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Title: Diabetic Eye Disease Not Just Retinopathy Eye Anatomy Lids


1
Diabetic Eye Disease
  • Not Just Retinopathy

2
Eye Anatomy
3
Lids, Lashes and Conjunctiva
  • Diabetics have an increased incidence of styes,
    chronic blepharitis, and bacterial conjunctivitis
  • More likely to be colonized by bacteria such as
    Staphylococcus Aureous and Staphylococcus
    Epidermidis that commonly cause these disorders
  • Can lead to scarring of lid margins and exposure
    keratopathy
  • Especially dangerous after surgery because can
    seed internal eye and cause endophthalmitis

4
Cornea
  • Function refraction, protection, window
  • Must be transparent achieved with uniform
    structure, avascularity and deturgescence
  • Corneal fluid balance maintained by active
    bicarbonate pump in endothelium and by barrier
    function of endothelium and epithelium

5
Cornea
6
Cornea
  • Diabetics have decreased corneal sensitivity
  • Decreased nerve fiber density seen
    microscopically
  • Predisposes to neurotrophic ulcers and
    difficulties with contact lenses
  • Early in course of disease some studies report
    corneal thickening (likely due to edema)
  • Late corneal thinning with associated increase
    risk in erosion

7
Cornea
  • Increased incidence of bacterial keratitis in
    diabetes, especially uncontrolled DM
  • Corneal ulcers due to Moraxella liquefaciens more
    common in diabetics and alcoholics deep
    penetration and prolonged, difficult treatment
  • Diabetics more prone to recurrent corneal
    erosions and to slow healing of corneal wounds
  • Epithelial basement membrane in diabetic eyes is
    poorly adherent to stroma, in part due to
    decreased numbers of hemidesmosomes, leading to
    sloughing of entire layer when traumatized.

8
Cornea
  • Diabetics tend to have more problems with contact
    lenses should they have LASIK or PRK?
  • Photorefractive Keratectomy (PRK) is problematic
    because it involves removal of the epithelium
    which is slower to heal in diabetic patients
  • Laser In Situ Keratomileusis (LASIK) is better in
    that respect because it involves making a flap
    and applying the laser directly to the stroma
    however trauma is still done to epithelium
  • A study done in Oregon showed that diabetic eyes
    treated with LASIK had an overall complication
    rate of 47 compared with the control population
    complication incidence of 6.9 (plt 0.01).
  • The most frequent complications occurring in the
    diabetic population are punctate epithelial
    erosions and persistent epithelial defects.

9
Cornea
  • Corneal edema develops during periods of relative
    hypoxia (including during contact lens wear) or
    when endothelium is damaged
  • Diabetic corneas do not recover from edema as
    quickly as normal corneas
  • Conflicting evidence regarding cause of decreased
    regulation of fluid balance
  • Enzymatic dysfunction of bicarb pump
  • Protein glycosylation within cornea
  • Involvement of aldose reductase with build-up of
    sorbitol in corneal stroma
  • Endothelial cell loss and fragility leading to
    impaired barrier function

10
Cornea
  • Any type of intraocular surgery results in some
    degree of corneal edema, thought to be due to
    mechanical stress on the endothelium with
    resulting decreased barrier function
  • Although diabetics appear to have normal number
    and density of endothelial cells, they often have
    irregular morphology and have prolonged recovery
    periods after surgery due to persistent corneal
    edema and endothelial cell loss

11
Cornea normal cell morphology
12
Cornea Diabetic Patient
13
Cornea Resolution of Edema After Cataract
Surgery
14
Cornea Endothelial Cell Loss After Cataract
Surgery
15
Primary Open Angle Glaucoma
  • No general agreement on whether there is an
    increased rate of primary open-angle glaucoma in
    diabetics
  • Largely due to inconsistent definitions of both
    DM and glaucoma and to study exclusions or
    sampling bias
  • 1994 Beaver Dam Eye Study Diabetics (mostly
    type II) had incidence of glaucoma 4.2 vs 2.0
    in participants without DM. When people treated
    for glaucoma included, rates were 7.8 in
    diabetics compared with 3.9 in those without
    diabetes. DM and POAG well defined and
    standardized
  • 1995 Baltimore Eye Survey Diabetics no more
    likely to have POAG than non-diabetics. DM
    defined by history only. Authors suggest
    reported increase prevalence due to more
    screening in diabetics (previously diagnosed POAG
    associated with DM)
  • 1996 Rotterdam Study Newly diagnosed diabetics
    had increased prevalence of high tension POAG.
    Glaucoma dx based on visual field defects
  • 2002 Ocular Hypertension Treatment Study Showed
    protective effect of DM on POAG. Excluded
    patients with diabetic retinopathy. DM defined by
    history only

