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The Eye And The Connection With Diabetes

Brad Emde OD

Description

This presentation will focus on how diabetes affects the eye in many ways. It will not only cover how a person could lose his or her vision from diabetes, but it will also help "connect the dots" on why the examination of the eye is such an important and critical component in the treatment and management of diabetes. This course is not only beneficial to eye doctors but also critically important to any health provider who comes into contact with patients with diabetes.


Objectives:

 1. Increase knowledge and competency in understanding the etiology, pathophysiology, diagnosis, and treatment of diabetic retinopathy.

2. Understand how diabetes affects vision and structures of the eye other than the retina.

3. Understand why yearly dilated retinal exams are important for diabetics and understand why communication between eye professionals and the health professional treating the diabetes is so important.

Presenter

Brad Emde OD

Optometrist practicing and Owner of East View Eye Care in Greeneville, TN

Conference

Recorded

  • October 27, 2017
    3:15 PM
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Really Father we thank you for the opportunity again to to look at some of the things the affect people's vision and again as this draws them into our clinics we asked that you figure out you help us figure out a way to connect them to you to give them true vision of eternal life and prevent some of the suffering that's in the world today and help us to be tools in your tool chest for that in your name and pray man. Again I have no financial incentives in any specific product or company mentioned here today and again I like this verse that the lamp is the body or the lamp or the body is the eye in the earth therefore the eye is good your whole body will be full of light but if your eye is bad your whole body will be full of darkness. So the old saying goes I is the window into the soul today we're going to change that in say the eye is the window into the soul of diabetes so again our learning objectives for this course are understand the etiology pathophysiology diagnosis and treatment of diabetic right now the and then how diabetes affects the vision structures and effects vision and structures of the eye other than the retina understand why your early dialogue diagrams are so important and why communication between professionals are so important as well so we're going start on types of diabetic retinopathy So you have non proliferative diabetic retinopathy in general and then proliferative diabetic retinopathy proliferative just means proliferation of blood vessel growth in the retina that shouldn't be happening. And so of non proliferative you have mild moderate severe or some people say preprinted forgive. In you have early and high risk proliferative diabetic retinopathy each one of these can be with or without diabetic macular edema so or D.M. me so you know D.M. me with non proliferative or you have D.M. me with proliferative. If the D.M. me is close to the macular in the macula then it's clinically significant macular edema. So you have D.M. me without C.S.I. me. But you can't have C.S.I. me without the Emmy. So C.S.I. me implies that you've got the Emmy is just where it's at and so C.S.I. me is not good clinically significant macular edema because that is. Leading cause of vision loss. So Demi so as defined is retinal thickening within two disk diopters from the center of the macula And so if we look at the macular right here in the optic nerve in the blood vessels. We're looking to distill ammeters. It has to be treated if it becomes C M E C M E is retinal thickening five hundred microns from the fully or less or hard edge of dates within five hundred microns from the four we are less with Rattle thickening or at least one D.D. or just diameter affecting any part of which is within one dist I am aware of the phobia. This is based on early treatment diabetic retina read out the study in one thousand nine hundred five in this kind of set are our guidelines and what we go by and so this all looks familiar to everybody in the i world because here is the phobia the center of the macula the para phobia the peri phobia in the macula in the in in right in there you have this vascular zone the full yolo and the on both which is right in the middle so. Let's go here case study so I go through a typical diabetic patient with you and just kind of. Take you back to your office which is just what you want right you know you are here and now to take you back and start thinking we got a fifty eight year old white male new patient that I saw about two years ago to an after years ago he was referred to me by a local family practice physician he's a welder and this is his first i exam ever at age fifty eight. So he smokes one pack a day and he has for forty years he has diabetes and he has for five years which begs the question what happened. How come it's five years later that he's getting his first an exam ever OK which you all have those patients into because standard of care for the last thirty years or more is your early dilated eye exams and so he's got hypertension he's got C O P.D. He has high cholesterol and heart problems so probably the local family physician was distracted by all the things going on and forgot completely about the eyes assuming that he was following the same doctor but he might have been non-compliant who knows. Any of that now had sleep apnea for seven years. In his fasting plasma glucose runs you know one eleven one nineteen which isn't too bad and he has no idea what is A one C. is how many can relate you know you get those patients all the time and so in Incidentally now over the last year or so you really have to go on A one C. So now my staff and they don't have an A one C. they know they're on