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The Goal is in Sight: Eye Care Concerns for Patients with Diabetes

The Goal is in Sight: Eye Care Concerns for Patients with Diabetes. Richard Savoy, OD, MPH, FAAO Wilson McGriff, OD, MPH. Workshop Objectives. Review the epidemiology of diabetes in the U.S. and Tennessee Discuss the effects and potential impact of diabetes on vision

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The Goal is in Sight: Eye Care Concerns for Patients with Diabetes

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  1. The Goal is in Sight:Eye Care Concerns for Patients with Diabetes Richard Savoy, OD, MPH, FAAO Wilson McGriff, OD, MPH

  2. Workshop Objectives • Review the epidemiology of diabetes in the U.S. and Tennessee • Discuss the effects and potential impact of diabetes on vision • Instruct in the use of the Health Belief Model to promote behavior change • Review initiatives and recommendations for preventing and minimizing diabetic complications

  3. Diabetes: A Definition • Failure of the pancreas to produce sufficient amounts of insulin -OR- • Resistance of the body’s cell to the action of insulin

  4. Epidemiology of Diabetes in the US • 29.1 million people have diabetes • 1.7 million people 20 years old and older diagnosed in 2012 • 86 million people have prediabetes • 15-30% of people with prediabetes will develop diabetes (Type 2) within 5 years

  5. Complications: Diabetes in the US is… • The 6th leading cause of death • The LEADING cause of: • Kidney failure • Non-traumatic lower limb amputation • New cases of blindness in adults • A MAJOR contributor to: • Heart disease (2nd leading cause of death) • Stroke (4th leading cause of death)

  6. Some Bad News and Some Good News with Diabetes • Bad: • Medical costs for people with diabetes are twice as high as for people without diabetes • Risk of death for adults with diabetes is 50% higher than for adults without diabetes • Good: • Prediabetics who lose weight by eating healthy and being more active can cut their risk of getting Type 2 diabetes in half

  7. Diabetes by Age (Years)Tennessee, 2005

  8. Diabetes by Gender and Race Tennessee, 2005

  9. Diabetes by Educational AchievementTennessee, 2005

  10. Diabetes and Cardiovascular DiseaseTennessee, 2005

  11. Diabetes and Specific Risk FactorsTennessee, 2005

  12. Types of Diabetes Mellitus • Type 1 • 5-10% of cases • Loss of ability to produce insulin • Type 2 • 90-95% of cases • Loss of ability to use insulin • Gestational and other types • Hyperglycemia is the defining feature of all types

  13. Effects of Chronic Hyperglycemia • Microvascular disease • Retinopathy • Diabetic nephropathy • Diabetic neuropathy

  14. Ocular Symptoms of Diabetes • Blurry vision at near or far • General decline in visual acuity • Spots or floaters • Straight lines do not look straight • Double vision • Persistent, red, painful eye • Increasing sense of pressure in the eye

  15. Refractive Error and Cataracts • Excess glucose causes the crystalline lens to swell • May alter or delay glasses prescription • 40% increase in risk for developing cataracts

  16. Glaucoma • Twice as likely in persons with diabetes • Gradual destruction of optic nerve • More likely to cause vision loss

  17. Diabetic Retinopathy • Most significant ocular complication • Leading cause of blindness: ages 20-74 • Slow progression in the beginning • Incidence increases with duration of diabetes • >10 years: >50% incidence of retinopathy • >15 years: ~90% incidence of retinopathy

  18. Diabetic Retinopathy Photos: National Eye Institute / National Institutes of Health

  19. Severity of Diabetic Retinopathy • Depends on • Disease Duration • High Blood Pressure • Smoking status • Hemoglobin A1c level (HbA1c)

  20. Hemoglobin A1c (HbA1c) • AVERAGE blood sugar level over 3 months • Normal HbA1c is below 5.7% • Average patient with diabetes is around 8.5% • Goal is <6.5% for newly diagnosed • Predicts likelihood of disability and death • Only 24% of persons with diabetes can remember their last HbA1c value

  21. HbA1c and Retinopathy Adapted from The Diabetes Control and Complications Trial Research Group, Diabetes 44:968, 1995

  22. Healthy Retina • Häggström, Mikael. "Medical gallery of Mikael Häggström 2014". Wikiversity Journal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 20018762.

