October 24, 2008
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Rishi P. Singh.
Dr. Singh is a graduate of the seven-year combined B.A./MD program at Boston University and Boston University School of Medicine. He served his residency in ophthalmology at Massachusetts Eye and Ear Infirmary, Harvard University, Boston, and completed his vitreoretinal fellowship at Cleveland Clinic.
Welcome Dr. Singh and thank you for being here with us today. Before we get started with questions that people have submitted, let's talk about the condition and explain some basic facts. Diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness in American adults in the United States. Nearly all patients with Type 1 diabetes and over 60% of patients with Type 2 diabetes have some degree of retinopathy. Diabetic retinopathy is a complication of diabetes that is caused by changes in the blood vessels of the eye.
Diabetic Retinopathy Overview
Cleveland_Clinic_Host: According to the National Eye Institute, it is estimated that 40%-45% of all Americans with diabetes are affected by diabetic retinopathy, and 24,000 of these people lose their vision each year. What is Diabetic Retinopathy?
Speaker_-_Dr__Rishi_Singh: Diabetic retinopathy is a change which occurs in the small vessels of the eye. Supportive cells of the vessels called pericytes are lost due to oxidative stress and glucose end products which damage these cells. When the cells are lost, there is loss of the integrity of the vessels resulting in outpouching called microaneurysms and obliteration of capillaries over time. This leads to an overall hypoxic state which causes the growth of new pathological blood vessels which leak and bleed into the eye.
CK: I have just been diagnosed with diabetes (age 63). During my last eye exam about eight months ago, I was told my vision improved. Lately, both eyes have been burning and, out of the right eye, I often see a small line or spot in the upper right corner of my vision. I have had migraine headaches years ago and had the optical spots. This is smaller and vague, but consistent. Since I have been diagnosed with diabetes and my father had it and also macular degeneration, I am wondering if I need to be concerned at this early time during the diagnosis.
Speaker_-_Dr__Rishi_Singh: The symptoms sound atypical for migraine headache. It is difficult to determine without an examination if these symptoms would be related to diabetes or macular degeneration. I would recommend that you continue follow up exams with your physician periodically.
Signs and Symptoms
Cleveland_Clinic_Host: What are the signs and symptoms for Diabetic Retinopathy that appear in adults?
Speaker_-_Dr__Rishi_Singh: The symptoms are of diabetic retinopathy are slow onset or insidious until very late in the disease and may only be picked during an eye examination. Early changes can be blurring of central vision, floaters, but the vast majority of patients have no changes until very late in the disease process. The late changes can be severe visual loss and eye pain/pressure.
Cleveland_Clinic_Host: Who is at risk for developing Diabetic Retinopathy? Does is matter what type of diabetes you have or the length of time you have had it?
Speaker_-_Dr__Rishi_Singh: Anyone with diabetes is at risk, but particular those with poor blood sugar control, high blood pressure, and high lipid levels. There are genetic components that have been associated as well with increased development. There is a difference in the type of diabetes and the development of retinopathy. Juvenile onset diabetics do not typically have retinopathy at the time of diagnosis in contrast to those with adult onset diabetes who can have retinopathy at the time of diagnosis.
Length of disease also does matter. The longer a person has had the disease, the greater the risk of retinopathy. Those with adult onset disease develop retinopathy at a much faster rate than those with juvenile onset diabetes.
Sally: How is diabetic retinopathy diagnosed?
Speaker_-_Dr__Rishi_Singh: It is diagnosed by a dilated eye examination performed by either an Eye MD or an optometrist. Sometimes additional tests such as fluorescein angiograms and OCT test are ordered.
Sally: What is the difference between proliferative and non-proliferative diabetic retinopathy?
Speaker_-_Dr__Rishi_Singh: Nonproliferative disease is the early stages of diabetic retinopathy which includes microaneurysms formation, capillary closure, and hemorrhages within the retinal layers. Proliferative disease refers to the development of blood vessels which grow on the surface of the retina or into the vitreous cavity.
VG: I recently went into DKA (diabetic ketoacidosis) and my eyes went blurring for about 2 weeks. Does this increase my chance to get retinopathy?
Speaker_-_Dr__Rishi_Singh: No. During exacerbations of high sugars which occurs in DKA, there is an increase in the sugar that this passed into the lens of the eye. When sugars are lower, the sugar then egresses from the lens over time restoring normal vision. Rarely are these changes permanent, but having continual DKA events will lead to an increased development of retinopathy and lens changes over time.
Howard: What are treatment options for early detected Diabetic Retinopathy? What are treatments for advanced stages?
