferative DR
Vitreous Hemorrhage
Macular Edema
Clinically
Significant
Macular Edema
and/or
Retinal Detachment
and/or
Neovascular Glaucoma
Vision Loss
Diabetic Eye Disease
Pathophysiology – Capillary Leakage
High blood sugar levels affect retinal capillaries
• Pericyte
Loss
• Endothelial
Cell loss
• Blood-retina
barrier
breakdown
Diabetic Eye Disease
Pathophysiology - Capillary Leakage
• Non proliferative
diabetic
retinopathy
– Damaged
capillaries leak
– Leakage into the
macula results
in vision loss
Diabetic Eye Disease
Symptoms/Signs - Preclinical
–None on exam
–Special techniques
demonstrate
• Leakage
• VEGF secretion
Diabetic Eye Disease
Symptoms/Signs – NPDR
• Usually no
symptoms
• Dot heme
– Microaneurysms
– Leakage
• Blot heme
– Leakage
• Flame heme
Diabetic Eye Disease
Symptoms/Signs – NPDR / Macular Edema
• +/- Symptoms
• Dot heme
– Microaneurysms
– Leakage
• Blot heme
– Leakage
• Hard exudates
Diabetic Eye Disease
Symptoms/Signs – NPDR / Macular Edema
• Hard exudates
• Retinal edema
• Vision loss when
edema occurs in
central visual
area
Diabetic Eye Disease
NPDR / Macular Edema
• Prevalence
–5% for pts
with DM for
≤ 5 years
–15% for pts
with DM for
≥ 15 years
Diabetic Eye Disease
NPDR – Macular Edema
• Prevalence
–Higher for
insulin
dependence
–Higher with
increased
HgbA1C
Diabetic Eye Disease
Treatment – NPDR – Macular Edema
• Fluoroscein Angiography
Diabetic Eye Disease
Treatment – NPDR – Macular Edema
• Focal Laser
Diabetic Eye Disease
Treatment – NPDR – Macular Edema
• Focal Laser
Diabetic Eye Disease
Treatment – NPDR – Macular Edema
Focal Laser reduces risk of
visual loss by 50%
Early Photocoagulation for
Diabetic Retinopathy
ETDRS Report Number 9
EARLY TREATMENT DIABETIC RETINOPATHY STUDY RESEARCH GROUP
Ophthalmology 1991; 98; 766-785
Diabetic Eye Disease
Framework
• 2 pathways of Visual
Loss in DR
–Capillary
Leakage
–Capillary
Closure
Diabetes
Preclinical Changes
Background DR
Preproliferative DR
Proliferative DR
Vitreous Hemorrhage
Macular Edema
Clinically
Significant
Macular Edema
and/or
Retinal Detachment
and/or
Neovascular Glaucoma
Vision Loss
Diabetic Eye Disease
Pathophysiology – Capillary Closure
High blood sugar levels affect retinal capillaries
• Basement membrane
thickening
• Increased platelet and
erythrocyte adhesion
• Closure of capillaries
Diabetic Eye Disease
Pathophysiology – Capillary Closure
• Proliferative
diabetic retinopathy
– Damaged capillaries
close off
– Ischemic retina
secretes VEGF
– New vessels form in
response to VEGF
Diabetic Eye Disease
Pathophysiology
• Proliferative
diabetic retinopathy
– Neovascularization
• Fibrous Proliferation
• Traction with
vitreous hemorrhage
• Traction retinal
detachment
• Neovascular
glaucoma
Diabetic Eye Disease
Symptoms/Signs – Preproliferative DR
• Symptoms None
• Cotton Wool
Spots
– Nerve fiber
layer ischemia &
infarction
Diabetic Eye Disease
Symptoms/Signs – Preproliferative DR
• Symptoms - None
• Cotton Wool Spots
– Nerve fiber layer
ischemia & infarction
• Venous beading
• Intraretinal
microvascular
abnormalities
(IRMA)
Diabetic Eye Disease
Symptoms/Signs – Preproliferative DR
• Symptoms - None
• Cotton Wool Spots
– Nerve fiber layer
ischemia & infarction
• Venous beading
• IRMA
• More heme
Diabetic Eye Disease
Symptoms/Signs – Proliferative Retinopathy
• Symptoms - None
• Optic Nerve
Neovascularization
