pacEYES Diabetes.pptx

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DIABETES FIJIAN STYLE

Materials and illustrations used in this presentation were obtained from and used with the permission of:

• UpToDate

• Duane’s Ophthalmology

• Harrisons Textbook of Medicine • American Academy of Ophthalmology • Photographs by GK Phelps

• Illustrations by GK Phelps and from the public domain

Biu Sikivou MSc(Ophthal)

Gary K Phelps MD

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Prevalence

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Prevalence

• The prevalence of diabetes in Fiji is ~40% in individuals over 40 years of age

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Prevalence

• The prevalence of diabetes in Fiji is ~40% in individuals over 40 years of age

• The prevalence of diabetic retinopathy can be expected to range from 20-30% in this population group, gradually increasing with age • Thus ~10% of all Fijians over 40 will have clinically significant

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Prevalence

• The greater Suva area has a population of ~330,000 • Approximately 100,000 of those are over 40

• Thus 10% of 100,000 means

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PEI Diabetic Clinic

• Even as the PEI Diabetic Clinic is increasing the number of patient visits every year, the actual number of people treated will decrease

• This occurs because the average patient generates 4 clinic visits every year on an ongoing annual basis (including laser and diabetic clinic

appointments)

Year

Diab

Rev

Laser

sessions

Total patient

visits

Individuals

2010

1,605

859

2,464

?

2011

2,702

1,204

3,906

?

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PEI Diabetic Clinic

Thus with the current treatment protocols, the ongoing capacity of the clinic

will level off at

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PEI Diabetic Clinic

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PEI Diabetic Clinic

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PEI Diabetic Clinic

With Suva having an at risk population base of 10,000 and the PEI having a capacity of 2,00 patients

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Diabetic Retinopathy

• Diabetic retinopathy is a progression of increasing ischemia

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Diabetic Retinopathy

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• Starting with minimal capillary damage and microaneurysms • Ending with vitreous hemorrhage or total tractional detachment • This progression is a predictable stepwise pattern from clinically non

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Diabetic Retinopathy

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detectable disease to blinding proliferative retinopathy • The rate of progression varies depending upon:

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Diabetic Retinopathy

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• Diabetic control – good control reduces risk by 75% • High blood pressure

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Diabetic Retinopathy

• Diabetic control – good control reduces risk by 75% • High blood pressure

• Genetic factors

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Basis of Medical Treatment

• The Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) • The Diabetes Control and Complications Trial (DCCT) 1993

• The United Kingdom Prospective Diabetes Study (UKPDS) 1998 Together they proved conclusively that:

• Better diabetes and blood pressure control correlated with lesser severity of retinopathy

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General Medical Treatment

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General Medical Treatment

• We thus know that the basic treatment of all types of diabetic vascular disease is tight control of the diabetes

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General Medical Treatment

• Ideal goal is blood sugar ≤ 6.5

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General Medical Treatment

• Ideal goal is blood sugar ≤ 6.5

• Successful treatment also requires treating all other risk factors of the “Metabolic Syndrome”:

• Raised triglycerides • Reduced HDL

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Basis of Laser Treatment

• Two other studies proved that thermal laser application could change the course of diabetic retinopathy

• Diabetic Retinopathy Study (DRS) 1972

• Proved the benefits of panretinal photocoagulation in advanced proliferative retinopathy

• Early treatment diabetic retinopathy study (ETDRS) 1979

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Grid Treatment CSME

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Grid Treatment CSME

• Treating CSME reduces the risk of progression of visual loss by ~50% over three years follow-up

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Grid Treatment CSME

• Treating CSME reduces the risk of progression of visual loss by ~50% over three years follow-up

• Laser treatment may be repeated several times at three month or greater intervals, but repeated treatments will damage any remaining healthy retina and capillary perfusion worsening the disease

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PRP for Proliferative

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PRP for Proliferative

• Treating high risk proliferative retinopathy reduces the risk of progression of visual loss by ~50% over a five year follow-up

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PRP for Proliferative

• Treating high risk proliferative retinopathy reduces the risk of progression of visual loss by ~50% over a five year follow-up

• Patients with severe Nonproliferative retinopathy may be treated in the same way as patients with PDR depending on patient’s diabetic control and ability to rock up for follow-up exams. This is because the risk of them progressing to proliferative disease is 45% within one year

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Intravitreal Drug Treatment CSME

• Intravitreal steroids • No lasting benefit

• Intravitreal anti-VEGF drugs

• Effective at thinning macular edema and improving visual acuity

• Require repeated injections over months to attain and sustain the effect • Are usually combined with laser treatment

