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Caring for Persons with Diabetes

Caring for Persons with Diabetes. Developed by: American Optometric Association Health Promotions Committee. Epidemiology of Diabetes. 26 million Americans have diabetes 90% have type 2 diabetes 79 million more Americans are at high risk for developing diabetes within ten years

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Caring for Persons with Diabetes

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  1. Caring for Persons with Diabetes Developed by: American Optometric Association Health Promotions Committee

  2. Epidemiology of Diabetes • 26 million Americans have diabetes • 90% have type 2 diabetes • 79 million more Americans are at high risk for developing diabetes within ten years • 1.8 million new cases diagnosed each year • Diabetes care accounts for 1 of every 6 health care dollars spent in the US

  3. Epidemiology of Diabetes • The incidence of Type 2 diabetes in Americans < 20 years of age has grown 1100% since 1970 • It is the fastest growing sub-population of diabetes by far • Diabetes is the 6th leading cause of death in the US • The leading cause of blindness in those < 74 yo • The leading cause of kidney failure • The leading cause of non-traumatic amputation

  4. Diabetes Myths • Diabetes is caused by eating too much sugar • Not taking medications to control diabetes means the disease is less serious • Having type 2 diabetes is ‘better’ than having type 1 diabetes • Type 2 diabetes is not hereditary

  5. A Look at the Numbers…

  6. Diabetes Affects 28.5 Million Americans • Of those: • 18.8 million diagnosed • 7 million not yet diagnosed • 215,000 are under 20 and mostly have type I diabetes

  7. Diabetes is… • The LEADING cause of • Kidney failure • Non-traumatic lower limb amputations • New cases of blindness in adults • A MAJOR cause of • Heart disease • Stroke • The 7th leading cause of death in USA

  8. Diabetes: A Definition • Failure of the pancreas to produce sufficient amounts of the hormone insulin - or - • Resistance of the body’s cells to the action of insulin

  9. Insulin • Insulin allows cells throughout the body to absorb sugar (glucose) from the bloodstream • The source of glucose is mostly from carbohydrates in the foods we eat, but it can also be made by breaking down glucose stored in our muscles and liver • Insulin & Glucose are necessary for the brain, heart & kidneys to function

  10. When Insulin isn’t Helping Glucose into the Cells… • Hyperglycemia occurs (blood sugar levels go up) • This causes damage to body tissues, especially blood vessels • This then leads to eye disease, kidney disease, nerve disease and heart disease • Diabetes-related eye disease predicts these other diseases

  11. Diabetes Mellitus - Classification • Insulin Dependent (IDDM) • Non-Insulin Dependent (NIDDM) • Gestational (GDM)

  12. Insulin-Dependent Diabetes Mellitus (IDDM) • Results from destruction of islet cells in the pancreas • More common in persons under 20 years of age • Etiology both genetic and environmental • Patients acutely symptomatic at the time of onset (“the polys”)

  13. Non-Insulin Dependent Diabetes Mellitus (NIDDM) • Resistance of body tissues to the action of insulin: • Insulin resistance • Beta-cell failure • Usually occurs after age 40 • Gradual onset of symptoms (half are unaware) • Occurring more frequently in children • Risk factors: • Overweight & sedentary • Family history of diabetes • Ethnic origin

  14. Gestational Diabetes Mellitus (GDM) • Glucose intolerance of variable severity with onset or first recognition during pregnancy (2nd & 3rd trimester) • Complicates between 1% and 4% of pregnancies • Limited to the term of the pregnancy • Fetal outcome - Macrosomia • GDM Moms are 50% more likely to develop NIDDM later • Offspring are more likely to develop NIDDM during their lifetime

  15. What Are the Symptoms? • All type 1 patients have symptoms • Many type 2 patients have few or no symptoms until serious complications develop (e.g. a heart attack)

  16. Symptoms of Hypoglycemia Shaking Weakness Sweating Fatigue Fast heart beat Head Ache Dizziness Irritable Anxious Hunger Impaired vision

  17. Symptoms of severe low blood sugar • Seizure • Loss of consciousness (coma) • Stroke • Death

  18. Treatment of Hypoglycemia • 15 to 20 grams of carbohydrate that puts glucose into your bloodstream in about 5 minute will raise your blood sugar about 30 milligrams per deciliter (mg/dL) in about 15 to 20 minutes • Check your blood sugar level again 15 minutes Have person drink ½ glass of juice or regular soft drink,or1 glass of milk • If symptoms don’t stop, call internist • Then eat a light snack (1/2 peanut butter or meat sandwich and ½ glass of milk) Always have a rapid-acting carbohydrate in the office

  19. Symptoms of Hyperglycemia Extreme thirst Blurred vision Frequent urination Dry skin Healing difficulties Hunger Drowsiness

  20. Treatment of Hyperglycemia • Have patient test blood sugar • You can often lower your blood glucose level by exercising. However, if your blood glucose is above 240 mg/dl, check your urine for ketones. • If you have ketones, do not exercise • Exercising when ketones are present may make your blood glucose level go even higher. • Drink more water • Change medication/ eating habits • If >200mg/dl for several tests, for two days, or if extremely elevated: Call internist

  21. Treatment Modes • Pen injectors • Inhaled Insulin (currently off the market) • Insulin pumps • CGMs • Net based education • New medications • Insulin used more than in past

  22. Non-Retinal Eye Complications • CORNEA - One of two clear tissues in the body • LENS - The other clear tissue • It is a very complex process to keep these tissues clear