(NVD)
Diabetic Eye Disease
Symptoms/Signs – Proliferative Retinopathy
• Symptoms - None
• Optic Nerve
Neovascularization
(NVD)
• Peripheral
Neovascularization
(NVE)
Diabetic Eye Disease
Signs – Proliferative Retinopathy
• Prevalence
≤ 5 years – 0%
≥ 15 yrs – 25%
≥ 20 yrs – 55%
Diabetic Eye Disease
Treatment – PDR
• Panretinal photocoagulation (PRP)
Diabetic Eye Disease
Treatment – PDR
• Panretinal photocoagulation (PRP)
Before
After
Diabetic Eye Disease
Treatment – PDR
• Panretinal photocoagulation (PRP)
Before
After
Diabetic Eye Disease
Treatment – PDR
PRP reduces the risk of severe
vision loss by more than 50%
Photocoagulation Treatment of
Proliferative Diabetic Retinopathy
Clinical Application of Diabetic Retinopathy Study
(DRS) Findings, DRS Report Number 8
THE DIABETIC RETINOPATHY STUDY RESEARCH GROUP
Ophthalmology 1991; 88; 583-600
Diabetic Eye Disease
Signs/Symptoms – Vitreous Heme
• Symptoms
– Floaters/Streaks
– Loss of vision
• Blood in vitreous
• Loss of red reflex
• No View
Diabetic Eye Disease
Symptoms/Signs – Retinal Detachment
• Symptom
– Visual Loss; often
severe
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Retinal Elevation
Fibrous Proliferation
Loss of red reflex
Marcus/Gunn Pupil
Diabetic Eye Disease
Treatment – Vitreous Heme
• Panretinal photocoagulation (PRP)
• Vitrectomy
– Removes blood
– Removes Traction
– Allows addnl PRP
Diabetic Eye Disease
Treatment – Vitreous Heme
Vitrectomy
Diabetic Eye Disease
Treatment – PDR
Vitrectomy results in improved
vision in patients with
persistent vitreous hemorrhage
Early Vitrectomy fo Severe Vitreous
Hemorrhage in Diabetic Retinopathy
Two-Year Results of a Randomized Trial
Diabetic Retinopathy Virectomy Report 2
THE DIABETIC RETINOPATHY VITRECTOMY STUDY RESEARCH GROUP
Arch Ophthalmol. 1985; 103 1644-1652
Diabetic Eye Disease
Symptoms/ Signs – Neovascular Glaucoma
• Symptoms
– Loss of Vision
– Pain
• “Red Eye”
• Iris Neovascularization
• High Intraocular
Pressure
• Marcus Gunn pupil
Diabetic Eye Disease
Other Manifestation of Diabetes in the Eye
• Branch Retinal Artery
Occlusion
• Central Retinal Artery
Occlusion
• Branch Retinal Vein
Occlusion
• Central Retinal Vein
Occlusion
Diabetic Eye Disease
Other Manifestation of Diabetes in the Eye
• Increased risk of
cataract
• Increased risk of
glaucoma
• Diabetic papillitis
• Acute CN III, IV or VI
paresis
Diabetic Eye Disease
What’s new and cool
• Intraocular steroid
– Injection
– Sustained release
device
• Stabilizes blood-retina
barrier
• Reduces Macular
Edema
Diabetic Eye Disease
What’s new and cool
• Anti VEGF drugs
• Protein Kinase C beta
inhibitors
• Intravitreal
hyaluronidase
Diabetic Eye Disease
What’s new and cool
• Ocular Coherence
Tomography
– Noninvasive imaging
of retina
– Can detect subtle
retinal thickening
Diabetic Eye Disease
Key Points
• Diabetes is a major cause of
visual loss
Diabetic Eye Disease
Key Points
• Risk factor control can prevent
and slow visual loss
Diabetic Eye Disease
Key Points
• Treatments exist but work best
before vision is lost
Diabetic Eye Disease
Key Points
• Diabetes is a major cause of visual loss
• Risk factor control can prevent and slow visual loss
• Treatments exist but work best before vision is lost
So … to prevent visual loss
• Control patient risk factors
• Insist your patients get yearly dilated eye
exams with an ophthalmologist