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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 Reference: 1. Agardh CD, Eckert B, and Agardh E. “Irreversible progression of severe retinopathy in young type I insulin-dependent diabetes mellitus patients after improved metabolic control” J Diabetes Complications 1992; 6: 96~100. 2. American Diabetes Association. “Standards of Medical Care in Diabetes – 2013” Diabetes Care January 2013; vol. 36 no. Supplement 1 S11-S66 3. American Diabetes Association. “Diabetes Statistics” http://www.diabetes.org/diabetes-basics/diabetes-statistics/?loc=DropDownDBstats Last Edited on August 20th, 2013. Retrieved on August 26th, 2013. 4. 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