93 Kooyong Rd
Tel: 9079 0888
Fax: 8692 1131
An update on management of Diabetic Eye Disease
Diabetes is an ever-increasing health issue in Australia. The prevalence of adult onset diabetes is predicted to rise from 2.8% in 2000 to 4.4% by the year 2030. Diabetic retinopathy is responsible for 5% of blindness worldwide.
Up to 44% of patients with diabetes will have some form of diabetic retinopathy. This rate increases in Type 1 diabetics, longer duration of disease and quality of systemic control.
Systemic control and eye disease:
Multiple large international studies have demonstrated the effects of systemic risk factor control and the associated with diabetic eye disease. Poor glucose levels, elevated blood pressure and poor lipid profile accelerate diabetic eye disease.
Targets to reduce diabetic retinopathy progression include:
-HBA1C levels less than 7%
-Systolic BP <130mmHG -Lower blood lipid levels. Fenofibrate and diabetic eye disease: Recent studies have demonstrated a significant protective effect of Fenofibrate Lipid lowering medications and diabetic retinopathy progression. Ophthalmologists are now able to prescribe Lipidil on the PBS for patients with diabetic eye disease. This should be done in collaboration with the patients treating physician. Screening for Diabetic Eye Disease: Early disease detection and appropriate management is key to success in preventing vision loss from diabetic eye disease. Appropriate screening is an integral part of diabetic patient management. An Ophthalmologist or an appropriately trained Optometrist can do screening. Dilated fundus examination still remains the gold standard investigation for diabetic screening. Fundus photography is an excellent tool for screening when done by the appropriately trained personnel and when appropriate expertise is unavailable. Screening schedule: Note: Visual acuity should always be checked at the time of screening Initial Screen: Juvenile Diabetes: At puberty Adult Onset Diabetes: At time of diagnosis Pregnancy (known diabetic): 1st Trimester Follow-up: Low-risk patient with no Diabetic Retinopathy: 12-24 months High-risk patient with no Diabetic Retinopathy: 12 months Minimal Diabetic Retinopathy: 9-12 months Moderate Retinopathy: 4-6 months Severe non-proliferative DR: 2-6 months Proliferative disease- Active treatment Urgent referral to Ophthalmologist: Loss of vision New vitreous haemorrhage New vessels in retina or anterior segment Vision threatening maculopathy Diagnostic tools: Fundus photography: Non-mydriatic fundus photography is an excellent tool for diabetic screening purposes. These instruments are fairly complex and need to be used by a trained technician. The photographs then need to be assessed by a trained Optometrist or Ophthalmologist. Serial fundus photographs are an excellent tool for tracking progression of disease and response to treatment. OCT: Ocular Coherence Tomography is a revolutionary instrument and essential for the accurate diagnosis and treatment of diabetic maculopathy. Spectral domain OCT has a resolution of up to 4um and can detect intra-retinal lipid, sub-retinal fluid and macula oedema. Heidelberg OCT has the ability to track individual patient’s responses to therapies directed at treating diabetic maculopathy. Fluorescein angiography: Fluorescein angiography is still the gold-standard diagnostic test for the diagnosis of diabetic maculopathy and retinopathy. Modern digital angiography systems require less fluorescein dye and hence have less adverse systemic reactions than the traditional cameras. Treatment: Laser- Argon laser photocoagulation remains the gold standard therapeutic tool for the treatment of diabetic macular oedema DME (focal laser) and proliferative diabetic retinopathy PDR (pan retinal photocoagulation- PRP). The principal aim of laser therapy is to prevent significant visual loss due to either DME or PDR. Intravitreal anti-VEGF therapy- The discovery and use of Intravitreal anti-VEGF therapy has revolutionised the management of neovascular retinal conditions. Their use has given Ophthalmologists the ability to improve visual acuity in diabetes-related conditions where previous treatments were aimed at preventing vision loss. Intravitreal injections do have potentially drastic complications such as endophthalmitis and hence this therapy should be reserved for suitable cases only. The main indications for Intravitreal therapy include: a) vision loss due to centre-involving DME which is not amenable to conventional laser, and b) proliferative retinopathy requiring urgent resolution of new vessels. Intravitreal steroid: Similarly, Intravitreal steroid therapy should only be used where clinically most appropriate. Intravitreal steroid therapy is especially effective in resolving treatment resistant macula oedema. Raised intra-ocular pressure, glaucoma and cataract development are the main complications associated with Intravitreal steroid use. Diabetic retinopathy and cataract: Cataract formation is accelerated in diabetes. This is attributed to changes in the osmotic gradients across the crystalline lens in times of osmolar imbalance experienced in uncontrolled diabetes. Cataract surgery is good, successful surgery in most instances. Cataract surgery is “pro-inflammatory” and it is well recognised that diabetic retinopathy and maculopathy can accelerate at the time of surgery. Management of pre-existing retinopathy/maculopathy is crucial to prevent exacerbation of the underlying disease following routine surgery. In some instances, focal macula laser or proliferative disease is difficult to treat due to the lens opacity and surgery needs to be supplemented with Intravitreal steroid/ anti-VEGF therapy to prevent the inevitable exacerbation of the underlying disease. Pre-treatment with topical non-steroidal anti-inflammatory drops is quite popular however has never been proven to be beneficial in preventing post-op macula oedema. Vitrectomy/Retinal surgery: Vitrectomy surgery is reserved for specific complications arising from severe proliferative disease. All the above treatment strategies aim to prevent the need for Vitrectomy surgery, however, in some cases, prolonged haemorrhage or continuing new vessel proliferation are unavoidable and require surgical intervention. New 23 and 25 Gauge techniques allow for quicker recovery from these invasive procedures. Facilities at Armadale Eye Clinic: We have diabetic retinopathy specialists on-site every day of the week. Dr’s Cochrane, Van Heerden Cohn and Hoffman are all experts at managing diabetic eye disease including the careful management of associated cataract. Dr Edward Roufail is a vitreo-retinal surgeon and manages all advanced disease requiring vitrectomy surgery. We have digital angiography, OCT, non-mydriatic fundus camera as well as the latest Ellex laser technology for performing focal and pan-retinal laser. We have a treatment room and facilities to perform Intravitreal therapy on-site. We have digital biometry and corneal topography required in preparation for cataract surgery, which all our doctors perform with or without Femtosecond assistance. Conclusion: Diabetes is an ever-increasing health issue in our society. Diabetic eye disease can be devastating however is avoidable if detected and managed early and appropriately. At Armadale Eye Clinic, we have the staff and facilities to manage all aspects of diabetic eye disease in an expert and professional fashion. Please contact any of the Ophthalmologists at Armadale Eye Clinic if you have any queries regarding the information provided in this brief summary of diabetic eye disease. Kind regards Dr Anton van Heerden