the phone with the physician's office getting the A one C. and that's a higher level of care and that's something that you are really supposed to be doing because that they one see is is a is basically on average a three month. Average of what's what's happening in that in that blood over that many times and as the red blood cells get Casa lated or sugar coated. Then that gives you an idea of how high that sugar was in the blood over the last three months I'm looking for a thermostat I see people shivering in here and I don't see one. Can you work on that dentist. Thank you so when you see this patient and you see the little bit of history that we've got is this patient What's the level of risk if any for a future vision loss is this you know low risk medium risk high risk which what you're thinking here it's like OK you have we haven't done anything but look at the history so let's go through this well first thing that you're going to worry about OK the diabetic retinopathy so so I grab the chart. Before I step into the room I've already started thinking what I'm looking for I'm looking for diabetic retinopathy I'm looking for hypertensive retinopathy why because you've got hypertension too. I'm looking for a R M D A macular degeneration Y. because he's a smoker OK. I'm also looking for nuclear sclerosis cataracts Why is a smoker he's got diabetes and he's fifty eight so pretty much normal Americans. Are going to start getting cataracts in their fifty's and sixty's and seventy's or eighty's usually when they have been a for surgery in general course and looking for glaucoma why coma specifically it's one of the three diabetic diseases cataracts glaucoma diabetic retinopathy those are the three diabetic eye diseases so more than that though sleep apnea so you know that. And he's a smoker that increase your risk but forty percent of people with sleep apnea. Have low tension glaucoma and seventy percent of your low tension glaucoma patients have sleep apnea this is highly correlated OK which just makes sense if you stop breathing and you don't get oxygen to that neural tissue the neural tissue is going to die so if you have a lot of sleep apnea events at night and you're not on a. Bipap you're you're not getting the oxygen that tissue needs same as any of the other organs in your body and that's why it's low tension because it's not a high pressure that's causing this it's actually the lope it doesn't matter what their pressure is the optic nerve is dying. Even with normal pressure OK so that's why it's it's it's correlated with the low tension. And of course you're thinking also I'm thinking OK All right well he's a welder and so you could have U.V. keratitis from yesterday's flash burn got last night. And also he has high cholesterol so he could have even Hollinghurst plaques of his age you could if it was really it which is a blockage you know of the of the arteries in there from the. Internal carotid. So what kind of risk are we at war and high risk so I walk in the room already in my mind this guy has tremendous risk for tremendous morbidity. And he doesn't even know it in NO I doctors ever told him because he never had and I am. So but at least the family doctor got him here so that's great that's that's a huge blessing for this guy. So now we're in the room in now his chief complaint he says I got glare at night first thing that comes to mind is dad or Xx. And I've got blurred vision well that to me cataracts that can be dry eyes that can be diabetic macular edema that can be a whole host of things right. He's got watery eyes so of course watery eyes on a diabetic what comes to mind first right what's your diagnosis. If you're not right meaning down yet I mean you're you're listening to him but what comes straight to mind on a watery I patient with diabetes is. And they do is look at you like what are you talking about and because it's a reflex tearing they do not feel pain like a normal patient does so they're not going to come in saying my eyes burn my eyes hurt like my eyes feel like knife sticking in like a non-diabetic would come in they are diabetics are going to come in they're going to tell you I've got watery eyes and you can tell me have dry eyes and they're going to laugh at you but it's just because they don't feel it and so the dry eye become severe and we're going to talk about this a little bit later too and then they start getting this reflex hearing and that's the last ditch effort to save the blindness that would come from extreme dryness and this is his vision so he's twenty one hundred twenty forty in the other eye so he's barely legal to drive so in Tennessee you have to have twenty forty or better in in one eye and that's what he's got barely All right so I can give him better so a lot of this is astigmatism so stigmatism can get up to twenty twenty five basically in both eyes so that that's good that tells me right off the bat that his cataracts can't be too severe and his retinopathy if he has and he can't be too severe because I can improve that now you can improve that even Obviously you would. Be more worried about that blood pressure was good though. And now as I pressure of course so people that have a lot of systemic sickness have a lot of ice sickness too so not only. Is he a risk for all these other things and we said glaucoma to sleep apnea low tension but now he's actually got high tension high tension so he's got high pressure in there especially in that left eye and so once you pressure's high the familiar you got to figure out is how much can you believe you're Goldman to monitor or you are depending on what's in on are you using but if you're using Goldman like I am you've got to do a Cornell pick on the tree and luckily in his particular case is Koreans were thick and so because he had thick corneas in the Normal is like five hundred forty microns in his was five ninety five and six a one. You know some