By: Paul M. Karpecki, OD, FAAO
Clinical Director – PECAA
They say that the five top medical area of growth for optometry include dry eye disease, macular degeneration, glaucoma, cataract and diabetes care. And since diabetes is growing at 6% per year in the United States, management of these patients well becomes increasingly important. Here are some key points to keep in mind:
20-39% of all type II diabetes patients have some retinopathy at the time of diagnosis. This means that these patients likely have had the disease for a number of years prior to diagnosis. Assessing risk factors and using innovative technologies like lens autofluorescence (e.g. ClearPath DS) may help determine a diagnosis sooner and help patients avoid complications like retinopathy.
The first five years of glucose control are more important than good control for 10 or 20 years after that. Of course it is during the first five years that it is more difficult to stabilize, but it is obviously worth encouraging.
A patient with type II diabetes for 15 years or longer has a 1 in 5 chance of having proliferative diabetic retinopathy and 60-80% will have some level of retinopathy.
Watch for patients that are on sulfonylurea type medications alone for diabetes (such as Glyburide) as they have a significantly greater risk of hypoglycemia.
If a patient with diabetes shows signs of confusion, consider the potential of hypoglycemia. Always have a can of orange juice available in your practice for circumstances such as this, to give to the patient. Never give a diet coke or any sugar-free beverage even though they are sweet tasting.
Finally whenever you examine a patient with diabetes ask the following questions:
• What is your A1c?
• What is your blood pressure?
• What is your cholesterol?
• Do you smoke?
Patients with high blood pressure, high cholesterol or smokers have a much greater risk of diabetic retinopathy progression and disease progression itself.
At one point there was debate about the importance of examining the retina beyond the posterior pole in patients with diabetes mellitus (DM). And although this new thinking of the importance of a thorough retinal examination has long been suspected, there is even more reason to closely examine the peripheral retina.
New research on 200 eyes of 100 patients, where mydriatic 7 field ETDRS photographs and ultra-wide field imaging was examined and compared to images over 4 years later. The researchers wanted to see which patients showed a 2 step progression in diabetic retinopathy (DR) or progression to proliferative diabetic retinopathy (PDR) over this time frame. The surprising findings were that patients with predominantly peripheral lesions including dot and blot hemes, exudates etc., independent of DR severity or Hemoglobin A1c levels had a significant progression. In fact there was a 3.2 fold increase of 2 step or more increase in DR progression and a 4.7 fold increased risk for progression to PDR (p<0.005 for both). Furthermore these findings remained statistically significant after adjusting for gender, diabetes type, diabetes duration, HbA1c levels, and baseline DR severity.
These findings clearly show the importance of a thorough retinal examination including using newer technology to view peripheral lesions plus a dilated funds examination. Identifying patients with predominately peripheral retinal signs of DM indicates a 3-5 fold risk of progression! It means communicating these findings and what they mean to the endocrinologist or family physician for their consideration of adjustments to systemic management, patient education about compliance and risks, and more frequent retinal examinations in your office with the potential for prompt referral to a retinal specialist should the patient progress through stages of PDR.
The American Optometric Associations, evidence-based clinical practice guidelines on caring for the patient with diabetes mellitus is chock full of clinical insights and pearls. It’s really worth downloading a copy of this guideline for doctors who manage patients with diabetes.