Eyeworld

EW NEWS & OPINION 38 April 2017 by Vanessa Caceres EyeWorld Contributing Writer cations make the latter group more vigilant about appointments. At Joslin Diabetes Center, researchers have studied thousands of patients with diabetes by taking pictures of the back of the eyes and tracking how aware they were of any present eye disease. "The amaz- ing thing is a large percentage of patients had vision threatening eye disease but when we asked them, 63% were not aware that they had any eye disease," Dr. Aiello said. These patients were seen at Joslin (although not by an ophthalmol- ogist), so they already had some self-awareness about the importance of diabetes care; the unawareness issue may be larger in the general population, Dr. Aiello said. Jos- lin's research in this area has been reported at meetings and is currently under review for publication. There are times when an oph- thalmologist may find signs that lead to a diagnosis of diabetes. Dr. Pillai saw a 37-year-old man with decreased vision and floaters that seemed to be getting worse. The patient ended up having a vitreous hemorrhage and PDR. However, he hadn't seen a primary care physician in 5 or 6 years so he wasn't aware that he had diabetes. Dr. Kunjukun- ju had a patient with changes to a cataract that developed over just a couple of months. It turned out that these changes were secondary to high blood sugars. The use of outreach programs or telemedicine in a targeted fashion at primary care clinics or pharma- cies—usually with the use of retinal imaging—may increasingly help identify patients at a greater risk of losing vision, Dr. Lauer said. Controlling disease before surgery Having diabetes usually requires more vigilance if eye surgeries are necessary. Dr. Norden recommends that patients interested in laser-assisted in situ keratomileusis (LASIK) first see their internist and get diabetes under control before considering LASIK. "If the diabetes isn't con- trolled, it needs to be before they get LASIK," he said. and warn them not to wait. If their blood sugar is poorly controlled, I usually have them come back in 6 months for a dilated eye exam," said Dr. Pillai, who is a uveitis specialist. If a patient requires medication for eye disease, retinal specialist Nancy Kunjukunju, MD, facul- ty ophthalmologist, Krieger Eye Institute, will have patients come in monthly for treatment or every 4 to 6 months if something unusual is occurring with their vision. Of course, part of the battle is getting patients to come into the office in the first place. Ophthal- mologists interviewed for this article report varied answers regarding how vigilant patients with diabetes are about getting eye exams. Richard Norden, MD, Norden Laser Eye As- sociates, Ridgewood, New Jersey, has found that patients with diabetes are usually good about getting regular screenings. On the other hand, "It depends on their age and comorbidities. Younger patients sometimes have trouble understanding [complica- tions], and older patients may have already had complications," Dr. Pillai said. Those previous compli- So how does the growth in diabetes—type 2, specifically—affect the exams, surgical planning, and education for patients? Starting exams An important first step is to schedule a comprehensive eye exam when a patient is newly diagnosed with type 2 diabetes, Dr. Aiello said. This is be- cause it is not always known when the patient first developed type 2 diabetes, so there could already be eye disease present. This contrasts with type 1 diabetes, where eye dis- ease does not develop as early after diagnosis. Retinal imaging is a crucial part of a comprehensive exam for longitudinal care and for planning purposes if treatment such as ocular injections, laser, or surgery are need- ed, Dr. Lauer said. That initial exam determines how often the patient should return for exams. "If there are no signs of diabetic retinopathy or cataract and the patient looks normal, we usually have them come back in a year," said Parvathy A. Pillai, MD, faculty ophthalmologist, Krieger Eye Insti- tute, Baltimore. "We educate them on the signs of diabetic retinopathy Managing the growing number of patients with diabetes T he growth in type 2 diabe- tes is hard to ignore, and it affects all specialties. A little over 9% of the U.S. population—or 29.1 million Americans—had diabetes in 2012, according to the American Diabetes Association (ADA). Of that 29.1 million, 8.1 million were undi- agnosed. The number of American adults with prediabetes was 86 million, a leap from 79 million in 2010. Be- tween 2005 and 2008, of adults with diabetes over the age of 40, 28.5% had diabetic retinopathy, the ADA reported. This growth in diabetes is no surprise to Lloyd P. Aiello, MD, PhD, professor, ophthalmology, Harvard Medical School, and direc- tor, Beetham Eye Institute, Joslin Diabetes Center, Boston. "The diabe- tes epidemic has been going on for many years. By 2050, there will be well over a half billion people with diabetes," he said. As people con- tinue to live longer, there's a greater chance they will develop disease in the back of the eye that is linked to diabetes, he added. As ophthalmologists know, having diabetes puts patients at a greater risk for a number of eye problems, including proliferative diabetic retinopathy (PDR), dia- betic macular edema, cataract, and glaucoma. Other problems such as abnormal eye or eyelid movement, double vision, and impaired wound healing are also more likely, said Andreas K. Lauer, MD, Kenneth C. Swan Professor of Ophthalmology, vice chair for education and chief, Vitreoretinal Division, Casey Eye Institute, Oregon Health & Science University, Portland. "Of all the diabetic eye diseas- es, diabetic retinopathy garners the most attention since this condition is prevalent and most likely to cause moderate to severe irrevers- ible vision loss and blindness," Dr. Lauer said. "In fact, in numerous countries, diabetic retinopathy is the leading cause of irreversible blind- ness in working age individuals." Dangers of diabetes and eye disease A pre-op view of extensive, proliferative diabetic retinopathy, with tractional macular detachment and somewhat hazy view secondary to associated cataract Source: Tamer H. Mahmoud, MD

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