of these studies suggest that the pressure actually might be lower inside but other studies are saying that actually because you have a thick cornea structure like more two by fours in your cornea. If you translate that all the way around the eye to the the outer optic nerve you can have more two by fours in your optic nerve to make it stronger so your your risk of glaucoma is much much less with the corneas. And that's fantastic in his case. In Sure enough he does have not only nuclear sclerosis sclerotic cataracts but he's also got cortical cataracts and that's why he's having the glare at night and sure enough one of the with Thorazine he's got the dry eyes and it's causing the watery eyes and we dilate him his CD ratio is great so that's good. But he has some vessel torturous that he has no diabetic retinopathy and he's got a small chirpy which is the congenital like a birthmark a congenital hypertrophy of the retina pigment at the little layer. And so we're going to order some tests though now we have to because the pressure is high and even though with the CD ratios you got to have a baseline because what you're trying to find is progression over time with glaucoma so you're going to or your visual field or macular of City University from his photos which thankfully in his case all came back normal Why am I doing a macular of city. Nervous C.T. I'm looking at the regular fiber layer. Ganglion cells but also specifically I'm also looking for clinically significant macular edema that I can't see under the slit lamp in it will show up on that very easily and so this is. Again our normal in this is. This is normal as well but I want to show you the kind of in gorge meant in the torturous blood vessels here. It kind of you think of like sludging of the blood a little bit there and normal but with torturous blood vessels there's the turkey right there you know it's not an evil because you put your red free filter in and it does not disappear and if it does not disappear then you know it's it's more in the in the superficial layers and not in the choroid. So this is his right eye looks great pretty good really good I don't see anything right in there and again the raster is this is a five line raster going right across the macula and they look good as well and this is baseline his Again you look right here good right over fiber layer this confirms his minimal cupping and you see a cross-section here very very little cupping it looks good and we didn't do that two thousand and fifteen so we didn't do gangland style analysis back then but we do now and so what's the treatment for this guy but we're going to monitor him every six months not for any diabetic written up the or the high risk necessarily of of just of that but we've got to what I do is I repeat the six months and check his pressure again so that I have at least two a year of what the Dayrell pressures are doing I'll try to check him at a different time of day am going to communicate the findings of course with a physician that there's no diabetic retinopathy but. I am going to do this for about a year and a half to two years. About every six months and then I will drop down to once a year on the nerve if it if I can demonstrate that there is zero progression. So if you can prove because because optic nerves look so good. That's my form that we use and so I say I like Dr so and so. The following is for your records and here is whether it's normal no diabetic or not the or abnormal and if it's abnormal what degree and that's just the form that we've used for the last twenty years and again if you do this you're doing a higher level of care and you should be paid more and that's what MIPS is all about the merit based incentive program so if you are doing what you're supposed to be doing the idea is that you should get paid more and I like that idea because I have been doing this for twenty years and I never got any more payment but I'm hoping that next year maybe I'll get two percent more what I've heard this and be able to do another Taco Bell. Here's the case study Number two. Seventy three year old white male diabetic now for ten years has his blood glucose is a little bit higher again a A one C. unknown vision twenty thirty and again normal I in looks pretty good this is a pretty cornea lens. Kind of view what you'd have to turn the lights down just a little bit more we're going to get into some more. Thank you. But we're you'll see right here is a little bit of a large CD ratio not bad but. They are. And so. We're going to look at that and when I order the five line raster right here this is going to reveal clinically significant macular edema because it's very close to the phobia right there and you will not see that. On that picture right there. And that's why I do it and I have caught so many people with some clinically significant macular edema and they don't really have a sick looking retina even on photos it's amazing so if you're diabetic you're going to get this especially if your vision is not twenty twenty if it's decreased at all they don't really have Significator X. you should be doing that if you have that technology. And this is this is why is because it's defined right there and so. Now he's going to have non proliferative diabetic retinopathy with D.M. and it's actually C S I me. So what do you do well you can refer him to a retina specialist and they're going to consider either laser injection and you can also communicate with the treating physician because that treating physician needs to know what the retina looks like because he could have bleeding already in his brain or heart or other places just like he has in these capillaries right here kidneys. And then I'm going to have him come back for a full glaucoma work up just based on the optic nerve and based on the fact these diabetic and based on the fact that he's over forty used to say fifty but now it's it's