PRESENTATION

Diabetes and the Eye

 Public Health Concern

• Type 1 and 2 Diabetes Mellitus is a growing

public health concern in Canada
• Projected prevalence to reach 5.0 million in
20251
• In Canada, only 32% of DM2 have annual exams
for diabetic eye disease2

1. Diabetes Canada. 2017. Diabetes Statistics in Canada

2. CDA Clinical Practice Guideline Expert Committee. CDA clinical practice guidelines for the
prevention and management of diabetes in Canada. Can J Diabetes. 2003;27(Suppl 1):S1-S152.
 Diabetes and the Eye

• Diabetes is the most common

cause of new cases of legal
blindness in people of working
age1

• Diabetes can cause changes to

virtually all structures of the eye

1. J.H. Kempmen B.J. O'Colmain M.C. Leske The prevelance of diabetic retinopathy among
adults in the United States Arch Opthlalmology 122 2004 552 563
 Ocular Effects of Diabetes
1. Cornea + tears 8
2. Aqueous
3. Iris 7
6
4. Lens 1 3 5
5. Vitreous 2 4
6. Retina 3
7
7. Ciliary Body
8. External muscles 8
 Fluctuating Vision
Diabetes can cause large shifts in
refractive error (nearsightedness and
farsightedness) as blood sugar levels
fluctuate
 Anterior Segment: Dry Eye
• More than 50% of patients with diabetes will
suffer from dry eye disease1
• Autonomic neuropathy – affects nerves that
control the lacrimal gland resulting in
decreased tear production
• Leads to corneal damage and
symptoms of dryness, irritation, etc.
• Reduced corneal sensation over time
• Delayed healing
• Reduced tear film – tear proteins
altered, increased MGD
• Increase Demodicosis (Demodex)
1. Manaviat MR,Rashidi M,Afkhami-Ardekani M,Shoja MR.Prevalence of dry eye syndrome and
diabetic retinopathy in type 2 diabetic patients.BMC Ophthalmol. 2008;8:10.
 Cataracts
Major cause of vision impairment in patients with diabetes:
• Earlier development in patients with diabetes1
• Suggested that patients with DM have higher
complication rate following cataract surgery1

1. P. E. Stanga, S. R. Boyd, and A. M. P. Hamilton, “Ocular manifestations of diabetes

mellitus,” Current Opinion in Ophthalmology, vol. 10, no. 6, pp. 483–489, 1999
 Cranial Nerve Palsies
• Isolated 3rd nerve (Ocular Motor Nerve)
and 6th nerve (Abducens) are most
common
• 4th nerve palsy (Trochlear) is less
common
3rd nerve palsy with ptosis
• Poorly controlled diabetes
• Usually with comorbity of HTN,
cardiovascular disease
Common Presentation
6th nerve palsy
• Acute onset diplopia
• Gaze restrictions and eye deviation
• 3rd nerve: ptosis, usually pupil sparing
• Unilateral headache
• Often resolves in a few months
 Glaucoma
Link between DM and Glaucoma is still not fully understood
• Generally accepted that patients with poorly controlled
DM are more likely to develop glaucoma
Diabetic Retinopathy Prevalence

It is estimated that almost all people with

diagnosed diabetes have some form of
diabetic retinopathy
• Retinopathy affects 23% of people with
type 1 diabetes and 14% of people with
type 2 diabetes on insulin therapy1

1. Diabetes Canada. 2017. Eye Damage (Diabetic Retinopathy)

 Risk Factors for Retinopathy
Non-Modifiable:
• Type of Diabetes (IDDM higher risk
than NIDDM)
• Ethnicity
• Aboriginal, Hispanic, South Asian,
Asian, and African are at higher risk
• Sex (male higher risk)
• Puberty (type 1)
• Pregnancy
 Risk Factors for Retinopathy
Modifiable:
• Hyperglycemia
• High blood pressure
• Reduction of BP decreases risk of DR
and macular edema in Type 2 DM
• Elevated Lipid Serum Levels
• High levels of triglycerides, high LDL,
very-low density lipoproteins may lead to
macular edema
• Smoking
 What is Diabetic Retinopathy?