16
Neovascular Glaucoma
  • Begins when ischemic retinal tissue releases VEGF
    into the ocular fluid resulting in stimulation of
    new vessel formation in the iris or anterior
    angle (known as rubeosis iridis)
  • Over time, a fibrovascular membrane forms,
    covering the iris and growing into the angle to
    inhibit aqueous outflow
  • Eventually this membrane contracts and anterior
    synechiae develop occluding the angle completely.

17
Neovascular Glaucoma
18
Neovascular glaucoma
19
Neovascular Glaucoma
20
Angle Closure Glaucoma
  • End result of neovascular glaucoma
  • Can also be caused or exacerbated by lens
    swelling during periods of hyperglycemia lens
    induced glaucoma

21
Lens Induced Glaucoma
22
Lens
  • Fluctuating myopia occurs when excess glucose in
    aqueous fluid diffuses into the lens.
  • Some of the glucose is reduced by aldose
    reductase to sorbitol, which accumulates in the
    lens drawing free water in with it
  • When the body rapidly changes from a
    hyperglycemic to a hypoglycemic state, sorbitol,
    which is less permeable and harder to metabolize,
    will remain in the lens longer. The difference in
    osmotic pressure results in the influx of water
    from the aqueous humor into the lens, causing
    lenticular swelling
  • Glycosylation of lens proteins also occurs
    causing irregularity in previously uniform
    structure and thus decreasing transparency
  • Causes change in index of refraction within
    different components of the lens
  • Also causes change in curvature of lens,
    affecting refraction
  • Can rarely result in lens-induced glaucoma

23
Lens - Cataracts
  • Diabetics 2 to 4 times more likely to develop
    cataracts than non-diabetics
  • Patients with DM develop cataracts earlier in
    life than non-diabetics
  • Risk increased with poor diabetic control as
    manifest by high HgbA1c or kidney disease and
    with increased age and/or duration of disease
  • May be partly due to glycosylation of lens
    proteins

24
Cataract
25
Lens - Cataract
  • Cortical cataract most common type in elderly
    (diabetics and non-diabetics)
  • May occur 20 to 30 years earlier in patients with
    DM
  • Special type of cortical cataract seen in young
    people with uncontrolled insulin dependent DM
    called a snowflake cataract
  • Rapid progression with total opacification in
    just a few weeks
  • Also has subcapsular opacities
  • not seen as much now because of better DM control

26
Cortical Cataract
27
Cortical Cataract
28
Lens - Cataract
  • Diabetics much more likely to get posterior
    subcapsular cataract (OR about 3)
  • PSCs appear to be caused by a dysplastic change
    in germinal epithelium resulting in vacuolation

29
Posterior Subcapsular Cataract
30
Posterior Subcapsular Cataract
31
Cataract Surgery
  • Indications are the same as for non-diabetics
  • Also indicated for monitoring of diabetic
    retinopathy when lens opacity prevents
    visualization of fundus
  • Increased rates of perioperative and
    postoperative complications, especially in
    presence of diabetic retinopathy

32
Cataract Surgery
  • Due to co-morbidities related to diabetes such as
    coronary artery disease and renal insufficiency,
    these patients have higher rates of perioperative
    morbidity (still generally very safe surgery)
  • However, there has recently been an emphasis on
    earlier cataract extraction in diabetics so some
    of the relative risks are offset by younger age
    at surgery

