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Diabetic Eye Disease Not Just Retinopathy Eye Anatomy Lids


Diabetic Eye Disease Not Just Retinopathy Eye Anatomy Lids, Lashes and Conjunctiva Diabetics have an increased incidence of styes, chronic blepharitis, and bacterial ... – PowerPoint PPT presentation

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Title: Diabetic Eye Disease Not Just Retinopathy Eye Anatomy Lids

Diabetic Eye Disease
  • Not Just Retinopathy

Eye Anatomy
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
  • Especially dangerous after surgery because can
    seed internal eye and cause endophthalmitis

  • 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

  • Diabetics have decreased corneal sensitivity
  • Decreased nerve fiber density seen
  • 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

  • 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.

  • 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.

  • 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

  • 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

Cornea normal cell morphology
Cornea Diabetic Patient
Cornea Resolution of Edema After Cataract
Cornea Endothelial Cell Loss After Cataract
Primary Open Angle Glaucoma
  • No general agreement on whether there is an
    increased rate of primary open-angle glaucoma in
  • 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
  • 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

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.

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

Lens Induced Glaucoma
  • 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

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

Lens - Cataract
  • Cortical cataract most common type in elderly
    (diabetics and non-diabetics)
  • May occur 20 to 30 years earlier in patients with
  • 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

Cortical Cataract
Cortical Cataract
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

Posterior Subcapsular Cataract
Posterior Subcapsular Cataract
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

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

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

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

Cataract Surgery Posterior Segment
  • 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

Cataract Surgery Complications Cystoid Macular
Normal Macula
Cystoid Macular Edema
Optical Coherence Tomography
Cataract Surgery Complications Cystoid Macular
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

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

Cataract Surgery - Outcomes
  • Pre-op NPDR with macular edema
  • Poor visual prognosis even with pre-op
  • 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

Cataract Surgery - Outcomes
  • Pre-op proliferative diabetic retinopathy
  • Outcome depends greatly on whether PDR is active
    vs quiescent and whether macular edema is present
  • When possible, panretinal photocoagulation done
  • With quiescent PDR and no ME, 60 had VA 20/40 or
  • 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

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

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
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

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

Central Retinal Vein Occlusion
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

Diabetic Papillopathy
Diabetic Papillopathy
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
  • Usually a fixed deficit

Non-Arteritic Anterior Ischemic Optic Neuropathy
Optic Nerve - Superior Segmental Optic Nerve
  • 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

Oculomotor Nerves
  • Diabetics are more likely than non-diabetics to
    have isolated or multiple oculomotor nerve
  • 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

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)

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

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

  • Reifler DM. Neovascular glaucoma after
    intracapsular and extracapsular cataract
    extraction in diabetic patients. American Journal
    of Ophthalmology. 101(3)386-8, 1986 Mar 15.
  • Garcia CA. Ruiz RS. Diabetes and the eye.
    Clinical Symposia. 36(4)2-32, 1984.
  • Olsen T. Busted N. Corneal thickness in eyes with
    diabetic and nondiabetic neovascularisation.
    British Journal of Ophthalmology. 65(10)691-3,
    1981 Oct.
  • Negi A. Vernon SA. An overview of the eye in
    diabetes. Journal of the Royal Society of
    Medicine. 96(6)266-72, 2003 Jun.
  • Nemesure B. Wu SY. Hennis A. Leske MC. Barbados
    Eye Study Group. Corneal thickness and
    intraocular pressure in the Barbados eye studies.
    Archives of Ophthalmology. 121(2)240-4, 2003
  • Langwinska-Wosko E. Chociszewska-Nitka A.
    Zielinska E. Hapunik A. Evaluation of corneal
    endothelium following cataract surgery in
    diabetic patients. Klinika Oczna.
    106(1-2)28-30, 2004.
  • Murphy PJ. Patel S. Kong N. Ryder RE. Marshall J.
    Noninvasive assessment of corneal sensitivity in
    young and elderly diabetic and nondiabetic
    subjects. Investigative Ophthalmology Visual
    Science. 45(6)1737-42, 2004 Jun.
  • McDermott AM. Xiao TL. Kern TS. Murphy CJ.
    Non-enzymatic glycation in corneas from normal
    and diabetic donors and its effects on epithelial
    cell attachment in vitro. Optometry (St. Louis,
    Mo.). 74(7)443-52, 2003 Jul.
  • Costin JA. Is laser vision correction safe in
    patients with diabetes?. Cleveland Clinic Journal
    of Medicine. 68(5)385, 2001 May.
  • O'Donnell C. Efron N. Boulton AJ. A prospective
    study of contact lens wear in diabetes mellitus.
    Ophthalmic Physiological Optics. 21(2)127-38,
    2001 Mar.
  • Morikubo S. Takamura Y. Kubo E. Tsuzuki S. Akagi
    Y. Corneal changes after small-incision cataract
    surgery in patients with diabetes mellitus.
    Archives of Ophthalmology. 122(7)966-9, 2004
  • Jacobson DM. Vierkant RA. Belongia EA.
    Nonarteritic anterior ischemic optic neuropathy.
    A case-control study of potential risk factors.
    Archives of Ophthalmology. 115(11)1403-7, 1997

