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Update On The Ocular Complications of DiabetesW. Craig Lannin, D.O.Ophthalmologist with retinal subspecialty practiceFormer member of Monty Python Sorry, not really, I was deliberately wasting your time. The BBC apologizes for that faulty introduction. To insert your company logo on this slide

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DisclosurePresentation will include discussion of off-label uses of medication, i.e. bevacizumab [Avastin].

Off-label use extremely common in ophthalmology, particularly in retinal practices. Sometimes standard of care!

No financial conflict of interestHow does diabetes affect the eye?Refractive fluctuationInfluence on cataract formationDiabetic corneal disease [keratopathy]Increased risk of glaucomaCranial nerve ischemic mononeuropathiesOptic neuropathyDiabetic retinopathyDiabetic Refractive ShiftsDiabetic refractive shifts often accompany episodes of uncontrolled hyperglycemia, or abrupt lowering of serum glucose by initiation or change of medication.This a frequent early manifestation of diabetes, and may lead to suspicion and diagnosis.When this happens, it may not be the best time for a patient to update their glasses.Diabetic Refractive Shifts Mechanism(s) not completely understood.Shift may be myopic or hyperopic [influence of patient age?, diabetes type?, duration of diabetes?]Not usually felt to lead to any long-lasting ocular effect, but some authors suggest that if there are repetitive episodes of significant refractive shift, this may contribute to earlier cataract formation.Diabetes and other Ocular DiseaseGreater incidence of primary open-angle glaucoma among diabeticsEarlier development of age-related cataractsDiplopia/EOM paresis associated with diabetic ischemic mononeuropathyDiabetic AION [diabetic papillopathy variant of anterior ischemic optic neuropathy]Diabetic autonomic neuropathy [tonic pupil]Diabetic keratopathy [peripheral neuropathy]Diabetic Ischemic Third Nerve PalsyOphthalmoplegia with pupillary sparing.Location usually subarachnoid or nerve fascicle.Can be quite painful.Characteristically resolves within 4-16 weeks without Tx.Resolution is almost always complete, and aberrant regeneration is extremely rare.Diabetic Ischemic Third Nerve PalsyFurther investigation warranted if:No pupillary sparingOphthalmoplegia is incomplete, even with pupillary sparingOther associated neurologic signs or symptomsHeadache as opposed to ocular/orbital painNo resolution after 3 monthsAberrant regeneration developsDiabetic Ischemic Sixth Nerve PalsyLoss of abduction with/without esotropia [deviation toward nose] in primary position.Probably the most common cranial nerve palsy in diabetics.Recovery is usually complete in ischemic cases of CN-VI palsy, within 2-4 months.Must differentiate CN-VI cause of abduction loss from myopathic [e.g. thyroid] & neuromuscular [e.g. myasthenia]Diabetic Ischemic Sixth Nerve PalsyFurther investigation warranted if:Other associated neurologic signs or symptoms [e.g. gaze palsy, trigeminal sensory neuropathy, facial paresis, hearing loss, or Horners syndrome]If there is any associated redness, swelling, or proptosis, consider cavernous sinus disease [diabetics also susceptible to mucormycosis].No recovery after 4 months.Onset of symptoms was gradual rather than sudden.

Diabetic Ischemic Fourth Nerve Palsy

Much less common than third or sixth nerve palsy. More difficult to recognize when it does occur.Vertical diplopia greatest in downgaze to the opposite side.Ischemic cases usually recover completely.Most patients with CN-IV palsy demonstrate torticollis.Again, if not isolated unlikely to be ischemic.Diabetic PapillopathyUnilateral or bilateral optic disc edema in diabetic patients, the majority of whom [80%] will have DR.Originally described in young patients with Type I DM, but is now known to occur in older people with Type II DM. Frequently associated with DME.Probably represents a mild form of NAION.Visual loss is usually mild-moderate, unless the macula is also edematous.VF testing usually shows only BS enlargement.Diabetic PapillopathyThe optic disc may demonstrate typical hyperemic edema, but about 50% of cases will demonstrate marked dilation and telangiectasia of the disc microvasculature, enough in some cases to be mistaken for NVD.Bilateral cases require neuroimaging and LP to rule out intracranial lesions and/or increased ICP.Untreated, the disc edema usually resolves over a period of 2-10 months, with minimal residual optic atrophy in ~20% of cases. No proven effective Tx.Long-term visual prognosis usually dictated by course of the diabetic retinopathy. Case #6: DMExample of diabetic papillopathy:68 yo man with Type II DM. He described some decrease in vision OS dating back 6 months, but noticed more significant loss over past 2-3 weeks.History also remarkable for hypertension.BS control not very good.No constitutional Sx. ESR=2 CRP=1.1He recalled two brief episodes of visual obscuration with a duration of several minutes, and was also aware of a desaturation of red objects when viewed with his left eye.Case #6: DMExam findings [8/17/10]:BVA: OD=20/25 OS=20/50VF: Mild blind spot enlargement OS; minimal contraction.Pupils: Trace RAPD OS.Fundus: Disc OD flat with C/D 63)Similar adverse influence on the incidence and progression of PDR.Influence of Cataract Surgery on Diabetic RetinopathyIf a patient has both clinically significant cataracts and significant diabetic retinopathy, the diabetic retinopathy should be treated first if at all possible.All diabetic patients who have undergone cataract surgery demand very close scrutiny over the first 6 months following surgery.The most dreaded complication following cataract surgery is NVI leading to NVG.Complications of Diabetic RetinopathyIschemic maculopathyMacular subretinal fibrosisMacular puckerCystoid macular edemaMacular tractional retinal detachmentCombined tractional and rhegmatogenous retinal detachmentVitreous hemorrhageSevere fibrovascular proliferationNeovascular glaucomaCataractPhthisis bulbiIschemic Maculopathy

Diabetic Vitreous Hemorrhage

Diabetic Fibrovascular Proliferation

Diabetic Macular Traction Detachment

SummaryScope of the problemAccomplishments to date and challenges for the futureImportance of public education effortsValue of a multidisciplinary team approachEconomic benefits of eradicating all preventable diabetic blindness

Age of Onset

First ExamMinimum F/U

0-305 years after

onset Yearly*

31 and older At time of Dx Yearly*

Prior to

pregnancyPrior to conception or early in 1st trimester

3 Months*

* Abnormal findings will dictate more frequent F/U.