  23. Diabetic Retinopathy Mild Moderate Severe Images from the Early Treatment Diabetic Retinopathy Study Neo of the optic disc Neo elsewhere Pre-retinal hemorrhage

  24. Responsible for nearly HALF of all vision loss in diabetes! Referred for immediate treatment Clinically Significant Macular Edema Images from the Early Treatment Diabetic Retinopathy Study

  25. Other Ocular Manifestations Anterior Ischemic Optic Neuropathy Corneal Ulcers Cranial Nerve Palsies

  26. Prevention and Treatment of Diabetic Eye Disease • Prevention • Annual dilated exams • ~75% reduction of diabetic retinopathy with proper control • Less than 50% of persons with diabetes get annual dilated eye exams • Treatment • Laser • Injections • Invasive surgery

  27. Health Insurance and Diabetes • Medicare • BlueCare/TennCare/United/AmeriGroup • Private insurance • Affordable Care Act

  28. Diabetes Health Promotion Programs National Level Initiative: Healthy People 2020

  29. Healthy People 2020 • D-1 Reduce the number of new cases of diabetes • D-2 Reduce the death rate • D-3 Reduce the diabetes death rate • D-4 Reduce the rate of lower extremity amputations

  30. Healthy People 2020 • D-5 Glycemic control • D-6 Lipid control • D-7 Blood pressure control • D-8 Annual dental examination • D-9 Annual foot examination • D-10 Annual dilated eye examination

  31. Healthy People 2020 • D-11 Twice a year glycosylated hemoglobin measurement • D-12 Annual urinary microalbumin measurement • D-13 Once daily self-blood glucose-monitoring • D-14 Formal diabetes education • D-15 Diagnosed proportion of persons with diabetes • D-16 Prevention behaviors in persons with prediabetes Retrieved from: http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx on 09/02/14

  32. Diabetes Health Promotion Programs State Level Initiative: Project Diabetes

  33. Tennessee’s Project Diabetes • Goals: • Decrease the prevalence of overweight/obesity across the State and, in turn, prevent or delay the onset of Type 2 diabetes and/or the consequences of this devastating disease. • Educate the public about current and emerging health issues linked to diabetes and obesity • Promote community, public-private partnerships to identify and solve regional health problems related to obesity and diabetes

  34. Tennessee’s Project Diabetes • Goals • Advise and recommend policies and programs that support individual and community health improvement efforts • Evaluate effectiveness of improvement efforts/programs that address overweight, obesity, prediabetes, and diabetes • Disseminate best practices for diabetes prevention and health improvement. Retrieved from: http://health.state.tn.us/projectdiabetes.htm on 09/02/14

  35. Social Ecology of Health Model A. Level I: Intrapersonal B. Level II: Interpersonal C. Level III: Organizational D. Level IV: Community E. Level V: Societal

  36. Diabetes Health Promotion Programs Patient Level Initiative: Intrapersonal/Interpersonal Behavioral Change

  37. Health Belief Model Cue to Action Self-Efficacy Perceived Susceptibility Perceived Benefits BEHAVIOR CHANGE!! Perceived Severity Perceived Barriers 1. Coreil, J. (Editor)(2010). Social and Behavioral Foundations of Public Health, 2nd Edition. Thousand Oaks, CA:Sage. 2. Retrieved from: http://www.utwente.nl/cw/theorieenoverzicht/theory%20clusters/health%20communication/health_belief_model/ on 09/02/14

  38. Health Promotion and Social Support “People, unlike fish, are unable to swim upstream for any length of time. When the entire responsibility for health enhancement and risk reduction rests with the individual, independent of the health norms……….the probability for success is very small” Bellingham, 1990

  39. Diabetic “Bullets”

  40. Potential Benefits of Preventing and Treating Diabetes • Feel better • Fewer symptoms • Longer, healthier life • Good vision • Reduce the risk for complications involving eye, foot, kidney, heart, and nerve disease

  41. Basic Recommendations for Preventing and Minimizing Diabetic Eye Disease • In consultation with a physician knowledgeable about diabetes care, and through proper diet, exercise, and medication: • Keep blood sugar levels as close to normal as possible • Check and control even mild high blood pressure • Check and improve blood lipid profile • Check blood sugar levels at home on a regular basis, and know HbA1c levels • Quit smoking • Have a dilated eye examination each year, more often if specifically recommended

  42. Diabetes “Team” • Family Physician • Optometrist • Podiatrist • Dentist • Retinal Specialist • Diabetic Educator • Dietician

  43. Additional Acknowledgements • Some information courtesy of your American Optometric Association 

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