Diabetic Retinopathy

Sandra M. Brown, M.D.

Ophthalmology and Visual Sciences
Texas Tech University Health Sciences
Center
 Outline of Lecture
• Review of the Retina
• What is Diabetic Retinopathy?
• Epidemiology and Screening
– type I diabetes (onset < 30 yo)
– onset > 30 yo
– “NEW” type II juvenile onset
• Diabetes Control and Complication
Trial
• Costs to Society
Review of the Retina
 What is
Diabetic Retinopathy?
 Pathogenesis

C a p illa r y O c c lu s io n

R e tin a l Is c h e m ia L e a k a g e o f B lo o d E le m e n ts

A n g io g e n e s is F a c to r s D ia b e tic M a c u la r E d e m a

P r o life r a tiv e D ia b e tic R e tin o p a th y

 Stages of Retinopathy
• Background

• Proliferative
 Background
Diabetic Retinopathy
 Capillary Damage
• Microaneurysm
s
– “dots”

• Small retinal
hemorrhages
– “blots”
Dot and Blot Heme
 Macular Edema
• Leakage of
– water
– lipid

• Macular edema

• Macular
exudates
Macular Edema
Fluorescein
Angiography
Microaneurysms on
FANG
Macular Edema on
FANG
 Macular Ischemia
• Occlusion of capillary beds
• Ischemia of multiple retinal
layers
• Decreased signal transduction
 BDR - Vision Loss
• Not treatable
– Macular ischemia
– Intraretinal hemorrhage in
macula
• Treatable
– Clinically Significant Macular
Edema (CSME)
• fluid
• exudate
• strict criteria
 BDR - Symptoms
• Painless

• Insidious

• If asymmetric - not noticed by

patient
– using “good eye”
 Detecting BDR
• D+B heme
• Exudates

• Visible with direct

ophthalmoscope

• Look along major vascular

arcades
 Proliferative
Diabetic Retinopathy
Pathogenesis
O c c lu d e d C a p illa r y B e d s

H y p o x ic R e tin a

A n g io g e n e s is F a c to r s

N e w V e s s e ls F o r m

O p tic D is c E ls e w h e r e in R e tin a
NVD N VE
NVD
 NVE

Photo here NVE

NVE
 PDR - Vision Loss

PDR

H e m o r r h a g e in to R e tin a H e m o r r h a g e in to V itr e o u s

P e rm a n e n t S tru c tu ra l D a m a g e R e tin a l D e ta c h m e n t

C o m p le t e B lin d n e s s
PDR - Retinal Heme
PDR - Vitreous Heme
PDR - Retinal
Detachment
Macular Detachment
 PDR - Symptoms
• Intraretinal heme
– abrupt onset
– central or peripheral vision
– unnoticed by poor observers
• Vitreous heme
– abrupt onset
– “floaters” if blood clumped
– vision reduced to shadows if blood
dispersed
Diabetic Retinopathy
Treatment
 Laser for Macular
Edema
• Focal laser photocoagulation
– laser treatment (surgery)
– works over weeks, not days

• Office procedure
– topical or local anesthesia
– several sessions
Severe Macular
Edema...

heavy
leakage into
retina
...After Laser
Treatment

Laser
burns
 Laser for PDR
• Pan Retinal Photocoagulation
– “PRP”
– laser treatment (surgery)
– works over weeks, not days

• Office procedure
– topical or local anesthesia
– several sessions
Nasal PRP with pigment
PRP - macula spared
Regression of NVE

Fibroti
c NVE

Laser
burns
Red Free NVE + Laser
 Treatment Frontiers
• Modulation of release of
retinal vascular stimulating
factors
– systemic medications (oral?)
– intravitreal injections

• “Cure” diabetes
Epidemiology and
Screening
 Type I Diabetes
100
90
80
70
60
50 BDR
40 PDR
30
20
10
0
< 5 years 5 years 10 years 15 years > 35 years
 Examination Schedule
• DM Onset < 30 Year Old

• FIRST exam = (whichever is

later)
– after 5 years of DM
– after 10 years old

• YEARLY THEREAFTER
 Danger Times - Kids
• Puberty

• After leaving home

– patients skip exams during
critical mid- and post-pubertal
years
– often corresponds to 10+ years
diabetes
– control worsens
Diabetes Onset > 30 yo