forty or the risk starts to go up. And the types of of retinopathy again are are this and the number one cause for the non proliferative diabetic retinopathy like he's got is D.M. E C S I me that's what they go blind from. So when you are going to treat diabetic retinopathy nonproliferation of you've got to control the blood glucose levels and for every one percent increase in A one C. there's a thirty five percent higher risk of retinopathy. For every every point so if you're it. Six point two. And you go to seven point two you've just increased your risk of blindness by thirty five percent. Per point. So that's huge and this is hard to say see right here but let me read this to you right here it says there was a sharp increase in retinopathy Now this comes out of the American Diabetes Association diabetic care back in two thousand and nine and it says there was a sharp increase in reading up the prevalence in those within A one C. level of five point five That's interesting OK increase risk even at five point five This this. It's abnormal so when your blood sugars are normal if if you go into pre-diabetes. There's a reason that that's not normal it's because pre-diabetics can go blind you can have written Opti is a pre-diabetic OK it's rare you don't see it very often but in so like a six point two that they want to see now that now that the risk of right now if they just skyrockets but that's why it's not normal because you can still have written up then you can still have an A for apathy and other things based on a on a blood sugar that's higher than what is considered normal. So you want to control these other felt factors too because hypertension and smoking and whatnot these wreak havoc on the blood vessels in the body as well so when you have hypertension and you have diabetes you are very much a double whammy for your. Run up the. Morbidity risk there so according to Diabetes Prevention Program lifestyle changes for pre-diabetics. Have a significant impact on diabetes diabetes prevention the study results showed that a diabetes incidence was reduced by fifty eight percent in those who received intensive training in proper dietary intake physical activity and behavioral modifications compared to now this is pretty diabetics compared to thirty one percent who receive metformin so this is two thousand and fourteen so in other words a program like diabetes undone which we have done at our church locally at least four times now we were the first place that it was ever done in my if I if I understand correctly as in Greenville Tennessee we we've. That's what that emphasizes right there so a program like that is much better almost twice as effective is putting somebody on metformin right off the bat when they're pretty diabetic and after ten years ten year follow up the D.B.P. researchers determined that the onset of diabetes could be delayed for at least a decade in patients who continued to eat properly and exercise regularly and follow the studies conclusion why only ten years because they only followed on for ten years. OK so if they if they keep if they do the principles in diabetes undone. The advantage health message you won't have diabetes it will continue to prevent diabetes that's the whole point of why we're doing that. Now. I do want to speak to this really quick because I do have a. I have shifted my tune a little bit on this in that is. So so we've got the data and we've got science behind this and we've got physiology behind this you know so when you're dicta the sugar fat salt and all these things and you cut that out you know if after several weeks your body doesn't crave that anymore you know so so all these things are on our side but I will tell you that if you've ever tried to change your diet it's hard to do it's hard because it doesn't matter if you're smoking doesn't matter if you're trying to cut out caffeine doesn't matter what it is that you're trying to change if it's a wanton desire of your heart. Good luck good luck changing it there's only one power in the universe says I will change your heart. And I will create a new new desires a new wants and that's God So if you can't connect your patient with the hand of Jesus and so what I tell my mom I'm like you know and I tell them exactly what I just told you basically before I do though I always say this I said I don't know if you believe in God. And I pause to look for a nod or a look in to know I look at a blank stare whatever because you have to be careful and I'm in the bible belt so I got it a little bit easier as far as that goes because most everybody believes in God There. And they're like oh yeah yeah and I'm like well then I tell them what I just told you about about you know the source of the change heart is just Christ. And I tell him this you know how many times have we heard stories where a serial killer is on death row. And a serial killer absolutely loves LOS to kill people that's what they that's what they like. Well if that serial killer turns to God. God can actually change that heart of that person on death row and you heard stories like this in that that murderer can actually have and become a loving human being totally repented of what they've done in the past in the hearts changed that's a miracle and that's the power of God And so when we look at stories like this and we fail to tell our diabetics and our smokers in those patients who are addicted to Mountain Dew and white bread and Bologna that their source of power isn't of themselves and it's not these studies the source of power needs to be the hand of God and so don't know so I tell I remind them because they just told me they believed in God and I remind them that look in now that you're going to connect in you're going to ask God to change your tastebuds and get him involved in your health care as well in the wants and desires of your heart whatever that whatever it is that needs to be changed