  • Harding JJ. Egerton M. van Heyningen R. Harding
    RS. Diabetes, glaucoma, sex, and cataract
    analysis of combined data from two case control
    studies. British Journal of Ophthalmology.
    77(1)2-6, 1993 Jan.
  • Xia X. Zhang X. Xia H. A study of factors related
    to the incidence of cataract in patients with
    non-insulin dependent diabetes mellitus. Yen Ko
    Hsueh Pao Eye Science. 17(3)180-2, 2001 Sep.
  • Hayashi K. Hayashi H. Nakao F. Hayashi F.
    Posterior capsule opacification after cataract
    surgery in patients with diabetes mellitus.
    American Journal of Ophthalmology. 134(1)10-6,
    2002 Jul.
  • Squirrell D. Bhola R. Bush J. Winder S. Talbot
    JF. A prospective, case controlled study of the
    natural history of diabetic retinopathy and
    maculopathy after uncomplicated
    phacoemulsification cataract surgery in patients
    with type 2 diabetes. British Journal of
    Ophthalmology. 86(5)565-71, 2002 May.
  • Hennis A. Wu SY. Nemesure B. Leske MC. Barbados
    Eye Studies Group. Risk factors for incident
    cortical and posterior subcapsular lens opacities
    in the Barbados Eye Studies. Archives of
    Ophthalmology. 122(4)525-30, 2004 Apr.
  • Hayreh SS. Joos KM. Podhajsky PA. Long CR.
    Systemic diseases associated with nonarteritic
    anterior ischemic optic neuropathy. American
    Journal of Ophthalmology. 118(6)766-80, 1994 Dec
  • Patel SV. Mutyala S. Leske DA. Hodge DO. Holmes
    JM. Incidence, associations, and evaluation of
    sixth nerve palsy using a population-based
    method. Ophthalmology. 111(2)369-75, 2004 Feb.
  • Trigler L. Siatkowski RM. Oster AS. Feuer WJ.
    Betts CL. Glaser JS. Schatz NJ. Farris BK. Flynn
    HW. Retinopathy in patients with diabetic
    ophthalmoplegia. Ophthalmology. 110(8)1545-50,
    2003 Aug.
  • Flynn HW, Smiddy WE. Diabetes and Ocular
    Disease Past, Present and Future Therapies.
    Foundation of the American Academy of
    Ophthalmology Monographs. China 2000.
  • Lazzaroni F. Laffi GL. Galuppi V. Scorolli L.
    Paralysis of oculomotor nerves in diabetes
    mellitus. A retrospective study of 44 cases.
    Revue Neurologique. 149(10)571-3, 1993.
  • Jacques PF. Moeller SM. Hankinson SE. Chylack LT
    Jr. Rogers G. Tung W. Wolfe JK. Willett WC.
    Taylor A. Weight status, abdominal adiposity,
    diabetes, and early age-related lens opacities.
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