• Includes a low risk of endophthalmitis

• Entails a high cost of drug procurement and administration

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Clinical Scenario

• We know that if we treat macular edema with grid laser we can reduce the risk of severe visual loss by 50%

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Clinical Scenario

• We know that if we treat macular edema with grid laser we can reduce the risk of severe visual loss by 50%

• But we also know that if diabetes is not well controlled the

microvascular leakage will progress to severe and untreatable visual loss

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Clinical Scenario

• We know that if we treat proliferative retinopathy with PRP we can reduce the risk of severe visual loss by 50%

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Clinical Scenario

• We know that if we treat proliferative retinopathy with PRP we can reduce the risk of severe visual loss by 50%

• Again, we also know that if diabetes is not well controlled the proliferative disease will progress to severe and untreatable visual loss

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Fijian Conundrum

• In Fiji we have only two treatment options for patients with diabetic retinopathy:

• General medical control of diabetes and hypertension

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Fijian Conundrum

• In Fiji we have only two treatment options for patients with diabetic retinopathy:

• General medical control of diabetes and hypertension

• Laser treatment for macular edema and proliferative retinopathy • We know that:

• Both treatment options are preventative not restorative • Successful management of diabetes and hypertension is

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Fijian Conundrum

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Fijian Conundrum

Given the limited number of patients who can be followed at one time and the preventative only nature of our treatment capabilities, what strategies should we be employing to best provide care for the entire population we serve?

1. Discharge all patients who have had three or more macular laser

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Fijian Conundrum

treatments and do not have high risk factors for proliferative disease? 2. Discharge all patients who have completed pan retinal

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Fijian Conundrum

photocoagulation and have either no or stable macular disease? 3. Discharge any patient who has four consecutive blood sugar levels

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Fijian Conundrum

photocoagulation and have either no or stable macular disease? 3. Discharge any patient who has four consecutive blood sugar levels

greater than 10?

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Good News

Winner gets a bottle of (cheap) Australian wine

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Pop Quiz !!!

1. What is the prevalence of diabetes in the over 40 aged

Fijians?

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Tie Breakers

1. What is the prevalence of diabetes in the over 40 aged

Fijians?

2. By what percentage (%) do we reduce the risk of visual

loss by laser treatment?

3. What sex was the patient being

treated by the famous Dr. Posala?

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Classification

• The classification we will be using is the Diabetes Retinal Screening, Grading and Management Guidelines for use in Pacific Island Nations 2010 edition

• Developed as a modification of the New Zealand National Diabetes Retinal Screening, Grading System and Referral Guidelines

• Designed to be adaptable to non-mydriatic photographic screening

• Will be periodically revised and updated to meet the Pacific Islands requirements

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Pacific Guidelines Macula

Grade Description Clinical Signs Outcome Action

M0 No disease No MA, heme or exudate within

2 DD of fovea Screen again in 12 months M1 Minimal MA and/or heme within 2DD of

fovea

No exudates or edema No ↓ VA

Screen again in 12 months unless peripheral disease requires otherwise M2 Mild Exudates and/or edema within

2DD of fovea but outside 1DD of fovea

Refer to ophthalmologist Ophthalmic review within 2 months M3 Moderate Exudates or edema within 1DD

of fovea No ↓ VA

Refer to ophthalmologist Ophthalmic review within 2 months M3 Severe MA and/or heme within 2DD of

fovea with ↓ VA OR

Exudates and/or edema involving fovea with ↓ VA

Urgent referral to ophthalmologist

Ophthalmic review immediately

MT Stable treated macular

disease

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Pacific Guidelines Retina

Grade Description Clinical Signs Outcome Action

R0 No retinopathy No abnormalities Rescreen in 12 months R1 Minimal <5 MA and/or heme Rescreen in 12 months R2 Mild >4 MA and/or heme and/or

Exudates >2DD form fovea If >20 MA or heme per image upgrade to R3

Rescreen in 6 months

R3 Moderate Any feature of R2 plus

Up to 3 quadrants heme

and/or 1 quadrant beading

refer ophthalmologist Ophthalmic review within 6 weeks R4 Severe One or more of:

Definite IRM

2 quadrant or more beading 4 quadrants heme

refer ophthalmologist Ophthalmic review within 6 weeks

R5 Proliferative One or more of:

NVE or NVD Vitreous heme

Tractional detachment or gliosis

Immediate referral

ophthalmologist Ophthalmic review immediately

RT Stable treated disease

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Standard of Care Treatment CSME

• For non-central macular edema focal/grid laser is still the standard of care

• For central macular edema causing decreasing vision anti VEFG drugs with or without focal/grid laser is the current standard of care in the USA

• Requires OCT • Requires FA

• Requires monthly examinations for up to a year