other gossip or pride or whatever. Once you connect to that. Then you're connecting with a power that is saw strong this you're not connecting to some rinky dink little. Buddhist Idol that I saw in Mongolia you're connecting with God who is a star breathing God you're connecting with God Yes so much power he can speak and there's an elephant he can speak and there's a. Giraffe this is a God who designed us and he is wanting you to be healthy and you want you to have a life any want you to have it to the full and so take the five minutes get your little spiel as I call it and somehow get that into their brain and in it doesn't mean that you're going to baptize them after the five minutes it means that that seed the your You're asking God you're asking him to use you as a tool to plant that seed and it's not our job to water the seed necessary of the Holy Spirit will do that our job is to do whatever Christ is asking us to do and are you willing is a very good motto for this meeting are you willing to go there are you willing to take a little bit of time plant the seed so a Holy Spirit can sprout it up later and. When you start getting your family doctor your optometrist your podiatrist your inner chronologist. In and everybody would give this patient that same message and hopefully they're there preacher and hopefully their Sunday school or Sabbath school teacher you know they're getting this message over and over that dats are that's our strength is that full dependence on God doesn't matter what it is. Then you've just. Done medical missionary work and that's what this meeting is all about so. This is an important important thing. When we go back here and look at these two types how people go blind from non proliferative diabetic ran out the is the D M E N C S I mean help people go blind typically from proliferative is the retinal detachment OK and that and they can also get the D M E N C M E But the main the main cause of vision loss is both of these these don't have the proliferation of blood. So they're not going to have retinal detachment. So you have to look at the mechanism of why the retinal detachment. Is cause this proliferation means new blood vessel growth OK And so the new blood vessels can grow in three locations and you've got to be looking at all three of these locations the iris the disc and elsewhere so neo it's a N B I N B D N N V E. And if you see any of this new vascular zation in any of these locations that's a bad sign because that means that there was chronic hypoxia or low oxygen in the retina and it's triggering this vascular into Theall you'll growth factor Jeff to. Cause this proliferate sorry this proliferation of new blood vessels within the retina Well that sounds like a great thing because it gets more oxygen but the problem with these new blood vessels is that they leak and when they leak and as they heal it causes scarring which then pulls the retina right off the back of the eye and that's what causes the vision loss. That's why a non prolifer two diabetic right now with the patient is not going to have this makes sense and so here we got this this is pretty prolific of diabetic retinopathy and the capillary walls are damaged and so you've got leakage of of limpid and. Blood into the retina. And if you've got a retina that looks like this you know their kidneys are leaking as well. In this is significant. Diabetic retinopathy and this has C.S.M.A. because it's got this lip it educate right there by the years well it is not something you want to see vascular ization of the iris and where you want to look by the way for N.V.I. you want to look at the people or referral right there. That's where it's going to happen just like this picture right here you're not looking out here in the angle and things like that it's usually going to start right in there in the problem is it will affect the angle it can affect quite a bit and be D. So Neal vascular zation of the disk right there well it's a very sick looking retina has also the C S I mean you're right there with bleeding and you're going to get these patients to a retina specialist very fast and they need to do pain retinal photograph P.R.P. and what basically that does is it kills the oxygen so there's a balance. Of oxygen demand in oxygen supply OK And so if you're in balance that's great but if the if you get chronic hypoxia or low low oxygen to the retina then what's going to happen is that you're going to there's a deficiency of oxygen and so the body's going to create these new blood vessels to try to overcome that and so what you're doing is there such a demand for the new blood of us I mean for the oxygen that you're going to do pant P.R.P. or pan retinal foetal laser photograph to basically kill off some of the healthy retina to lower the demand for the oxygen to equalize that in in the new blood vessels go away. And so. And they can do grid laser for diabetic macular edema they can do steroids injections. Macular edema and the new ones of course for the anti have a Jeff medications very similar to macular degeneration that we talked about the last hour this again is in phase three with the R T H two fifty eight that's going to be nice because those patients don't have to go in every month they might have to just go in every three months or so and they can also do the trick to me if the blood vessels. Or the not only moves that removes the blood vessels but it eliminates that traction that causes that worsening diabetic macular edema so let's third Tayseer So sixty five year old white female again new patient that I saw three years ago. She's divorced she lives alone an apartment her last I examined a year ago at Wal-Mart and can't remember if they dilated her and I sure hope they did. But they might not have and so her health is managed by a local family or a practitioner she's been diabetic for twenty five years so they had better dilated this patient. And