10/26/2010

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Diabetic Retinopathy

Edward Cherney, MDA i t P fAssociate Professor

Vanderbilt Medical University

Honored Professor

Pavlov State Medical University

St Petersburg RussiaSt. Petersburg, Russia

Webinar Oct. 27, 2010

Socioecononic Factors

Yearly economic cost of aid to the blind isYearly economic cost of aid to the blind is ten times the amount of the cost to examine every American, and to laser them if they have diabetic retinopathy

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Diabetic Epidemiological Facts

23.6 Million diabetics in US

1.6 Million new cases each year

Leading cause of blindness in working age Americans

95% of the blindness is preventable95% of the blindness is preventable

84% inadequate A1C control

10% T I di b i i i i i10% Type I diabetic receiving intensive treatment (80% in Germany)

46% patients with high-risk retinopathy had not been treated

Lack of annual eye exams

Tennessee 49th in the country!!

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1997, Ophthalmology (at initial eye exam at UCLA)

62% h h l i di62% ophthalmic disease

40% advanced ophthalmic disease

6.8% legally blind

58% never had a dilated exam

ETDRS Scale of Severity

Severity Definition

No Retinopathy DR Absent

Very Mild DR Microaneurysms only

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ETDRS Scale of Severity

Severity DefinitionSeverity Definition

Mild NPDR Microaneurysms, Hard Exudates,

Cotton Wool SpotsMild Hemorrhages

ETDRS Scale of Severity

Severity DefinitionSeverity Definition

Moderate Microaneurysms + NPDR mild IRMA or

moderate retinal hemorrhages

but not both

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ETDRS Scale of Severity

Severity Definition

Moderately Mild IRMA, severe Severe NPDR hemorrhages, or

venous beading one quadrant

Severity Definition

ETDRS Scale of Severity

Severe NPDR Severe hemorrhages in four quadrants, or venous beading in 2 quadrants, or moderate IRMA in

one quadrantq

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ETDRS Scale of Severity 

Severity Definition

Mild PDR NVE <0.5 disc area

ETDRS Scale of Severity

Severity Definitiony

Moderate PDR NVE > 0.5 Disc Area

or

NVD < 0.33 Disc Area

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ETDRS Scale of Severity

Severity Definition

High Risk PDR NVD > 0.33 disc area and / or Vitreous hemorrhageg

MildMicroaneurysms,  Hard Exudates,  Cotton Wool Spots,  Mild Hemorrhages

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Moderate RetinopathyModerate hemorrhages or Mild IRMA Not both

Mild IRMA

Mild Intra Retinal Microvascular Abnormalities

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Level 47Moderately Severe Diabetic Retinopathy

S h h d tSevere hemorrhages one quadrant

and Mild IRMA

Mild beading one quadrant

Severe Hemorrhages 

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IRMA and Beading

Venous Beading

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IRMA and Beading

Severe Retinopathy

Severe hemorrhages four quadrants

Or venous beading 2 quadrants

Or severe IRMA one quadrant

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Severe IRMA

IRMA

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ETDRS Progression to PDR

Level Year 1 Year 3 Year 5

Mild 4 5% 14 4% 25 1%Mild 4.5% 14.4% 25.1%

Moderate 12.2% 29.6% 44.3%

Moderately 26% 47.6% 66.4%

Severe

Severe 51.5% 71.1% 79.5%

Two year risk of severe visual lossin Proliferative Retinopathy

61 Mild PDR NVE < 0.5 disc area 7%

65 Moderate PDR NVE > 0.5 disc area orNVD < 0.33 disc area 26%

71 High risk PDR NVD > 0.33 disc area or gNVE with vitreous hemorrhage

37%

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High Risk Proliferation

NVD > 0.33 disc area

O Vi H hOr Vitreous Hemorrhage

Standard 10A

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Percent Doubling Visual Angle in 5 Years

45

50

15

20

25

30

35

40

45

0

5

10

15

None Questionable Definate Obvious Moderate Severe

Initial level of hard exudates

Obvious Hard Exudates

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Moderate Hard Exudates

Severe Hard Exudates

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Survey of Dr. Cherney’s Referral Patients

Level of A1C

A1C < 7% (recommended) 26%

A1C 7% to 10% 44%

A1C > 10% 26%

Unknown 4%

Diabetic Status

60

Length of time of Diabetes

20

30

40

50

60

0

10

6 mos to 1 yr 1 to 5 years 5 to 10 years > 10 years Unsure

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Why No Yearly Eye Exam?

Not told it was important 12

S i l 12Social reasons 12

No insurance 8

No symptoms 8

Other 3

Level of Retinopathy

Macular Edema 25

P lif i 23Proliferative 23

Vitreous Hemorrhage 11

Vision < 20/40 27

Any combination of

the above 38

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Patient Education

Who has talked about diabetic retinopathy?

E D 26Eye Doctor 26

MD 15

Both 12

No One 47

Patient Preferences

Who should be the primary source of i f ti f di b t d th ?information of diabetes and the eye?

Eye Doctor 38

Primary MD 55

Unsure 7O h h i i l d d di b i iOther choices included diabetic screenings,

newspaper notices, TV and radio etc.

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How could Medical System Ensure Yearly Eye Exams?

MD make appointment 26Only if decreased vision 5Only if decreased vision 5No idea 8

66% of patients who had not had yearly eye exams stated that if their primary doctor made an eye appointment, they would have gone despite social and insurance problems

Summary

Diabetic Control

25% of patients had A1C < 7

24% of patients had A1C > 10

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Summary

Patient Education

43% h h h d h d f A1C43% state that they had not heard of A1C

Only 29% knew their A1C level

Summary

Status of Retina

38% f i h d i i h i h (38% of patients had vision threatening changes ( macular edema, PDR , or Vitreous Hemorrhage)

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Summary

Patient personality

Some patients will follow doctors’ suggestions ? 60%

25%- 35%

Some patients will follow doctors’ orders

Summary

Some patients are recalcitrant and

will not seek medical help whether it is suggested or ordered until they are symptomatic

5% to 10%

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Summary

66% of patients who missed their annual eye exam stated that if the primary doctor’s office had made anstated that if the primary doctor s office had made an appointment, they would have seen the eye doctor regardless of their insurance or social situation

Here are the average numbers, aggregated from the previous two years:

No evidence of any retinal disorder: 65%

Mild diabetic retinopathy, not needing ophthalmic intervention*: 25%Sight-threatening diabetic retinopathy, requiring eye follow-up: 10%

Glaucoma suspect, needing further eye workup**: 10%