Speaker_-_Dr__Rishi_Singh: The treatment depends on the type of retinopathy. For diabetic macular edema, treatment can consist initially of laser treatments to the areas of retinal disease. If the patient is not responsive to laser, other agents such as steroids and anti-VEGF agents may be tried. For proliferative diabetic disease, laser is the gold standard of care. Anti-VEGF agents are sometimes given as an adjunct to laser therapy.
Howard: Are there negative side effects that occur from treatment?
Speaker_-_Dr__Rishi_Singh: Treatments for diabetic macular edema can lead to small spots or scotomas in the vision of few patients. Those treated for proliferative disease typically have a decrease in their peripheral vision from laser treatments and they may complain of night blindness.
RGS: What can be done to prevent Diabetic Retinopathy?
Speaker_-_Dr__Rishi_Singh: The first line in prevention is to ensure tighter glucose control and control of blood pressure. Those with tight glucose control significantly reduced their rate of retinopathy over time. In particular, examining the 3 month level of glucose control, Hemoglobin A1c, is as important rather than following fluctuating blood sugar levels. Lipid lowering has been shown in few studies to help prevent diabetic retinopathy, but long term studies have been non-conclusive.
The second line of prevention is annual screening. A dilated eye exam is critical in determining the level of retinopathy and the need for treatment to prevent visual loss.
Barriers to patients having annual eye exams are multi-factorial. The most recent studies indicate that patients only get adequately screened 50% of the time. Some of this extends from confusion about whom an eye care provider is and what type of examinations need to be performed. Access to care is problematic in some regional areas as well. The recommendations are to get a dilated eye examination with an eye care professional (Eye MD or optometrist) once yearly.
theniter: Are there any statistics that show a correlation between good blood glucose control and developing diabetic retinopathy?
Speaker_-_Dr__Rishi_Singh: In the largest study done to date, the diabetic retinopathy study, patients who had lower hemoglobin A1c levels had less retinopathy over a 10 year period - by about 50%.
There is also a significant correlation between high blood pressure and developing retinopathy. Currently studies on lipid levels and cholesterol levels have been suggestive of increased risk. But more studies need to be done.
HildaB_: Are there other vision problems that can occur from diabetes?
Speaker_-_Dr__Rishi_Singh: Diabetics are at increased risk for the development of cataracts and glaucoma. Cataracts are due to the accumulation of insoluble sugars within the lens over time. Glaucoma can occur when blood vessels growth in the front of the eye as a result of severe ischemia in diabetes. This is referred to as neovascular glaucoma.
HildaB: Does Diabetic Retinopathy increase your chances of developing other types of eye disease or conditions? If so, what are they?
Speaker_-_Dr__Rishi_Singh: As mentioned above, diabetes does lead to cataract and glaucoma formation. Taking a look at the larger picture, since diabetic retinopathy is a manifestation of end organ damage from diabetes, patients should have other common site of diabetes manifestations examined. Particularly, they should have their urine tested for protein suggesting renal disease, their feet examined for retinopathy, and their blood pressure check as a means to reduce both their retinopathy and cardiovascular risk.
Juvenile Diabetes and Eyes
JH: Our six year old was diagnosed in May 2008 with Type 1 diabetes, what are the chances for her to develop diabetic retinopathy? What can we do to help prevent it? We keep tight control but she still has highs and lows especially at school. Is there a study showing how often of highs cause this or how high they would need to be to increase chances? Like her norm is 80-180 so if she were 250 at times for weeks would that be considered danger zone or would she be ok unless her BG level was closer to 350 at times for weeks?
Speaker_-_Dr__Rishi_Singh: The chance of developing retinopathy is low early in the disease, but higher after 10 or 15 years. Prevention was discussed in the previous question. If sugars fluctuate significantly, a better measure would be hemoglobin A1c levels. If A1c levels are high (9 and above), their rate of retinopathy development is much higher.
Cleveland_Clinic_Host: How common is it for children with juvenile diabetes to be treated for eye- related problems?
Speaker_-_Dr__Rishi_Singh: It is very uncommon for children to be treated with the disease since they don’t develop the complication for years.
theniter: What can we do to help avoid Diabetic Retinopathy in our 6-year-old with Type 1?
Speaker_-_Dr__Rishi_Singh: As stated earlier, Type I or Juvenile Onset typically does not develop into diabetic retinopathy in the early phase of the disease. Usually those with poor blood glucose control seen in their teens or early twenty's may be experiencing eye changes and early signs of diabetic retinopathy.