fasting blood glucose three hundred the day before in the last A one C. it was thirteen now notice that the A one C. I saw her in December they one C. was at the beginning of the year so either the north practitioner is NOT GETTING A one C. is thirteen you better be checking that every three months. So probably non-compliant though I'm sure the nurse practitioner would know better than that and so the patient just non-compliant I'm sure so. Best corrected visual acuity not bad twenty twenty five twenty thirty. Blood pressure again not too bad and against the way up dry eyes which is very common cataracts both cortical and nuclear sclerotic and. The suspect based on high pressure and. Here's the in here look in side and again not too bad. You know not too bad fairly normal oh city of the macula. The other I am not too bad macula looks pretty good little blood hemorrhage right there. In the macula. And so you up sure enough see a semi right there showed up what you couldn't really see on the picture otherwise which we see quite often but there is something more ominous in this picture and of course it's hard to see you touch this on your slightly upper immediately. This area right there. Right at the optic nerve there is a huge amount of neo vascular ization right there in of course we're in a picture so you're not going to see it but that's the O.C. of the optic nerve and you see this neo vascular zation extending into the vitreous and that is going to blind this patient if left untreated this is this is an eminent blindness So yes so you get them right then to the retina specialist and we got her there within three days and he performed the P.R.P. the same day on that eye to decrease that demand of oxygen. And he may need to do the. Injection as well of course both of us stressed the need for good blood glucose control and compliance with her P.C.P. and we communicated with P.C.P. what was going on and then once that is stable then we will continue to monitor for the glaucoma possibility cataracts through in the US. The other stuff so here's a door them what the P.R.P. scars look like in there and these are just a few. This is a little bit more superior and in this is like three sixty And so we've all seen that before so diabetes is the leading cause of new cases of blindness among adults aged twenty to seventy four. In the end. Or the N.E.I. the National Institute reports that nearly half of Americans with diabetes have. Diabetic retinopathy That's a lot a lot of sick eyes out there so prevention early detection is critical. And many attempts to approve improve patient compliance and better glucose monitoring are available including you probably saw this three years ago that Google was working on and this is the. Group contact lens with a device that measures the blood glucose levels within the tears to try to estimate live twenty four seven what the blood glucose is doing and it's got a little sensor right in there. The only problem with this that I see. One of the big problems is that diabetes is a relative contra indication for contact lens wear. Why is that because they usually have dry eyes and they don't feel it and so you put a contact lens on diabetics cornea you're just asking for an ulcer because they're not to get there they're not going to get the contact lens out quick enough. To do that and so if I have a patient who just absolutely. Has to be in contact lenses and wants that after much education I will fit them but they're going into a daily disposable silicone hydrogels lens and that breathes very will that they're getting the waste thrown away every day and that's going to decrease their risk tremendously. And so that. Covers that but what I want to talk to next is is how diabetes affects vision in structures other than the eye I mean other than the retina in the eye all the way from the front to the back in so let's start with the outside of the eye and work our way in how many of you have ever seen these palsy. With the binocular diplopia with the diabetic common six nerve palsy bingo right there and so almost always it you ask you know. Seventy year old patient comes in with this nine times out of ten it's going to be some kind of vascular cause that's going to resolve itself usually within two or three months if it doesn't then you go order an M.R.I. but usually it almost always gets better within two or three months. Very very common and that's just a scheme Mia to the. In that particular case it was the left eye this is the right eye but it would be that lateral rectus muscle right there that's. The innovations impaired so Xstrata muscles are affected the cornea in the contact Tiber if you've seen these the cornea will. Micro aneurisms basically. These are these are areas where the contact title Mike Rann you're isms. To be more common in a diabetic as well there's a close up of it so you see these little things sometimes as well I took that picture years ago with my slant camera this this is dry is extremely common and so multiple studies have shown that more than half of your diabetic patients are going to have dry eye disease over fifty percent walking in and it's just very common so they can have burning in foreign body sensation but their number one complaint of course is going to be the watery eyes and that's due to reflex hearing that we talked about earlier. And more that we see every day. And again the Bible mingle and drop out there so why so much well the purple neuropathy of the Cornell nerve center feeds interferes with that feedback loop and then the insulin. Is less so insulin is secreted by accident Grant glands and it's found in saliva breastmilk in tears insulin in the tear affects the opposite feel cells proliferation and maintenance of the cornea so if you have less insulin in your tears you're going to have more dry eyes so when you have insulin impairment in the body it's going to. Affect this as