A renowned specialist panel consisting of a cardiologist, ophthalmologist, neurologist and nephrologist discusses how to manage complications of diabetes - ophthalmology session.
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would like to introduce Dr Alexander Nugent, who is an ophthalmologist here in San Diego, practicing at Kaiser Permanent Day, where he has a focus on glaucoma. But I'm sure has seen a lot of diabetic eye disease. So we're happy to hear from you. Everyone can hear me. Okay, alright, so I've been asked to talk about diabetic related ocular complications. Uh, before I begin, I just wanted to point out, Let's see here. And we tried to get control. The mhm. All right, there we go. So in today's most recent political climate, I just wanted to thank a bunch of scripts doctors who reached across party lines and invited the Kaiser doctor to come give a talk. But jokes aside, I'm very grateful for the opportunity to speak to everyone today. Um, I have no financial disclosures before I get into all the atomic conditions. I just want to share with you that my wife sees a lot of diabetic patients, and when she comes home, she always says, You know, I can't believe that I saw this patient, that patient with multiple limb amputations and stage renal disease on dialysis, needing, uh, can you transplant or history of stroke. But yeah, the one thing that she pulls away from this that Ah, lot of those things don't scare the patients as much as losing their vision. Eso some of these conditions are important. Patients will come to you with fears they'll come to you with concerns. Um, when we talk about the I, we mainly focused on, uh, four conditions cataract, glaucoma, diabetic retinopathy and diabetic macular oedema. Sure. Um so I often tell patients and I joke with them that you know, his doctors. We have all this education, all this training, But at the end of the day, you either have a plumbing problem or electric problem. That's very true when it comes to ocular complications. Um, just a quick review of anatomy. So if you're looking from the from the side of your head looking at your eye, um, the front of your eyes, the cornea, that's the clear party. I kind of like the face of your watch, followed by the Irish, which is the color part of your eye, then the lens, the retina and the optic nerve. Um, starting from the front of the eye cataract, it affects your lens. So when you're born, your lenses clear like a regular window. As you get older, it starts to frost over like a bathroom window. So as a cataract surgeon, you know, kind of Ah, window contractor on top of glaucoma specialist. A fancy plumber. Um, cataract leading cause of visual impairment. Diabetics five times more likely to have early cataract formation. Um, some people will think that cataract surgery can hasten progression of diabetic retinopathy. There's no data to support. This is very debatable. Clinically speaking, you know, that usually doesn't hold us back from doing cataract. Justus. Muchas patients can't see out. We cannot see in to look at the retina so we usually go forward with cataract surgery. Um, cataract surgery. One of the most successful surgeries in all modern medicine. 98 99% success rate. 15 minute procedure. Outpatient procedure usually done in a very minimal sedation. So a lot of your diabetics, with a lot of co morbidity still can often times get cataract surgery, modern day cataract surgery. It's a minimal incision surgery, no suitors, who is just a short video. We make too clear corneal incisions that we introduce a fickle multiplication ultrasonic probe that basically breaks up the cataract lens and a bunch of pieces, and we removed those pieces. Once the entire cataracts removed, we insert a prosthetic lens with a specific prescription to it that it helps patients see much clear, very safe procedure about 15 minutes or less. But oftentimes, very life changing next step is called coma. Glaucoma is an optic neuropathy that affects at first your peripheral vision. It's the second leading cause of blindness in the world, affects 2% of the US population, three times more common in African Americans and Latinos compared to Caucasians and the most common cause of blindness in African Americans, um, glaucoma is a plumbing problem to the I. Again, I'm just a fancy plumber. Um, some just basic anatomy. So the celery body, which is right behind the Irish the color party ride, produces the fluid. So that's the quickest humor. And this fluid, uh, what? Sorry about that. This food flows through your lens around your pupil around the IRS and out through a structure called the angle. The angle is where your cornea and your Irish meat, and that's basically the internal plumbing of your eye. now just to orient you here. If I was just to kind of rotate the pictures that I've shown you if I were to put Donald Trump standing right on the pupil in the lens, just like on the right here, looking out over the valley of your iris, the colored party, I this dark band here and the structures around it, that is the beginning of your angle. So basically the outflow facility of your eye. So the internal plumbing my whole career is just centered around this small structure on just like, you know, poorly draining, draining your house. You know, the fluid kind of backs up, and it's very similar in glaucoma for one reason. Whether the outflow facility, the internal plumbing goes bad. And when the internal plumbing goes bad, the fluid starts to back up and it starts to increase the pressure on your I. And when the pressure goes up, it could damage the optic nerve asses just the cable that connects your eyeball to your brain. When you look at the optic nerve, it looks just like a donut. You have the donut hole, which is the optic cup and the doughy part which is the optic disc. In glaucoma, that doughnut hole gets bigger, and as the donut hole gets bigger, you start to lose more that new room tissue and the more tissue lose, you start to lose your peripheral vision and sometimes all way towards the central vision. Um, there are many different types of glaucoma, but the two most associate with glaucoma or diabetes is primary. Open glaucoma, which you'll tend to see in your older patients in the vascular