Diabetes is a major health concern that is taking over the United States. Despite the major advancements in research and public awareness the number of Americans being diagnosed is staggering. According to the American Diabetes Association 1.4 million Americans are diagnosed with diabetes each year.
From an eye-care providers stand-point this is alarming considering that diabetic related eye disease is the leading cause of blindness in adults in industrialized countries. The Center for Disease Control reported that blindness associated with diabetes costs $500 million dollar every year. With rising costs of health-care this number will most likely be increasing. Ideally, these patients would have annual comprehensive dilated eye examinations to monitor for any ocular changes. Then if any ocular changes are noted, appropriate treatment and documentation would occur more promptly to reduce the risk of vision loss.
The most common cause of vision loss is secondary to diabetic retinopathy. Retinopathy is damage to the retina vasculature resulting in poor retinal perfusion. Essentially the retina is unable to receive the nutrients and oxygen it needs to function properly resulting in neovascularization (new blood vessel growth). These new blood vessels and very weak which can lead to more problems such as hemorrhaging. These hemorrhages can enter the vitreous (gel inside the eye) and cause decreased vision. Besides retinopathy there are other ocular changes that can compromise sight.
Cataracts: Cataracts are a contributing factor to decreased vision. Fluctuation in blood glucose and poor glucose management can increase cataract development at a faster rate. Intra-ocular lens changes can cause the patient's refractive error to fluctuate. While cataract extraction is a common procedure there is an added complication with uncontrolled diabetes which is diabetic macular edema following the cataract extraction. Not every diabetic patient will have macular edema but there is a higher risk of edema developing in diabetic compared to non-diabetics.
Diabetic Macular Edema: Macular edema is swelling at the eye's center of best vision. This swelling leads to decreased vision. Edema can occur in the eye regardless of the magnitude of associated retinopathy. However, macular edema is more prevalent in type II diabetes compared to type I.
Neuropathy: Neuropathy is death of the nerve fibers (retinal ganglion cells) that compose the optic nerve. A diabetic can also suffer from ischemic neuropathy, which is nerve fiber death secondary to an ischemic event (lack of oxygen). It is important to remember that once a nerve fiber has undergone apoptosis it cannot be regenerated.
Cornea Edema: Just like macular edema, corneal edema is swelling of the cornea. Corneal changes are prevalent in 70% of diabetics and can cause delayed wound healing and ulcers. Diabetic patients are more prone to having decreased corneal sensitivity, which can be problematic especially if they suffer from delayed wound healing. Corneal damage may be more severe than their symptoms indicate and can lead to vision loss. These are specific considerations when a diabetic patient is considering contact lens wear or LASIK surgery. Another interesting note about diabetic surface quality is diabetics have 4x higher glucose within their tears than non-diabetics. Researchers are currently working on developing a contact lens to monitor blood glucose through a contact lens and to develop a topical drop to administer insulin.
Cranial Nerve Palsies: The most common cranial nerve palsy associated with diabetes is a diabetic third nerve palsy. A third nerve palsy results in an outward eye turn with a drooped eye-lid. Symptomatically a patient may experience double vision, pain, and a cosmetically noticeable lid droop that may completely cover the eye. Generally this nerve palsy has normal pupillary response. When a patient experiences a recent onset cranial nerve palsy they require a complete evaluation with a Neuro-Optometrist or Neuro-Ophthalmologist.
With the increasing number of diabetic patients in the United States there is an increased risk of associated vision loss. Eye care should be considered an integral part of diabetic patient care. Diabetic patients, at a minimum, should undergo an annual dilated eye examination with a comprehensive report to the primary care physician. Some diabetic patients require more frequent dilated visits to monitor pathology. It is important to note that fundus screening photos do not replace a dilation in diabetic patients. However, photographic monitoring may be indicated in conjunction with dilation. This continuous care and communication can help decrease permanent vision loss and improve the patient's quality of life.
Artisan Optics - Uptown
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