well in inflammation is the real big factor though and that is you're going to have so they're thinking diabetes you've got to think of it as an inflammatory disease because that's what it is and they have found that the fat in your body around your organs and everything they actually act is their own indicator and organ and they secrete this interleukin six that increases that inflammation and so dry of course that's how Restasis and Ziad Jarrah the two to prescribe the dry medicines that we use to chronically lower the inflammation every information is really bad you go through steroids add it temporarily sometimes you know in conjunction to to lower it and it's just crazy and it's all because of this inflammation and that's what dry eye is so that's that now let's keep on going in the eye you got that Neal vascular ization of the iris sort of fix the iris you've got it it makes you more prone to have cataracts earlier diabetes does it's one of the diabetic eye diseases like I said earlier and then sort of affects the lens and you can get cataracts commonly up to ten years earlier in a diabetic patient just like you can with a smoking patient so a smoker that's also a diabetic they're going to have cataracts of the young age. Vitreous keep working our way through the if you're going to have potential vitreous hemorrhage best there is a sion you have new blood vessels potentially growing into the vitreous like we saw in that patient earlier it affects the optic nerve with glaucoma and it. Is like that with the moderate cupping there a little bit more cupping right there. Some more examples of this cupping right here. Look at the donut not the whole Ok so if you remember back I'm going to go back here a little bit. Cupping don't look at the cupping you want to look at the donut so that neural retinal rim tissue right here that's what you want to be looking at this should be nice and pink and healthy looking thick and when it starts to thin. Remember that isn't rule the inferior spear in a zone temporal fitting in so that the donut here you can see is very thin and almost nonexistent right here. Don't mix up the pier papillary atrophy with the rim tissue. And so that patient looks like that that's the same patient machine showed you earlier so it can affect the comb and then of course Neil vascular glaucoma so now these new blood vessels if they grow right here they can grow in that angle and that will cause an angle. Closure based on like a neo vascular. Wall coma that is very very difficult to treat because by the time the P.R.P. kicks in and everything. You've lost the eye because the pressure's up to seventy and so it's it's not quick enough to save their vision in that eye because that those new blood vessels just kind of block this to regular meshwork right here it's like a blockage kind of event. All right so let's go down here. So narrowing goals when we're talking about narrowing goals you always have to remember that just because the angles were opened six months ago doesn't mean the angles are open out so always check for angles always check the angles I should say the angles I see narrow angles. I have to refer in fact I see narrowing all the time but I see narrowing those that are narrowing anough once a month to have to have prophylactic LP eyes and that's it's it's I don't think that we're. My own opinion is I don't think doctors are paying close at the Luckily angle closure is very very rare OK So that's on our side but you don't want to be the one there was a there's a. Of a family I know that actually went to a pediatric got them all a just and the kid had cerebral palsy and the pediatric of them all just did not check angles dilated the kid with C.P. blinded her and that was not good and so very rare and it's a and it's somebody that I know personally that that happened to not a patient of mine but tragic very very sad and it could have been prevented with a simple shadow test even if the patient is in a wheelchair shadow test with a penlight simple simple simple to do so. Be careful when there's a narrowing those These are the medicines that you you want to kind of look at even Topamax and doctoral L.A. and any of these anticholinergic that are prescribed also can affect this angle you know R O C T Does anterior O.C.T.A. imaging and so it's really nice to be able to look if you have a questionable angle and you look at this and that that's that's narrowing for sure there's no question about that and you look at this one and as almost touching right there but we do a five line raster here and so you know the rest of the lines going through that angle or are still open but I don't like that I don't know that's definitely narrowing so you're you have to watch these patients and you would watch them fairly close enough and I I when it's this narrow I'm going to get the console by a coma specialist and you know and if this patient goes blind it's not going to I'm not going to be the last one to see the patient you don't want to be the last one to see a patient before you go blind either and so. Other things that diabetes can increase the risk is non are terrific a scheme or a TO ENTER scheme a got to interrupt the end especially if they're owned by Agra is well documented forty one percent of these events resolve and especially seventy percent if you give them a High Court of steroids but my associate doctor she had a patient that had this and was on via grew as a diabetic and called the P.C.P. and this guy is a much older physician that just said oh that's garbage that's ridiculous and did you know because she wanted him to know and so you can kind of tell and you guys all know who the better physicians are in your town and who are based on things like that it's that who's up to date and who's not and. So that of course happens right there. And that affects the optic nerve so why are diet dilated retinal exams important for diabetics. Either