Non-insulin Treatment
60

50

40

30 Any DR
PDR
20

10

0
< 2 years > 15 years
Diabetes Onset > 30 yo

Insulin Treatment
90
80
70
60
50
Any DR
40 PDR
30
20
10
0
< 5 years > 15 years
 Examination Schedule
• DM Onset > 30 Year Old

• FIRST exam = AT TIME OF

DIAGNOSIS
– high incidence of baseline
disease

• YEARLY THEREAFTER
Gestational Diabetes
E le v a te d G lu c o s e D u r in g P r e g n a n c y

P re -p re g n a n c y P re -p re g n a n c y K n o w n D ia b e tic
g lu c o s e n o r m a l g lu c o s e u n k n o w n

N O R IS K D R ? U n d ia g n o s e d D M P re -p re g n a n c y
d u r in g p r e g n a n c y (w ith in 1 2 m o n th s )

P r o m p tly F ir s t T r im e s te r
O u tp a tie n t

Abruptly improved control during

pregnancy can precipitate worsening
DR.
Diabetes Control and
Complication Trial
 DCCT
• 13-39 years old
• Conventional therapy
– two injections/day
– no sliding scale
– glycosylated Hgb average 9.0%
• Intensive therapy
– 3 or more injections/day or pump
– sliding scale, glucose monitored
qid
– glycosylated Hg average 7.0%
 DCCT and Retinopathy
• Primary prevention (no
retinopathy at start)
– 76% decrease in risk of developing
retinopathy

• Secondary intervention
(retinopathy at start)
– 54% decrease in risk of progression of
retinopathy
 DCCT Caveats
• 2-3 fold increase risk of
hypoglycemia
• Temporary worsening of
retinopathy with abrupt
improved control
– still had 74% decreased risk
progression
– good ophthalmologic oversight
Costs to Society

$$$$
 Demographics
• Diabetic retinopathy is the
LEADING cause of blindness in
working adults in the US

– 40,000 new cases of blindness

due to diabetes per year
• Persons with DM are 25 times
more likely than the general
population to go blind

• Minority populations have a

higher prevalence of DM
 Econo-Speak
• Various statistical models
– population studies of diabetic
retinopathy
– dollar amounts (usually federal)
• What does it COST to
• screen
• treat

• What do you SAVE

– direct disability payments
(tangible)
 Econo-Speak
• Less tangible but more costly
to society

– loss of economic productivity of

workers

– loss of productivity of family

caregivers
• “Cost per person-year of vision
saved”

– disability benefits

• (minus)

– costs to screen/treat
 Crunching Numbers
• Screening • Cost
protocol – $996/person-
– Am Academy of year PDR
Ophthalmology – $1118/person-
year macular
edema
• Treatment
protocol
• SS Disability
– DRS
– $6900/person-
– ETDRS
year of
blindness
 Savings to Society
• On average $5800
– PER DIABETIC PERSON
– PER YEAR

• And this is just one

calculation…

• (...that doesn’t include the productivity

loss)
Crunch It Another Way
• Type I DM

– 60% screen/treat level saves

$101 million/year

– 100% screen/treat level saves

>$167 million/year
• Type II DM

– 60% screen/treat level saves

$250 million/year

– 100% screen/treat level saves

> $472 million/year
 DCCT and Cost
• Intensive Therapy guidelines (2-3
times more expensive) STILL show
a powerful net savings
– lower incidence of expensive
complications
• blindness
• renal failure
• limb amputations
Conclusions
Screening and Treating

Diabetic Retinopathy is

Profoundly Cost
Effective

for Society
Screening and Treating

Diabetic Retinopathy
Saves

Years of Blindness and

Disability for
What Should We Do?
 Initiate Screening
• Type I diabetes - first screen
after
• 5 years of diabetes OR 10 years of
age
• yearly thereafter until retinopathy
develops
• then as needed to monitor and treat

• Onset > 30 years old

– first screen at time of diagnosis
 Improve Glycemic
Control
• Better glucose control
markedly decreases the
incidence of all complications

• Education for Diabetes

Treatment

• Education for Diabetes

Prevention
 Insure Access
• Cost barriers

• Travel barriers

• Cultural barriers

• Provider barriers
The End