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

Diabetes and the EyePresented to

DES chapters by theCanadian Association of Optometrists

An optometrist knows your eyes inside and out OPTO.CA

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.

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.

Components of visual function

• light energy• dioptric

system

• photoreceptors• neurological

processing

• visual perception• cognitive

functions

PHYSICAL PHYSIOLOGICAL

PSYCHOLOGICAL

Ocular effects of diabetes

1. Cornea + tears

2. Aqueous

3. Iris

4. Lens

5. Vitreous

6. Retina

7. Internal muscles

8. External muscles

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

Fluctuating vision

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

Diabetic lens changes

Transient hyperopic refractive changes in newly diagnosed juvenile diabetes. Giusti C. Swiss Med Wkly 2003;133:200–205

• 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

Cortical cataract

Mature cataract

Cataract surgery – foldable implants

YAG capsulotomy

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

Glaucoma

Canadian Diabetes Association2008 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 sight-threatening diabetic retinopathy.

• Laser therapy reduces the risk of significant visual loss.

Normal fundus

Retinopathy

Individuals with type 1 diabetes

• 100% will have some diabetic retinopathy after 15-20 years of diagnosis

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

Dots, blots, microaneurysms

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

Macular edema

Moderate background diabetic retinopathy

Hypertensive and diabetic retinopathy

Retinopathy NVD

Retinopathy NVE

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.

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.

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.

Laser vision correction

Floaters

Basal cell carcinoma

Subconjunctival hemorrhage

Pteyrgium

Retention cyst

Allergic conjunctivitis

Bacterial conjunctivitis

Viral conjunctivitis – pink eye

Early dry ARMD

Dry – geographic ARMD

Wet AMD with fibrosis

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

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