from an optometrist or an ophthalmologist and that is because it's the leading cause of blindness in this age group the working age group diabetes is the leading cause of blindness for that eighty percent of all patients who've had diabetes for ten years or more will have diabetic retinopathy So ten years if somebody comes in and says I've had diabetes for ten years. You should be seeing some right now I mean they they're going to have written up the unless proven otherwise OK And so I'm looking for that and. This is a no brainer you know macular you're going to be doing on this because you're going to be looking at that so early detection is course critical and Gail is going to talk about that here in just a little bit and because diabetes affects more than just the retina it affects all parts of the eye and affects all parts of the body so that's why it's so important this is new technology this we got this about seven or eight months ago and this is my right eye and you see I had a vitreous tuft pulling to traction on that about twenty years ago that my brother in law who's an optometrist down southwest Florida who would have been here for this convention couldn't be but you know he caught that way back when and so when I was a Sikh own Atlanta the last year I'm like well let me look in there sure enough you know you picked it up just easily this is a two hundred degree field of the retina All right why is that so important. Because the current standard protocol from the diabetic retinopathy Clinical Research Network is this seven field or four field digital photo and you'll see you'll recognize this here and in just a second the images but it's like sixteen or more flashes per side to get this combined image and you're only going to get thirty percent of the retina when you do this. So this technology captures eighty percent of the retina on one picture. By using the screen in red laser wavelengths. And they also have force an angiogram capabilities depending on which model you get and so the retina specialist now are starting to incorporate these and I'll tell you why here in the second. These also do the new fund the finest auto fluorescence And what's nice about that is that this auto fluorescent picture will pick up death so if you're a little right there where my photo receptors are dead it's going to show dark OK where they're where they're still alive but the R P E is accumulating the outer segments of the photoreceptors is like a fusion and it but your flag of psychosis in the R.P. layer. You'll even get some little hot spots I have two little hot spots right there which I was not happy to see because that means because macular degeneration runs in my family and I'm in we're just going to watch that over time but that's great technology and this is. The standard seven field picture of the retina that takes like sixteen flashes to get it combines all of those pictures together and look at what you're missing though. So if you're going to grade it even based on that you're going to miss all of this diseased retina out here that's easily seen all right. In there is the color picture of that. You can detect twice as much diabetic retinopathy with these new new cameras than you can with even the seven fields and we're going to without that you're going to underestimate the level of right now three in ten percent of the cases. And according to these studies people with more peripheral diabetic retinopathy lesions are more likely to progress than those without So if you're only doing a central photo like we used to do. You're in you're missing that are you going to seed dot haemorrhages with your B. IO in the periphery of the retina No you just not you're going to miss it and so that's why it's important because these patients with predominantly perforate lesions are P.P.L. there's a three point two percent increase or not percent three point two times so three hundred twenty percent more increased risk of two steps or more progression of diabetic retinopathy or a four year period so that's huge OK So the bottom line on this is that if you see Doc blood hemorrhages in the poster poll. And you see another patient with blood hemorrhages in the periphery which one do you worry about more now that's right in the macula you worry about this one but which one is higher it this chronic non perfusion of the of the retina it's the P.P.L. it's these patients that are more in we see we see this all the time where we don't see diabetic retinopathy until we actually look at the picture and zoom in patients with P.P.L. had a four hundred seventy percent increased risk for progression from non proliferative to proliferative so very because of the non profusion because of the lack of oxygen and they believe now that this non profusion actually starts in the peripheral retina so. And. Retinopathy if this if a if the fundus. Horses can pick that up with very very easily so when if you're screaming patients on Plaquenil you have to have either the spectral domain of city F.A. off or the multifocal electro the argy electorate Ogram all right and the last thing I have here is understand why communication is so important between professionals it's because the eyes the only place to view directly the blood vessels. And if there's damage in the eye there's a risk of damage to the rest of the body and so good communication between the care provider and the treating physician the straining the diabetes they have to know the information even if they don't know why and the team approach is always of the hear this from many providers. Much more like. Good compliance. This media was brought to you by audio from a website dedicated to spreading God's word through free sermon audio and much more if you would like to know more about audio first if you would like to listen to more sermons leave a Visit W W W. Or.

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