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(1) Shared care and ocular therapeutics > Week 17 - DM > Flashcards

Week 17 - DM Flashcards

1
Q

Types of Diabetes Mellitus

A
  • Insulin Dependent (IDDM)
  • Non-Insulin Dependent (NIDDM)
  • Pre-Diabetes
  • Gestational
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2
Q

Diabetic eye disease types:

A

Anterior Segment
- Dry Eye
- Diabetic Keratopathy
- Uveitis
- Cataract
Posterior Segment
- Vitreous Haemorrhages
- Diabetic Retinopathy (DR)

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3
Q

Examples of Anterior Segment Complications of Diabetes

A

Aqueous Deficient Dry eye
Diabetic neurotrophic keratopathy
Epithelial fragility
Delayed epithelial healing
Superficial punctate keratopathy
Persistent epithelial defects
Recurrent corneal erosions
Neurotrophic corneal ulceration
Filamentary keratitis
Descemet‘s folds

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4
Q

Diabetic Keratopathy

A

70% of diabetic patients suffer from corneal complications
Cornea experiences 4-fold higher glucose level in diabetics

Examples:
- Superficial punctate keratitis
- Recurrent corneal erosion
- Persistent epithelial defect (corneal)
- Diabetic neurotrophic keratopathy

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5
Q

Diabetic Neurotrophic Keratopathy

A

Occurs in up to 64% of diabetic patients
Involves reduction of corneal nerve density
May lead to permanent vision loss
Characterised by structural and functional changes of cornea

Signs/Symptoms:
Impaired corneal sensitivity
Epithelial defects (loss of protective function)
Impaired healing
Corneal ulceration
Loss of vision
Three stages

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6
Q

Corneal Sensitivity in Diabetes

A

Up to 55 % of diabetic patients have reduced corneal sensitivity
Corneal sensitivity still difficult to measure and quantify

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7
Q

Anterior Uveitis in Diabetes

A

Presenting features
Poor glycaemic control
Type 1
Advanced Type 2 (Neuropathy etc.)
Acute
Anterior

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8
Q

Diabetes and Cataract

A

Cortical
Nuclear
Snowflake

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9
Q

Main Risk Factors: Who is likely to have DR?

A

Hyperglycaemia
Hypertension
Diabetes duration
Ethnicity (African, Hispanic, South Asian)
Puberty and pregnancy (DM type 1)

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10
Q

Signs of DR

A

Microaneurisms
Retinal haemorrhages
Hard exudates
Cotton-wool spots
Venous tortuosity and beading
Neovascularisation
Tractional retinal detachment
Macular oedema

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11
Q

Scottish diabetic retinopathy grading:

A

When assessing the fundus, you are grading 2 things:

General and Peripheral Retina
Macula

and note any other findings

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12
Q

What are the DR Grades?

A

R0
• No diabetic retinopathy anywhere Rescreen 12 months

R1
• Background diabetic retinopathy BDR - mild
• The presence of at least one of any of the following features
anywhere
- dot haemorrhages
- microaneurysms
- hard exudates
- cotton wool spots
- blot haemorrhages
- superficial/ flame shaped haemorrhages

R2
• Background diabetic retinopathy BDR - observable
• Four or more blot haemorrhages (ie >AH) in one hemi-field only (Inferior and superior hemi-fields delineated by a line passing through the centre of the fovea and optic disc)

R3
• Background diabetic retinopathy BDR – referable
• Any of the following features:
- Four or more blot haemorrhages (ie >AH) in both inferior and superior hemi-fields
- Venous beading (>AH)
- IRMA (>AH)

R4
• Background diabetic retinopathy BDR – referable
• Any of the following features:
- Four or more blot haemorrhages (ie >AH) in both inferior and superior hemi-fields
- Venous beading
- IRMA (>AH)

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13
Q

What are the DM Maculopathy Grades?

A

M0
• No features 2 disc diameters from the centre of the fovea sufficient to qualify for M1 or M2 as defined below.

M1
• Lesions as specified below within a radius of > 1 but 2 disc diameters the centre of the fovea
- Any hard exudates

M2
• Lesions as specified below within a radius of 1 disc diameter of the centre of the fovea
• Any blot haemorrhages
• Any hard exudates

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14
Q

How do Optometrists Contribute to DR?

A

Screening and early detection of diabetic eye problems

Monitoring and patient advice

Treatment of anterior segment disease

Referral for further investigation and/or treatment

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15
Q

How may DR present during H+S?

A

Vision:
Px may tell you that their vision fluctuates throughout the day – may be worse when they are hungry or after exercise.
General Health:
Px may tell you they are being investigated for diabetes
They may be diet controlled (no meds)
Family History:
Who (immediate family) had DM? TYPE? Age of Onset? Any effect on this family members eyes?

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16
Q

H+S - Monitoring already diagnosed?