Over time, diabetes will affect the

circulatory system of the retina
• Non-proliferative diabetic retinopathy can
proceed to vision threatening
proliferative diabetic retinopathy
• End organ response to systemic disease
What is Diabetic Retinopathy?
Development of Diabetic Retinopathy

• Basement membrane thickening

• Pericyte loss
• Smooth muscle cell depletion
• Vascular endothelial cell loss
• Vascular occlusion and re-canalization
• Neovascularization
Development of Diabetic Retinopathy
Types of Diabetic Retinopathy

• Macular Edema
• Non-proliferative Diabetic Retinopathy
• Proliferative Diabetic Retinopathy
 Diabetic Macular Edema (DME)
Mechanism for the development of macular edema is
similar to that for tissue edema elsewhere in the body
• Increased intravascular hydrostatic pressure drives
fluid across the vascular wall, causing fluid
accumulation in the macula
• Can occur at any stage of Diabetic Retinopathy:
• Causes a decrease in visual acuity
• Usually treated with focal laser photocoagulation
an/or anti-VEGF intravitreal injections
Non-Proliferative Diabetic Retinopathy

Ischemic blood vessel changes

• Microaneurysms
• Intraretinal hemorrhages
• Cotton wool spots
• Vascular tortuosity and malformation
• Patients are often asymptomatic
Non-Proliferative Diabetic Retinopathy

Flame and blot hemorrhages and microaneurysms

Mild Non-Proliferative Diabetic Retinopathy
Moderate Non-Proliferative Diabetic Retinopathy
Severe Non-Proliferative Diabetic Retinopathy
 Omega Loop

Omega Loop
• From severe localized retinal
ischemia
• Seen in very severe NPDR
• Should be monitored within 3
months as can quickly
progress to PDR
 Proliferative Diabetic Retinopathy

Ischemia leads to neovascularization in the retina

• Abnormal blood vessel growth
• These new vessels tend to leak
• Vitreous hemorrhages, Tractional Retinal Detachments
• High risk of severe irreversible vision loss
Proliferative Diabetic Retinopathy

Normal Neovascularization of the disc (NVD)

 Proliferative DR

Neovascularization Pre-retinal (sub-hyaloid

heme)
 Proliferative DR

Vitreous Pre-retinal
Hemorrhage fibrosis/tractional RD
 When is 20/20 Vision Lost?

When does a diabetic stop seeing 20/20 vision?

A.Moderate Non-Proliferative DR
B.Severe Non-Proliferative DR
C.Proliferative DR without macular edema
D.None of the above

One can still see 20/20 in advanced stages

if the macula is still intact
 Example of Referral Guideline
To Retinal Specialist
Immediate Referral
Endophthalmitis
Intraocular foreign body
Ruptured globe – send to General Ophthalmologist that is On-Call
Central Retina Artery Occlusion (CRAO) – if acute (<6 hours)

Within 24 Hours
Retinal Detachment
Retinal Tear
Vitreous Hemorrhage
Neovascular Glaucoma
Branch or Central Retinal Artery Occlusion
Papilledema – Swelling of Optic Disc
 Retina Referral Guideline (cont'd)
Within 1 Week
Choroidal Neovascular Membrane (wet AMD, myopia, Histoplasmosis)
Sub retinal Hemorrhage (AMD, Trauma, Retina Arterial Macroaneurysm)
Uveitis – that threatens the disc or macula
Proliferative Diabetic Retinopathy
Dislocated Crystalline or Intraocular Lens

Within 2 Weeks
Diabetic Macular Edema
Retinal Vein Occlusion (BRVO,CRVO)
Central Serous Chorioretinopathy (CSCR)
PVD – No Symptoms
Full Thickness Macular Hole (FTMH)
Posterior Segment Tumors (Melanoma)
Treatment of Diabetic Retinopathy

Kertes PJ, Johnson TM, ed. (2007). Evidence Based Eye Care.
Philadelphia, PA: Lippincott Williams & Wilkins.
 Laser Treatment for DR
Panretinal Photocoagulation (PRP): AKA
“Scatter”
• Gold standard for proliferative diabetic
retinopathy
• Decreases VEGF levels and causes resorption
of new blood vessels and stops new blood
vessels from forming
 Laser Treatment for DR

• Multiple laser spots throughout the peripheral retina

needed
• Has been shown to reduce legal blindness by 90%
in those with severe NPDR or PDR1-3
• Will cause peripheral vision loss but save central
vision

1. F.L. Ferris 3rd How effective are treatments for diabetic retinopathy? JAMA 269 1993 1290
1291
2. Photocoagulation treatment of proliferative DR: the second report of the DRS findings
Opthalmology 85 1978 82 106
3. F. Ferris Early photocoagulation in patients with either type I or type II diabetes Trans Am
Opthalmol Soc 94 1996 505 537
PanRetinal PhotoCoagulation (PRP)
 Laser Treatment for Macula

