Preventing Vision LossPreventing Vision Lossin Diabetic Retinopathyin Diabetic Retinopathy

Rick Trevino, OD

VA Outpatient Clinic

Evansville, Indiana

Diabetic Retinopathy

Background Retinopathy Microaneurysms Hemorrhages Lipid Exudates Cotton Wool Spots (infarcts)

Preproliferative Retinopathy Multiple Cotton Wool Spots Numerous Hemorrhages Venous Dilation and Beading IRMA

Proliferative Retinopathy Neovascularization (New vessel formation) Vitreous Hemorrhage

Diabetic Macular Edema

Background Retinopathy

Background Retinopathy

Background Retinopathy

Preproliferative Retinopathy

Preproliferative Retinopathy

Proliferative Retinopathy

Proliferative Retinopathy

Diabetic Macular Edema

Diabetic Macular Edema

Diabetic Macular Edema

Diabetic Macular Edema

Preventing Vision Loss

Primary Prevention Physical Activity Weight Reduction

Secondary Prevention Glycemic Control BP Control

Tertiary Prevention Laser Therapy Angiogenesis Inhibitors

Tertiary Prevention

Laser Therapy DRS: PRP ETDRS: CSME

Angiogenesis inhibitors (Avastin)

Drawbacks Access to Care Late Disease Stage Side Effects

Role of Glycemic Control

GLYCEMIC CONTROLIS THE SINGLE MOST EFFECTIVE MEDICAL

TREATMENT FOR DIABETIC

RETINOPATHY

Role of Glycemic Control

DCCT (1993)1441 subjects with IDDM followed for 6.5yrsRandomized into strict and conventional txStrict control group had average HbA1c 7.2% Conventional: 8.8%

Strict control resulted in… Reduced risk of retinopathy by 76% Reduced risk of progression by 54%

Role of Glycemic Control

DCCT (1993)There is a continuous nonlinear relationship between risk of retinopathy and mean level of HbA1c

Role of Glycemic Control

Conclusions of the DCCT (1993)

Total lifetime exposure to glycemia was the principal determinant of the risk of retinopathy Earlier intervention decreases risk

There is no level of glycemic control below which a reduction in risk does not occur Improved control always reduced risk of

retinopathy

Role of Blood Pressure

Hypertension is an independent risk factor for DR and its progression Use of anti-

hypertensive medications may decrease risk independent of lowering blood pressure

Role of Blood Pressure

UKPDS (1998)1148 hypertensive type-2 diabetics randomized into tight and less-tight BP control and followed for 8.4 yrs

Average BP: Tight: 144/82 Less tight: 154/87

Tighter BP control resulted in… 34% reduction in

progression of DR 47% reduced risk of loss of 3 lines VA

Role of Cholesterol

WESDR (1991): Higher serum cholesterol increased risk of hard exudates in type-1 DM

ETDRS (1996): Higher serum lipids increased risk of hard exudates and loss of VA

Elevated lipids may increase the morbidity of diabetic macular edema

Preventing Vision Loss

Primary Prevention Physical Activity Weight Reduction

Secondary Prevention Glycemic Control BP Control

Tertiary Prevention Laser Therapy Angiogenesis Inhibitors

Thank You!