JL: I'm a 55 year old male, 180lbs, in good physical condition (competed in triathlons until this year). I have loss of vision in both eyes (resembling doughnut shaped rings). This problem has developed over the last 1-1/2 to 2 years, resulting in major loss of peripheral vision. I have had chest and abdominal CT scans, brain MRI, and a brain angiogram… as well as 16 tubes of blood drawn for various blood tests. I very frequently have flashing lights in my eyes (not torn retina/retinal detachment).
I'm told the flashing lights are optical migraines (mostly without the headache component). I was wondering if you had any insight as to possible causes for this loss of vision? Retinitis Pigmentosa hasn't been completely ruled out, although there are none of the traditional visual "markers" seen in my eye exams, and I don't have a family history of Ret-Pig… and the accelerated rate of loss of vision is not typical of Ret-Pig, or so I'm told. HELP?
Speaker_-_Dr__Rishi_Singh: This is likely not a diabetes related condition and unfortunately without testing or examination personally, I cannot answer this question.
MKC1: Can the damage done from diabetic retinopathy be healed or reconstructed so the vision loss is not permanent?
Speaker_-_Dr__Rishi_Singh: The visual loss is unfortunately for the most part permanent. The current treatments are excellent at preserving vision and new treatments with Anti-VEGF appear to lead to visual improvement.
theniter: You mentioned the types of treatment and the side effects like less night vision. If diagnosed and treated early, will the person's vision be very consistent for years to come, or do they usually need ongoing treatments?
Speaker_-_Dr__Rishi_Singh: Ongoing treatments for maintenance are likely. The goal of these treatments is to preserve the current level of vision.
LMN: What are anti-VEGF agents?
Speaker_-_Dr__Rishi_Singh: VEGF is vascular endothelial growth factor. It has been found to be elevated in patients with severe diabetic retinopathy. Some anti-VEGF agents that are available include Avastin® and Lucentis®. These are currently being studied in clinical trials.
theniter: We have a history of glaucoma, cataracts and diabetes. Should one get eye exams more often than once a year, or are yearly dilated exams usually enough?
Speaker_-_Dr__Rishi_Singh: Annual examinations are fine for individuals without any co-morbidities. In patients who have advancing diabetic retinopathy, or get diagnosed with glaucoma, an exam as frequent as every 3 months is recommended.
theniter: Are there any percentages of those diagnosed with diabetic retinopathy and complete vision loss? Do they usually lose more vision each year, every 2-3 yrs, etc.?
Speaker_-_Dr__Rishi_Singh: It is difficult to give exact percentages since many of the studies are very old and the treatments have improved vastly over the years. The visual loss that occurs is usually gradual over time. Quick drops in vision may be due to bleeding in the eye in the end stages of diabetes.
Eric18: What is occurring in research about Diabetic Retinopathy?
Speaker_-_Dr__Rishi_Singh: Numerous clinical trials are examining the role of growth factors in the pathogenesis of diabetic retinopathy. Vascular endothelial growth factor (VEGF) appears to be the key mediator in diabetic retinopathy. I currently oversee clinical trials in the use of Anti-VEGF agents for diabetic retinopathy.
Research into better detection of diabetic retinopathy has also occurred with the development of optical coherence tomography (OCT). This technology is non-invasive and non-contact and delivers pictures of the retina equivalent to an optical biopsy. At Cleveland Clinic we are conducting multiple clinical trials on diabetic disease and the affect on eyes. To participate, contact 216.444.2020 to request an appointment for evaluation.
Eyes1: Do vitamins with lutein have any effect on macular degeneration or diabetic retinopathy?
Speaker_-_Dr__Rishi_Singh: We think that there some benefit of lutein with macular degeneration. There is an on-going study looking at the relationship that is called the AREDS2 Study. There currently has been no support of data that lutein makes a difference in diabetic retinopathy.
Cleveland_Clinic_Host: We are getting ready to close for today. A large number of questions were received and we apologize if we did not get to your question. We will try to answer as many questions as possible in these last few minutes. If you have additional questions, please go to my.clevelandclinic.org/health/chat.aspx to chat online with a health educator.
Dr. Singh, thank you for joining us today to answer questions. A lot of information has been shared and we hope that it will increase awareness of diabetic retinopathy and the importance monitoring diabetes control.
Speaker_-_Dr__Rishi_Singh: This forum has been great. If you have further questions or concerns, make an appointment to see an Eye MD. You may also call the Cleveland Clinic Cole Eye Institute at 800.223.2273 ext. 4-2020. Thank you very much.
- For more information about Cleveland Clinic Cole Eye Institute and the entire spectrum of conditions of the eye, including complex problems such as diabetic retinopathy, retinal detachments, macular degeneration, glaucoma, cataracts, uveitis, strabismus and pediatric eye disorders visit us on the web at my.clevelandclinic.org/eye/default.aspx.
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