Focal laser photocoagulation

• Small area of laser applied to retina
to decrease swelling from macular
edema
• 50% decrease in edema1

1. Early treatment diabetic retinopathy study (ETDRS)

 Intravitreal Injections
Anti-VEGF Therapy
• Helps prevent leakage of blood vessels causing
macular edema
• Helps prevent development of neovascularization
• Needs more than one treatment
• Often monthly until stabilized
• Usually done in conjuction with PRP
• May cause subconjunctival hemorrhages, mild
eye pain, floaters, inflammation of eye, visual
disturbances
• Side effects can be managed by Optometrists
Intravitreal Injections
 Vision Rehabilitation
In some unfortunate patients, vision loss is inevitable
• Many optometrists offer low vision services to help
with aids and vision rehabilitation
 Intensive Insulin Therapy
Type 1 DM:
• Intensive insulin therapy reduced
development and progression of retinopathy1
• 3 or more daily
Type 2 DM:
• Intensive insulin therapy reduced microvascular
complication rate by 25%1
• Every percentage point decreased in
bHbA1c (e.g., 9 to 8%), there was a 35%
reduction in the risk of microvascular
complications1
1. UKPDS (United Kingdom Prospective Diabetes Study)
 Targets for Prevention
The ABCDEs:1
 A A1c -optimal glycemic control <7%
 B BP -optimal blood pressure control <130/80 mmHG
 C Cholesterol LDL-C <2.0mmol/L if decision made to treat
 D Drugs to protect the heart A-ACE or ARB, S-Statin, A-ASA
if indicated
 E Exercise – regular physical activity and healthy diet
 S Smoking cessation

1. 2013 CDA Clinical Practical Guidelines

 Prevention
Nutrition:
• High fiber diet, low fat = less proliferative diabetic
retinopathy
• Anti-Inflammatory nutrition
• GHA and EPA
• Vitamin D
• Anti-Oxidant nutrition
• Carotenoids (lutein and zeaxanthin)
 Prevention
Ensure patients are getting routine eye examinations

CLASSIFICATION RECOMMENDED INITIAL EXAM1

Type 1 5 years after onset >= 15 yrs old (not needed <15)
Type 2 At time of diagnosis
Pregnancy Prior to conception and early in 1st trimester

1. 2013 CDA Clinical Practice Guidelines

 Diabetic Retinopathy Follow-up1

NO NPDR Q 1-2 years by Optometrist or General Ophthalmologist

Mild NPDR </= 1yr by Optometrist or General Ophthalmologist
Moderate NPDR </= 1yr by Optometrist or General Ophthalmologist
Severe NPDR or Any PDR Referral to General Ophthalmologist or Retinal Specialist

DME Referral to General Ophthalmologist or Retinal Specialist

1. 2013 CDA Clinical Practice Guidelines

 Co-management
Communication is necessary to improve quality of care
and prevent blindness.

Helping prepare the patients for their eye exam:

• Name of primary care physician/NP
• List of medications
• Blood work results (at least las A1c)
• Educate them on a dilated eye exam
• Remind them to have the eye examination report sent to
other eye health provider or physician
 Diabetic Retinopathy
Screening and Diagnosis Method
Retinal examination through a dilated
pupil by an optometrist or
ophthalmologist (ophthalmoscopy or
indirect slit-lamp fundoscopy or
fundus photography)
 Telemedicine
• Digital retinal photographs performed and interpreted
remotely by a trained reader
• Only should be used in rural areas where access to an
optometrist or ophthalmologist is unavailable for a
dilated retinal exam

IT IS NOT A SUBSTITUTE FOR A

COMPREHENSIVE EYE EXAM

(WILL NOT DETECT SOME EYE DISEASES, SOME

DME AND VISION REDUCTION)
 Key Messages
• Early detection/treatment is important
• Improve communication of health care
team for earlier intervention and
management
• Tight control of BS, BP, Lipids
• Low vision services for permanent
vision loss
 Optometry’s Role
• Optometrists can diagnose and stage DR and
refer timely to ophthalmologist (eg DME)
• Many already have an Optometrist they see regularly
• Optometrists also manage other concurrent optical
and ocular conditions
• No referral to Optometrist needed
• Often longer wait for opthamologist, especially if
no diagnosis
• Optometrists can reinforce compliance
75% OF BLINDNESS IS PREVENTABLE
Diabetes and the Eye

Questions?