Diabetes

and the
Eye
Presented to
DES chapters by the
Canadian Association
of Optometrists

Diabetes mortality
Three million Canadians will be living with diabetes by the end of
this decade.
Diabetes contributes to the death of 41,500 Canadians each year.
Type 2 diabetes shortens life expectancy by 5-10 years.

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Diabetes morbidity
Diabetes doubles the risk of stroke.
Diabetes quadruples the risk of heart disease.
Diabetes is the leading cause of non-traumatic lower extremity
amputations.
Diabetes causes 33% of the new cases of end stage renal disease.
Diabetes is the leading cause of blindness in adults aged 25-75.

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Components of visual function

visual perception
cognitive
functions

PS
YC
HO
LO
GIC
AL

PHYSICAL

light energy
dioptric
system

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PHYSIOLOGICAL

photoreceptors
neurological
processing

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Ocular effects of diabetes

8

1. Cornea + tears
2. Aqueous
3. Iris

4. Lens

5. Vitreous
6. Retina

6
1

7. Internal muscles
8. External muscles

2
3

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Ocular effects of diabetes

Cornea hypoesthesia, delayed healing, thickness changes

Aqueous glucose concentration, refractive index changes

Iris neovascularization, secondary glaucoma

Lens refractive changes, cataract development

Vitreous lipid deposits, hemorrhage

Retina edema, ischemia, hemorrhage, neovascularization

Intraocular muscles paresis, accommodative dysfunction

Extraocular muscles paresis, sudden onset diplopia

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Fluctuating vision
Diabetes can cause large shifts in nearsightedness and
farsightedness as blood sugar levels fluctuate

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Diabetic lens changes

Transient hyperopic refractive changes in newly diagnosed juvenile
diabetes. Giusti C. Swiss Med Wkly 2003;133:200205
Transient refractive changes are highly dependent on the
magnitude of plasma glucose concentrations
Correction of hyperglycemia is strictly correlated with complete
recovery of ocular refraction
Sorbitol production via the polyol pathway with overhydration of
the lens remains the best pathophysiological hypothesis

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Cortical cataract

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Mature cataract

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Cataract surgery foldable implants

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YAG capsulotomy

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Diabetic iris changes

Ischemia is thought to initiate
retinal & iris neovascularization
Vascular endothelial growth
factor (VEGF) likely plays a
central role in
neovascularization
New vessel growth at the
pupillary border, iris surface
and iris angle leads to
formation of fibrovascular
membranes
Membranes in the anterior
chamber angle block aqueous
outflow causing glaucoma

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Glaucoma

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Canadian Diabetes Association

2008 Clinical Practice Guidelines
Retinopathy key messages:
Screening is important for the detection of treatable disease.
Screening intervals for diabetic retinopathy vary according to the
individuals age and type of diabetes.
Tight glycemic control reduces the onset and progression of sightthreatening diabetic retinopathy.
Laser therapy reduces the risk of significant visual loss.

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Normal fundus

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Retinopathy
Individuals with type 1 diabetes
100% will have some diabetic retinopathy after 15-20 years of
diagnosis

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Retinopathy
Individuals with type 2 diabetes
20% will have some diabetic retinopathy at the time of diagnosis
50% will have some diabetic retinopathy after 7 years of diagnosis
85% will have some diabetic retinopathy after 15 years of
diagnosis

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Dots, blots, microaneurysms

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Retinopathy - macular edema

Remains the leading cause of vision loss in people living with
diabetes
Can occur at any time in type 1 and 2

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Macular edema

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Moderate background diabetic retinopathy

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Hypertensive and diabetic retinopathy

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Retinopathy NVD

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Retinopathy NVE

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Canadian Diabetes Association

2008 Clinical Practice Guidelines
Recommendations:
1. In individuals 15 y/o or older with type 1 diabetes, screening and
evaluation for retinopathy by an expert professional should be
performed annually starting 5 years after the onset of diabetes
2. In individuals with type 2 diabetes, screening and evaluation by an
expert professional should be performed at the time of diagnosis
of diabetes. The interval for follow-up assessments should be
tailored to the severity of the retinopathy. In those with no or
minimal retinopathy, the recommended interval is 1-2 years.

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Canadian Diabetes Association

2008 Clinical Practice Guidelines
3. Screening for diabetic retinopathy should be performed by
experienced professionals, either in person or through
interpretation of retinal photographs taken through dilated pupils.
4. To prevent the onset and to delay the progression of diabetic
retinopathy, people with diabetes should be treated to achieve
optimal control of blood glucose. People with abnormal lipids
should be considered at high risk for retinopathy.

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Canadian Diabetes Association

2008 Clinical Practice Guidelines
5. Patients with sight threatening diabetic retinopathy should be
assessed by a general ophthalmologist or retina specialist. Laser
therapy and/or vitrectomy and/or pharmacologic intervention
should be considered.
6. Visually disabled people should be referred for low vision
evaluation and rehabilitation.

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Diet

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Laser vision
correction

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Floaters

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Basal cell carcinoma

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Subconjunctival hemorrhage

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Pteyrgium

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Retention cyst

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Allergic conjunctivitis

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Bacterial conjunctivitis

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Viral conjunctivitis pink eye

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ARMD

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Early dry ARMD

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Dry geographic ARMD

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Wet AMD with fibrosis

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