A

General Health:
If Px is already diagnosed, you need to ask:
- Type
- Duration
- Medications
- Stability with meds/lifestyle
- Who monitors it?
- When was the last check-up with GP?
Are they attending DRS
- If yes – when was it? Were they advised of any changes in the back of their eye?
- If no – any reason why not? Consider putting them on annual recall and monitoring them within your practice

17
Q

During Refraction:

A

Biggest indication: Fluctuating visual acuity throughout refraction

You should consider DM as part of your differential diagnosis whilst refracting if this is the case, especially if there are other risk factors.

18
Q

What needs to be checked during Anterior Eye Health

A

Quantitative and qualitative evaluation of tear film

Measurement of corneal sensitivity

Treat any dry eye and monitor corneal defects

Look for inflammation in the anterior chamber

Look for any structural changes in the lens

Refer if persistent visual impairment

19
Q

What needs to be checked during Posterior Eye Health

A

Fundoscopy Assessment

Consider dilation if:
Small pupils (<2mm)
>1 year since Px attended DRS
Poor blood glucose level control (H+S, Refraction)
First eye exam since diagnosis (yet to attend DRS)

Assessment can be aided with fundus photography
The best way to detect retinopathy early—when still treatable and before vision is irreversibly lost

20
Q

Management: Shared Care and Recall

A

Monitor:
Every 2 years if Px is under a DRS scheme and seen annually
Annually, if Px does not under a DRS scheme and seen annually
(This can vary depending on health board)

Letter to GP:
To reassess blood glucose level and/or medication if clinically indicated

Referral:
GP – If first presentation at eye exam, for assessment and diagnosis
Ophthalmology - If clinically indicated

21
Q

How does GP: Investigation and (Confirmation of) Diagnosis

A

Assessment of Blood Glucose Level
Blood Test
Urine Test

Once diagnosed, Px name goes on diabetes list

All diabetic patients are invited to attend annual retinal screening

22
Q

How does GP: Management

A

Management of underlying IDDM or NIDDM

Monitor Px frequently to check general health
- Glycated haemoglobin (HbA1c) blood test (IDDM)

Referral to community optometry

Referral into local diabetic retinal screening scheme (DRS)

23
Q

NHS Diabetic Retinal Screening Service

A

Nation-wide service
All diabetic patients over 12 years of age will be invited annually
Screening based primarily on digital fundus images
Non-mydriatic fundus photo (technicians, nurses)
Dilation if required (approx 25% of patients)
All images will be graded by an Optometrist

24
Q

Optometrists’ role at the Diabetic Retinal Screening Service

A

Medical Retina Specialisation

Advanced grading of digital fundus images

Run slit-lamp clinics

Clinical decision-making/referrals

25
Q

Diabetic retinal screening service: Management

A

Any images that may require referral will be graded at least by two graders

Referral from DRS directly to ophthalmology outpatient clinic

Screening result letter will be sent to patient and GP

If image quality at screening appointment inadequate: patient to be booked for appointment at slit-lamp clinic

26
Q

NHS Diabetic Retinal Screening Service

A

Format of screening can vary based on health board:

Glasgow: Patients attend hospital-based screening clinics, also mobile clinics (van-based)

Lothian: Patients attend hospital or GP practice-based screening clinic, or are seen annually by their community optometrist

Ayrshire: Patients are see locally by an accredited community optometrist

27
Q

DRS Referral Criteria

A

Can be considered appropriate for community optometry

Retinopathy and maculopathy are graded separately

Refer to Ophthalmology only if graded as:
R3 (advanced background retinopathy)
R4 (proliferative retinopathy)
M2 (severe maculopathy)

28
Q

Ophthalmologist: Treatment

A

• Pan-retinal Photocoagulation (PRP)

• Anti-Vascular Endothelial Growth Factor Treatments
- Anti-VEGF agents can arrest, or even reverse, proliferative retinopathy and macular oedema
- E.g., intravitreal ranibizumab (LUCENTIS®)
- Less destructive than laser

• Intravitreal Corticosteroids
- Intraocular corticosteroids widely used to treat macular oedema
- Modest improvement of VA possible
- Long-acting steroid implants may be used

• Vitrectomy
- May be useful in advanced diabetic retinopathy
Example: vitreous haemorrhage
- May develop in proliferative DR, when new fragile vessels burst

29
Q

Key Role of Optometrists

A

Optometrists are primarily involved in the diagnosis and monitoring of diabetic eye disease

Referral urgency depends on severity of retinopathy and maculopathy
Refer to HES when (Scottish DRS Grading):
R3 (advanced background retinopathy)
R4 (proliferative retinopathy)
M2 (severe maculopathy)

30
Q

Optometrists goal:

A

Optometrists goal: is to identify anyone with pre-proliferative diabetic eye disease

With early diagnosis and laser photocoagulation, vision loss may be prevented/reduced

In case of vision loss, some sight may be regained by with anti-vascular endothelial growth factors or vitrectomy

31
Q

DRS Criteria and Recall

A

Diabetic Retinal Screening
Optometrist (with medical retina specialisation certificate)
Perform (dilated) fundus photography in these patients annually and report any changes to GP/Ophthalmologist.

Routine Eye Examination
Annual recall for these patients IF they are not seen annually. If under DRS annually already – you see these Px’s every 2 years.

(1) Shared care and ocular therapeutics (20 decks)

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