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Integrative Analysis > Diabetes 2 > Flashcards

Diabetes 2 Flashcards

1
Q

ocular manifestations of DM: visual function

A
  • loss of VA
  • refractive error changes: myopic or hyperopic in association w/ hyper- or hypoglycemia; symptom of undiagnosed DM
  • changes in color vision; can precede development of retinopathy
  • accommodative dysfunction
  • VF changes; secondary to hemorrhages, fibrous proliferation, neo/glaucoma, papillopathy, ischemic optic neuropathy, as consequence of PRP
  • contrast sensitivity decrease
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2
Q

ocular manifestations of DM: extraocular muscle neuropathies

A
  • DM is leading cause of 3rd nerve palsy (ptosis, XT, and hypotropia w/ pupil sparing)
  • 4th nerve palsy
  • 6th nerve palsy
  • usually resolves in 2-6 months; pt typically presents with associated peri-orbital pain
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3
Q

ocular manifestations of DM: pupillary reflexes

A

can affect sympathetic innervation of iris, miotic pupil with weaker reaction to topical mydriatics

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4
Q

ocular manifestations of DM: cornea

A
  • diabetic keratopathy: neuropathy of ophthalmic division of trigeminal nerve (V) leading to decreased corneal sensitivity… decreased basal tear production, as well as lacrimal gland dysfunction - essentially a feedback loop
  • corneal wound healing: recurrent corneal erosions more likely to occur in DM patients due to basement membrane abnormalities
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5
Q

ocular manifestations of DM: iris

A

-neovascularization of the iris: usually first viewed at pupillary margin, may be in angle without any visible vessels on pupil border, in response to severe retinal ischemia

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6
Q

ocular manifestations of DM: lens

A
  • hyperglycemia leads to swelling via aqueous delivery and lens absorption; patient complains of fluctuating vision
  • DM linked with premature nuclear sclerosis, leading to refractive index shifts; DM linked with cortical cataract, vacuoles, clefts; DM leads to increased risk of cataract progression
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7
Q

ocular manifestations of DM: optic disc

A
  • papillopathy: uncommon condition and diagnosis of exclusion; essentially a chronic hypoxic state leading to capillary bed dilation, edema, and eventually ischemia/atrophy; may exist for months to years and may have no overall effect on vision initially; usually resolves w/o treatment within a year, visual prognosis good
  • ischemic optic neuropathy: classic microvascular complication to pial, ophthalmic, and short posterior ciliary blood supply- presents with disc pallor, swelling and hemes, sudden decreased vision, APD, altitudinal VF defect- often results in optic atrophy and reduced VA
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8
Q

where does optic nerve get its blood supply?

A

mostly short posterior ciliary arteries, posterior aspect some from pial blood vessels, anterior some from choroidal vasculature

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9
Q

ocular manifestations of DM: retina

A
  • vaso-occlusion: complicated by other systemic issues, similar to ION, such as HTN, dyslipidemia, smoking, etc.
  • retinopathy: the most common, and likely earliest presentation of diabetic eye disease; roughly 40% of diabetics over age 40 have retinopathy; hyperglycemia damages the smallest and most fragile vessels first, leading to collapse and leakage of capillaries
  • diabetic macular edema
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10
Q

majority of diabetic retinopathy arises in _____ layers of retina

A

inner nuclear and outer plexiform

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11
Q

non-proliferative retinopathy

A
  • microaneurysms
  • dot-blot hemorrhages
  • flame-shaped hemorrhages
  • edema
  • exudate
  • cotton wool spot
  • venous beading/tortuosity
  • IRMA
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12
Q

proliferative retinopathy

A
  • neovascularization at or near the optic disc (NVD) or elsewhere in the retina (NVE)
  • typically arise from endothelial cells of venous system
  • affects 5-10% of DM population, especially Type 1 DM (50-60% progress to proliferative after 20 years)
  • protective factors include carotid occlusive disease, posterior vitreous separation, high myopia, and optic atrophy
  • approx. 1/4 of retina must be non-perfused to develop PDR
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13
Q

mild NPDR

A

H/Ma < EDTRS standard photograph 2a (at least one retinal Ma)

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14
Q

moderate NPDR

A

H/Ma > EDTRS standard photograph 2a in 1-3 retinal quadrants and/or soft exudates, venous beading, or IRMA definitely present

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15
Q

severe NPDR

A

4-2-1 rule:

  • H/Ma > ETDRS in 4 retinal quadrants
  • venous beading in 2 or more retinal quadrants
  • prominent IRMA in at least 1 retinal quadrant
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16
Q

eyes with severe NPDR have a _____ risk of developing PDR in one year

A

greater than 50%

17
Q

very severe NPDR

A

two or more criteria for severe NPDR are met, in absence of frank neovascularization

18
Q

PDR

A
  • neovascularization is accompanied by an influx of inflammatory cells and myofibroblasts into the retina, leading to extraretinal fibrovascular proliferation that may cause vitreous hemorrhages and retinal detachment
  • NVI: arises in response to severe pan-retinal ischemia; viable vascular tissue just so happens to be anterior uvea/ciliary body and so neo arises here and grows across iris/angle
  • characterized by NVD or NVE
19
Q

high risk PDR

A

characterized by the presence of at least 3 of the 4 risk factors for severe visual loss from diabetic retinopathy:

  • presence of pre-retinal or vitreous hemorrhage
  • presence of new vessels
  • presence of new vessels on or near the disc (NVD)
  • presence of moderate or severe new vessels (NV ? standard photo 10A or NVE >1/2 disc area)
20
Q

without appropriate treatment, _____% of eyes with PDR are blind within 5 years

A

50

21
Q

diabetic macular edema (DME)

A

collection of intraretinal fluid in the macular area of the retina, with or without lipid exudates or cystoid changes; VA is generally compromised when DME affects the fovea; macular edema is retinal thickening within 2 disc diameters of the center of the macula, which can either be focal or diffuse

22
Q

most common cause of acute vision loss in DM patients

A

diabetic macular edema

23
Q

clinically significant macular edema (CSME)

A

term was introduced to signify an increased risk for moderate visual loss, defined as doubling of the visual angle (eg. 20/40 to 20/80); to be classified as CSME, one or more of the following must be present:

  • any retinal thickening within 500 um (1/3 DD) from center of macula
  • hard exudates within 1/3 DD of macula with associated retinal thickening
  • retinal thickening > 1DD in size < 1 DD from macula
24
Q

non-central involved DME

A

retinal thickening in the macula that does not involve the center subfield zone that is 1 mm in diameter

25
Q

central involved DME

A

retinal thickening in the macula that does involve the central subfield zone that is 1 mm in diameter

26
Q

DME can appear ____

A

at any level of diabetic retinopathy, even without any other sign

27
Q

current standard of care Tx for high risk PDR

A

pan-retinal photocoagulation (PRP)

28
Q

pan-retinal photocoagulation (PRP)

A
  • 1200-2400 laser burns scattered throughout the retina, sparing the macula
  • reason: induction of neovascular involution; treatment of photoreceptor layer (outer segment and RPE) leads to overlying/associated NFL apoptosis and eventual decrease in oxygen demand/release of VEGF by ischemic tissue
  • pattern is relatively standard, but based upon severity
  • in-office procedure with topical corneal anesthetic and/or retro-bulbar block
  • patient may feel some pain; oral analgesic Rx’ed
  • retreatment based upon neovascular regression; regression with residual fibrovascular tissue is okay; retreatment limited by viable retina left to treat
  • patient needs educated on potential VF loss
29
Q

focal/grid laser for DME

A

-has been shown to be beneficial in reducing the risk of further vision loss in DME, but generally is not effective in reversing already reduced VA (anti-VEGF does both)

30
Q

vitrectomy (PPV)

A

indications include:

  • persistent vitreous hemorrhage (usually greater than 2-3 months)
  • hemorrhage making retinal treatment difficult
  • potential for tractional retinal detachment
  • areas of traction threatening the macula
  • persistent DME with vitreous traction
  • DME nonresponsive to focal laser treatment
31
Q

intraocular steroids

A
  • currently three types are available
  • have been shown to be effective in decreasing macular thickness and improving VA, although intravitreal anti-VEGF are primary treatment
  • higher risk of side effects such as cataract and IOP spikes
32
Q

vascular endothelial growth factor inhibitors

A
  • Lucentis FDA approved for DME
  • Eyelea FDA approved for DME and diabetic retinopathy
  • others (Macugen, Avastin) used off label
33
Q

DRCR.net demonstrated that center-involved DME, with vision reduced to 20/32 or worse, is best treated ____

A

with intravitreal anti-VEGF followed by either prompt or deferred (up to 6 mo) focal laser photocoagulation

34
Q

_____ may be a reasonable strategy for CI-DME presenting with good vision

A

observation without treatment unless VA worsens

Integrative Analysis (5 decks)

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