33
Cataract Surgery Anterior Segment Complications
  • Most significant anterior segment complication of
    cataract surgery is development or progression of
    neovascularization of the iris or angle, leading
    to glaucoma
  • Removal of cataract allows easier pathway for
    VEGF produced by ischemic retina to reach
    anterior chamber and promote neovascularization
  • Risk lower when diabetic retinopathy has been
    treated with laser photocoagulation therapy
  • Preservation of posterior lens capsule common in
    phacoemulsification surgical technique does not
    appear to provide any extra protection against
    neovascularization in anterior chamber

34
Cataract Surgery Anterior Segment Complications
  • Pupillary block (by lens), posterior synechiae,
    severe iritis, and pigment precipitation on the
    IOL are all more common in diabetic patients
  • Prolonged period of corneal edema after surgery
    and more damage done to corneal endothelial cells
  • Posterior capsule opacification occurs more
    frequently and sooner postoperatively in
    diabetics, requiring NdYAG laser capsulotomy

35
Cataract Surgery Posterior Segment
Complications
  • Diabetic retinopathy and macular edema frequently
    occur or worsen after cataract surgery
  • Other sight threatening complications such as
    vitreous or suprachoroidal hemorrhage or
    tractional retinal detachment happen more
    frequently in patients with diabetes
  • Post-surgical complication rates and visual
    outcomes in diabetics depend on several factors
  • Most important predictor of outcome is
    preoperative severity of retinopathy and presence
    or absence of macular edema
  • Also important age, gender, insulin treatment,
    glycemic control, prior laser photocoagulation,
    prior vitrectomy

36
Cataract Surgery Complications Cystoid Macular
Edema
Normal Macula
Cystoid Macular Edema
Optical Coherence Tomography
37
Cataract Surgery Complications Cystoid Macular
Edema
38
Cataract Surgery - Outcomes
  • Pre-op no/mild retinopathy post-op visual
    acuities similar to non-diabetics (85 VA 20/40
    or better) however
  • cystoid macular edema after surgery much more
    prevalent in diabetics
  • Retinopathy progresses in 15 of pts within 18
    months after surgery

39
Cataract Surgery - Outcomes
  • Pre-op moderate nonproliferative diabetic
    retinopathy without macular edema
  • Higher incidence of progression of retinopathy
    and incidence of macular edema
  • Early Treatment Diabetic Retinopathy Study 12
    month VAs for all eyes with mild to moderate
    NPDR only 53 better than 20/40 but 90 better
    than 20/100
  • Benson et al showed development of clinically
    significant macular edema in 50 of these pts
  • In some cases progression of DR and ME cause VA
    to be worse than preoperatively

40
Cataract Surgery - Outcomes
  • Pre-op NPDR with macular edema
  • Poor visual prognosis even with pre-op
    photocoagulation
  • Progression of retinopathy in 30 of eyes
  • Worsening of ME to point of requiring laser in
    50 of eyes
  • Only 50 have post-op improvement in VA
  • Only 40 have post-op VA of 20/40 or better

41
Cataract Surgery - Outcomes
  • Pre-op proliferative diabetic retinopathy
  • Outcome depends greatly on whether PDR is active
    vs quiescent and whether macular edema is present
    preoperatively
  • When possible, panretinal photocoagulation done
    preoperatively
  • With quiescent PDR and no ME, 60 had VA 20/40 or
    better
  • With quiescent PDR and ME, only 10 had VA 20/40
    or better
  • With active PDR, very few have VA 20/40 or better
    unless simultaneous vitrectomy and endolaser PRP
    performed (still less than 30)
  • Other complications of cataract surgery much more
    prevalent in pts with PDR such as
  • 50 of pts with active PDR will have anterior
    fibrinous uveitis
  • 6-9 of pts with PDR will develop
    neovascularization of the iris or angle

42
Cataract Surgery
  • Given the inverse association between the level
    of retinopathy and visual outcome, it may be
    better to perform cataract extraction in diabetic
    patients during earlier stages of retinopathy
  • However, may cause progression of retinopathy or
    occurrence of macular edema in previously mild
    cases so should not be done unless necessary

43
Cataract Surgery - Outcomes
Distribution of visual acuity before and 1 year
after lens extraction for all eyes, stratified by
the severity of retinopathy before lens
extraction - ETDRS
44
Ciliary Body
  • Ciliary body used to change shape of lens in
    order to accommodate
  • In diabetes, increased glucose in aqueous is
    deposited in ciliary body, decreasing mobility
    and thus accomodation
  • Results in early presbyopia in diabetics

