Eyeworld

14 August 2018 EW NEWS & OPINION by Vanessa Caceres EyeWorld Contributing Writer Dr. Wang also noted the impor- tance of asking about blood glucose. "The most common population with diabetes needing eye surgery will be those with cataracts. Frequently we will have to delay cataract surgery because their blood glucose is not adequately controlled," he said. This can sometimes delay surgery for weeks. The opposite problem is blood sugar that is too low on the day of surgery (generally 60 mg/dl or below), as seen with symptoms such as fatigue, lightheadedness, or shakiness. "This can arise related to the need to fast and have surgery on an empty stomach," Dr. Wang said. "This is a much easier issue to control as it can generally be raised safely, and surgery can proceed on the same day." Generally speaking, cataract surgery can be done with minimal disruption to the routine of a patient with diabetes, said endocrinologist Rahil Bandukwala, MD, Memori- alCare Saddleback Medical Center, Laguna Hills, California. "Oculoplas- tic surgery, done for patients with Graves' eye disease, is a somewhat different matter. In this case, we like to have thyroid disease stabilized to prevent a thyroid storm from occurring as a result of any surgery," he said. 2. Require more frequent eye checks in pregnant patients with preexisting diabetes, Dr. Halprin recommended. This could be as often as every trimester to assess for new or worsening retinopathy or edema. Additionally, for those with active retinopathy, it is helpful if the ophthalmologist gives clearance for a vaginal delivery, which involves bearing down and could exacerbate retinopathy more. 3. Stay in touch with an endocrinologist when regular eye exams are completed by a patient. "Communication with the endo- crinologist that a diabetic eye exam has occurred along with the results is very helpful for continued care, as we can reinforce and give feedback to the patient that they took a pos- itive step toward better health," Dr. Bandukwala said. Graves' disease, Dr. Wang said. He recommends annual exams for these patients and sometimes even more frequent checks. Patients with an enlarged pituitary generally require annual visual field exams, he added. With the importance of regu- lar eye exams already on the radar screen of ophthalmologists and endocrinologists, what else can oph- thalmic surgeons do to ensure the best care for patients with diabetes and thyroid or pituitary conditions? Several endocrinologists shared advice with EyeWorld. 5 tips for better patient care 1. Hold off on elective surgery if a patient's fasting blood glucose is above 200 mg/dl or if the hemo- globin A1c is above 8–9%. "While ophthalmologic surgery is generally considered low risk, we often aim for a hemoglobin A1c of below 8–9% in patients pursuing elective surgery," Dr. Miller said. Complications that can occur from poor glycemic con- trol include delayed corneal healing, corneal defects, persistent corneal edema, and an increased risk for macular edema, Dr. Wang said. "The most optimal control is always best, with an A1c under 7% being ideal," Dr. Wang said. Ensuring that the A1c is less than 9 prior to any surgery is recommended, as this will help prevent infection and aid in the healing, Dr. Halprin said. which Dr. Wang refers directly to an endocrinologist, such as in a patient with diabetes who has more than mild retinopathy and needs more optimal control or someone with a severe presentation of a thyroid or pituitary-related condition, Dr. Wang said. Once a patient is diagnosed and seen regularly, endocrinologists often urge patients to get regular eye exams to check for new problems or progression of any problems. "Patients should be screened for retinopathy, and generally it is a patient's primary care doctor or endocrinologist who makes sure that is being done," said endocrinologist Elizabeth Halprin, MD, clinical director of adult diabetes, Joslin Diabetes Center, Boston. "If they are having any eye symptoms, flash- es, loss of vision, or floaters, they should be seen sooner than their annual visit." Endocrinologist Rajesh Garg, MD, director, University of Miami Health System's Comprehensive Diabetes Center, Miami, advises an eye exam annually or more often if there is any evidence of retinopa- thy in a patient with diabetes. "For Graves' disease and for pituitary problems, the frequency of eye ex- amination depends on the severity of the disease," he said. Dry eye, proptosis, and strabis- mus are just some of the problems that can result from uncontrolled Advances within diabetes particularly important as patient numbers increase R outine eye care is an integral part of care for patients with endocri- nology-related disorders, including those with diabetes, thyroid conditions such as Graves' disease, and pituitary condi- tions. Are you doing all you can to thoroughly monitor these patients' eyes? Although all of these disorders require vigilance, optimal care for those with diabetes is especially crucial due to the surging number of patients with this disease. In fact, 9.4% of the adult population in the U.S. had diabetes in 2015, according to the American Diabetes Association. Most of those had type 2 diabetes. Another 84.1 million adults have prediabetes, the Centers for Disease Control and Prevention reported last year. Prediabetes can develop into diabetes within 5 years if the person who has it does not make health changes. Sometimes, identifying a person with diabetes or another endocrino- logical problem falls in the hands of ophthalmologists. "A common scenario involves a patient with no known history of diabetes seeking out ophthalmologic care for blurry vision," said endocrinologist Joshua Miller, MD, medical director of diabetes care, Stony Brook Medi- cine, Stony Brook, New York. "The ophthalmologist, after evaluating a patient, can sometimes be the first clinician to recognize undiagnosed diabetes due to acute changes seen in the eye with hyperglycemia and glucose toxicity." Once ophthalmologists iden- tify eye changes that may indicate diabetes, they generally will refer to primary care providers. "We would allow them to make the determi- nation if the condition is at a stage that needs an endocrinologist," said ophthalmologist Ming Wang, MD, PhD, Wang Vision 3D Cataract & LASIK Center, Nashville, Tennessee. However, there are some scenarios in Endocrinologists share tips for better patient care

• Cover