Download SD-16 Outline - American Academy of Optometry

Title:
A window into the diabetic body: recognizing possible end-organ-damage when
viewing the retina
Author:
Kuniyoshi Kanai, O.D., F.A.A.O.
Brian Wolff, O.D.
Abstract:
The diabetic eye contains a goldmine of information not only on the vascular
integrity of the retina, but also on the rest of the body. There is increasing evidence
in the literature that link diabetic retinopathy (DR) with other end-organ-damage:
ranging from stroke to renal failure to even mortality risk. The goals of this lecture
are to review major risks for developing DR, examine the current evidence on the
risk of developing comorbidities when DR is present, and spotlight how
optometrists are well positioned to properly detect and educate patients of these
risks.
Keywords:
Diabetes, retinopathy, end-organ-damage, mortality, stroke, neuropathy, nephropathy,
cognitive impairment
Learning objectives



Examine the link between diabetic retinopathy and its predictability of other
systemic micro- and macrovascular complications
Review current treatment guideline to minimize progression of retinopathy
and other comorbidities.
Discussion of proper patient evaluation (including telemedicine) and
education of risk factors associated with diabetic retinopathy
Outline:
1. Background
a. Diabetic Retinopathy (DR)
i. Why lecture on this?
1. Leading cause of blindness in working age population
2. Financial impact
a. Health care-related costs and loss of work
productivity
b. Diabetes: 245 billion in 2012 (not DR)
c. DR: 990 million in 2007
ii. Risk of developing DR
1. Of people with diabetes mellitus (DM) 40 years old and
older
a. 28.5% have DR
b. 4.4% have advanced DR
2. Increased risk of DR in the presence of HTN and
dyslipidemia
b. Associated health risks
i. Increased risk of mico and macrovascular comorbidities and
mortality when DR is present
c. Patient care
i. Patient Care
1. What you need to do
ii. Patient Education
1. Optometry’s role in helping prevent DR and associated
comorbidities
iii. Telemedicine
2. Diabetic retinopathy
a. Risk factors for development and progression of retinopathy
i. Diabetic related
1. Glycemic control
2. Duration of diabetes
3. Gender
4. Insulin use
ii. Other cardiovascular markers
1. blood pressure
2. dyslipidemia
b. Level of diabetic retinopathy and its risk of progression to the next
stage and blindness
i. The Early Treatment Diabetic Retinopathy Study
ii. The Diabetic Retinopathy Study
3. Link between DR and other systemic End-Organ-Damages (EODs)
a. Mounting evidence that suggests their association
i. Diabetic retinopathy and
1. Microvascular
a. Peripheral neuropathy
b. Nephropathy
2. Macrovascular
a. CVA - Stroke
b. CVD - Myocardial Infarction (MI) - Heart attack
c. Peripheral Artery Disease
3. Cognitive impairment
4. Mortality rate
5. Limited predictive accuracy
b. Basis for the connection
i. Homology of retinal vasculature to microcirculation in the
other parts of body
1. Embryological homology
2. Morphological homology
3. Functional homology
ii. Microvascular change in the retina
1. = Microvascular change in brain
2. = Microvascular change in myocardium
3. Association with Macrovascular change
4. Patient care: how to decrease DR and co-morbidity risk
a. Patient Care
i. Thorough history
1. BP, BS, A1c, Lipids
ii. Thorough eye exam
1. Funduscopy: DR, HTN ret, or plaques
iii. Auxiliary Tests
1. Blood sugar, A1c, Blood pressure
b. Patient education
i. Blindness risk reduction
1. Hyperglycemia
a. Principal risk factor of retinopathy
i. Benefit of tight glycemic control
1. The United Kingdom Prospective
Diabetic Study (UKPDS)
2. The Diabetes Control and
Complication Trial
ii. Intense control and transient worsening
in retinopathy
b. Recommended guideline from the American
Diabetes Association
i. Balancing benefit and adverse reactions
from treatment
1. Aggressive glycemic control and
risk of hypoglycemia
a. Lesson from the Action to
Control Cardiovascular
Risks in Diabetes (ACCORD)
2. Lower BP is not always better =
“bottom-out” effect
2. Blood Pressure
a. Cause of atherosclerosis
b. Benefit of BP control on retinopathy progression
i. Data from UKPDS
c. Added benefit of Renin-Angiotensin-System
controlling medications
3. Dyslipidemia
a. Special role of Fenofibrate in retinopathy
control?
ii. Comorbidity risk reduction
a. Studies showing decreasing above will decrease
macro and microvascular comorbidities
c. Role of telemedicine - beyond retinopathy screening
i. Current application
1. Diabetic retinopathy screening
2. Retinopathy of prematurity screening
ii. Toward automation
1. Imaging of retinal vasculature
2. Analysis of vessel morphology
a. Generalized arteriolar narrowing
b. Venular widening
iii. Automated prediction of future EODs from fundus imaging
1. Stroke
2. Coronary heart disease
5. Summary
a. Review of risks of DR and DR risks of co-morbidities
b. Clinical application of present lecture
i. Education as a key for patients’ success
1. Impact of face-to-face education on patient behavior
2. Increasing role of ODs in patient management beyond
the eye
ii. Telemedicine
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