  23. Refractive error • In poorly controlled diabetes very high levels of glucose can cause the lens metabolism to shunt down a sorbital pathway • Sorbital buildup in the lens creates an osmotic swelling of the lens with resulting in refractive changes

  24. Poor Pupil Response Before Dilating Drops 30 minutes After Dilating Drops

  25. Non-Retinal Eye Complications • IRIS - Colored part of eye - rubeosis irides - new vessel growth that can cause serious glaucoma complications and is usually associated with PDR • Typically is associated with advanced diabetic retinopathy; not easy to identify • GLAUCOMA - Twice as likely in persons with diabetes and more likely to cause vision loss

  26. Non-Retinal Eye Complications • OPTIC NERVE - Can sometimes swell (optic neuritis) - generally found in younger persons with diabetes and can lead to permanent vision loss • CRANIAL NEUROPATHIES - Ptosis (lid droop) and proptosis (eye bulge); occasional reversible diplopia; Bell’s Palsy • Eyelids - Skin related problems

  27. Eye Muscle Problems

  28. Retinal Eye Complications • BDR - Background Diabetic Retinopathy • Microaneurysms, leakage of intravascular fluid, intraretinal hemorrhage, retinal ischemia • PPDR - Pre Proliferative Diabetic Retinopathy • PDR - Proliferative Retinopathy • New Vessel Growth • Remember – the retina is a very thin tissue

  29. Mild NPDR • Standard Photo 1

  30. Moderate NPDR • Standard Photo 2A

  31. Severe NPDR • Standard Photo 2B

  32. Very Severe NPDR • Standard Photo 5

  33. Proliferative Diabetic Retinopathy (PDR) • Neovascularization of the Disc (NVD) • Neovascularization Elsewhere (NVE) • Pre-retinal Hemorrhage (PRH) • Vitreous Hemorrhage (VH)

  34. Non-High Risk Proliferative Diabetic Retinopathy • Standard Photo 10A • Standard Photo 6B

  35. High Risk Proliferative Diabetic Retinopathy • Standard Photo 10C • Standard Photo 7 • Standard Photo 10 • Standard photo 13

  36. Laser Photocoagulation Treatment

  37. Injections • Triamcinolone acetonide • Lucentis and Avastin

  38. Diabetic Macular Edema(DME) • The collection of intraretinal fluid in the macular area • Disrupts retinal structure • With or without lipid exudate or cystoid changes • Focal or diffuse • Can occur at any stage of retinopathy • Only treated when it becomes “clinically significant” • Follow-up every 3 to 4 months by a retinal specialist

  39. Clinically Significant Macular Edema (CSME) • Patients referred for treatment immediately. • CSME responsible for nearly HALF of all vision loss in diabetes!

  40. Diabetic Retinopathy • The most significant ocular complication of diabetes • The leading cause of blindness - ages 20-74 • All complications of diabetes have a slow progression in the beginning • leads to patient non-compliance

  41. Type I Diabetes • Past thinking: Usually free of retinopathy for first ten years after diagnosis • Present Thinking: 20% have retinopathy at one year;67% have retinopathy at five years • 95% have retinopathy after 15 years or more

  42. Type II Diabetes • May have retinopathy at diagnosis • 30% have retinopathy within 5 years • 80% have retinopathy within 15 years

  43. Severity of Diabetic Retinopathy • Depends on • Disease Duration - always ask how long • High Blood Pressure - very serious • High Glycosolated Hemoglobin • Smoking = major risk • Example: • Patient A.J. (HTN, A1c = 10, smoker): diabetes less than 20 years; vision: 20/800 • Patient D.D. (good control of all risk factors): diabetes greater than 25 years, vision: 20/15

  44. Optometric Management of Persons with Diabetes • Frequency of Exams • After Diagnosis: Every Year Dilated Pupil Exam (Should be pre-scheduled) • After First Diagnosis of Diabetic Eye Changes: Every year or six months • At Pre-Proliferative Stage • Should be referred to retinal specialist • Less than 50% of persons with diabetes get dilated eye exams yearly • You must preschedule!!

  45. Treatment Options • PREVENTION - 75% of all diabetic retinopathy could be eliminated with proper control of the disease • Medication - Drs. do adequate job • Exercise - Drs. do poor job • Diet - Drs. do poor job • One of the greatest causes of death and disability in the USA is overeating and a diet heavy in fats, meats, and sugars

  46. Treatment Options • Argon Laser Photocoagulation • Pan Retinal Photocoagulation • Laser kills peripheral retinal tissue • feedback to brain says - “this is dead tissue, no need to grow vessels here” • Victrectomy • Remove bloody scarred vitreous and replace with saline • Injections

  47. Laser Photocoagulation • Reduces visual loss by 50% • Goals: • Prevent further neovascularization • Reduce risk of vitreous hemorrhage and/or reduce traction retinal detachment • Side Effects (lessened now with injections) • Constriction of peripheral vision • Decreased night vision • Loss of acuity

  48. Treatment Options • Early Diagnosis is the Key • ALWAYS preschedule your patients with diabetes for annual (and other) visits • Education/Motivation is Essential • 1-800-DIABETES/diabetes.org • Diet Consult • Exercise Consult • Diabetes Education Classes now covered by major medical and Medicare

  49. Why Does Diabetes Kill So Many Americans? • Doctors do not seem to understand the disease • Patients do not seem to understand the disease • The public does not seem to understand the disease • Not many people care • primarily affects older people, or under/un-insured

  50. Obesity by the numbers • Complications from obesity kill more Americans than smoking – and smoking kills 1000 Americans per day!!!! • Strokes, hypertension, cardiovascular disease, and diabetes can all cause blindness, as well as other disabilities and death

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