45
Retinal Vein Occlusion
  • Diabetics, especially type II, at higher risk for
    central retinal vein occlusion
  • Must be distinguished from diabetic retinopathy
    because treatment differs
  • CRVO also lead to retinal ischemia and
    neovascularization

46
Central Retinal Vein Occlusion
47
Optic Nerve - Diabetic Papillopathy
  • Acute optic disc edema typically associated with
    mild visual loss (20/50 or better)
  • Most common theory is that it represents a mild
    form of non-arteritic ischemic optic neuropathy,
    with reversible ischemia of both the prelaminar
    and inner surface layers of the optic nerve head
  • Visual field defects may include increased blind
    spot, arcuate scotoma or altitudinal scotoma
  • FA shows diffuse leakage on disc
  • Bilateral in 50 of cases
  • More common in type I diabetics (70 of cases)
  • Good visual prognosis, most younger pts recover
    to 20/30 or better
  • Optic disc swelling usually resolves within 2-10
    months with residual mild optic atrophy
  • Must be differentiated from papilledema and from
    anterior ischemic optic neuropathy

48
Diabetic Papillopathy
49
Diabetic Papillopathy
50
Optic Nerve Non-Arteritic Anterior Ischemic
Optic Neuropathy
  • Sudden onset, non-progressive monocular visual
    loss, usually in elderly patients, often noticed
    upon waking
  • Swollen optic nerve, RAPD, dyschromatopsia,
    inferior altitudinal visual field defect
  • Occurs 2.7 to 5 times more commonly in diabetics
    than non-diabetics, especially with co-morbid
    hypertension
  • Usually a fixed deficit

51
Non-Arteritic Anterior Ischemic Optic Neuropathy
52
Optic Nerve - Superior Segmental Optic Nerve
Hypoplasia
  • Children born to mothers with Type 1 DM may have
    superior segmental optic nerve hypoplasia
  • Often asymptomatic with inferior visual field
    defects or have long history of tripping or
    running into things at their feet
  • Rates as high as 8.8 of children of Type I
    diabetics have been reported in small studies
  • Pathogenesis unknown

53
Oculomotor Nerves
  • Diabetics are more likely than non-diabetics to
    have isolated or multiple oculomotor nerve
    palsies
  • In a large study of 2229 pts with oculomotor
    nerve palsy, 13.7 had known diabetes
  • 50 involved CN 6, 43 CN 3, and 7 CN 4
  • Multiple nerves involved in 2.6 of pts
    simultaneously and 3.9 of pts consecutively
  • Prevalence of DR lower in pts with palsy than in
    diabetic controls matched for disease duration
  • Can be presenting sign of diabetes, rare in pts
    under 45 yrs old
  • Ischemic injury to nerve causing demyelination
  • Third nerve ischemic palsy usually spares pupil
    because vessel is in center of nerve bundle and
    pupillary fibers run on exterior surface with
    alternate blood supply
  • Usually resolves spontaneously in 3-4 months

54
Infection - Endophthalmitis
  • Several studies have shown increased risk of
    post-operative endophthalmitis in diabetics
  • Not surprising since diabetics have been shown to
    have impaired cellular and humoral immunity as
    well as delayed wound healing after surgery
  • May also be because diabetics often have more
    complicated surgeries and longer operative time
    (although this was controlled for in some trials)

55
Infection - Mucormycosis
  • Over 50 of mucor cases occur in diabetics,
    especially in pts with ketoacidosis
  • Usually originates in sinuses
  • Complete internal and external ophthalmoplegia,
    decreased vision, proptosis, ptosis, chemosis,
    black eschars and discharge
  • Vascular invasion and tissue necrosis
  • Mortality over 50

56
Mucormycosis
57
Take Home Messages
  • Diabetics, especially Type I patients, are at
    increased risks for many types of ocular disease
  • Tight glucose control can significantly reduce
    the incidence of disease and the number of
    complications associated with treatment
  • Diabetics should see an ophthalmologist early and
    often

58
Bibliography
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