glaucoma, which you'll tend to see in your younger, more poorly controlled diabetics, the mainstay of treatment or eye drops. Basically, all the eye drops do is they either open up your drain a little bit more so increase your outflow facility or turn off your spout. So decrease Equus production. Um, there's no cure for glaucoma. All we can do is lower your eye pressure to prevent additional vision loss. When medical therapy fails, there's surgical options. There's many different types of glaucoma surgery from the minimally invasive end to the more invasive end. Here is just a short video of one of the minimally invasive procedures you see down here is a basically a cutter and cauterize is called the Trebek tome, and what we do is we insert it into the angle. So the outflow facility, the I, and we just cauterizing cut it open. Here I am placing a lens on the I to give better visualization of the structures. As you probably imagine. I don't drink coffee in the morning that I operate. Um, but here I am. Here's the cutter into the angle. And once it's inserted, Kateri begins, and we just literally cut open the internal plumbing of the eye or the outflow facility. Um, when that doesn't work, we bring our bigger guns in a way will sometimes install or implant called coma tube shunts basically install new plumbing to the I s. So what we do is we open it up here conjuring Taiba, which is basically the skin of the I, uh, exposing the underlying square of the white part of the eye and we insert this glaucoma tube shot. Here we are inserting the shunt That's pretty big. About 350 millimeters sometimes depending on the type of implant you use. Once we lock it down between the rectus muscles, we suitor down the implant to this, Clara. Once that structure down, we basically cut the tube to size. And then I make a little school Rostami, which is just a hole into the I, where we will insert the tube. Here we are inserting the tube on once the two for the new plumbing installed. We covered up with the content type, so we just bring the content type of back over the implant and we close everything up. It might be hard to see here, but you'll see the tube here. It's probably a little bit grainy. Um, that's okay. The next photo you'll see a new image, a still image of the tube inserted into the anterior chamber. Here, here's a picture of patient looking down. You'll see that plate that was implanted in future, down with the overlying hunting Taiba, and then the tube snaked into the eye. Next up is diabetic retinopathy. Diabetic retinopathy effects. Your retina, which is kind of like the film in the camera is the leading cause of blindness among working age Americans. Prevalence rate about 4.4% in the U. S. And essentially, the longer you have diabetes, the higher the chance of developing retinopathy. Um, there many different stages. So you have the mild, non prolific stage where you have small micro aneurysms in your retina and those things become more ischemic. You get more signs of ischemia, so exits and cotton wool spots a smaller. A swell is more interesting hemorrhages and more. In the prolific of stages, you get retinal knew of accusations, so new blood vessels grow in the retina. But these new blood vessels tend to be brittle. They tend to leak oftentimes so leak blood into the vitreous cavity, causing a vitreous hemorrhage. The neo vascular station, also called, cause contraction of the readiness of causing retinal detachment. The mainstay of treatment is way laser burn areas of ischemic retina. Um, Thio regress the neo vascular ization. So that's Ah pan Retinal photo coagulation Laser prp laser. It could be done in the office or in the operating room. Here. We are doing the trick to me to show you a quick video. We access the back of the eye with these attractive reports, and we put a laser probe inside. You'll see the laser probe here and the target here, and we essentially just burned little tiny holes into the retina. You'll start to see the laser burns here. Treatment is about 2 to 3000 laser burns in the retina, so it can be quite painful. Here is just a still image of a patient who's had prp laser. You'll see all these burns scars throughout the peripheral retina, with the central part the macula preserved. Um, a significant portion of these patients lose peripheral vision as a result of this last step is diabetic macular oedema eso The way you wanna think about the retina is just like a sandwich. You know, a sandwich has many different layers to it, and so does the retina. So there's O T C o C t scan, uh, takes cross sections of the retina so you'll see on the right. Here you'll see these different layers of the retina, and then you'll see this nice little dip here. That's the phobia or the center part of your vision, which gives you the clearest part of vision. Um, in diabetic macular oedema, the neo vascular ization. As I said before, the retina causes protein and blood to leak into the retina. Eso the way you want to think about it. It's just like a leaky pipe in your house. When you have a leaky pipe in your house, the sheetrock tends to swell up. Here's a picture of macular oedema on the right hand side. Here, you see these little cysts. We call them Interational cysts, this characteristic of macular oedema, the mainstay treatment. Intra vitriol injections So these patients get monthly anti VAT. Jeff. Some get steroid injections in the eye. It's highly effective, and I can promise you it looks bad, but it's not too painful from what I've heard. Oftentimes I'll tell my patients, though you know radio graphically. With these injections and treatment, we can get rid of the swelling, but sometimes one of that, you know, just like a leaky pipe in your house. Once you fix that leak, that sheet rock might be stained. It might never be the same, so it leads me. Sort of. The last part is prevention on barriers, So in terms of cataract, we recommend yearly dilated exams or screening photos for diabetics. Um, just some more information. You know there is no association with status and cataract formation, but their strongest there are strong associations with diabetes hypertension, obesity, metabolic syndrome with increased risk of cataract. Some of the barriers is what we all probably faces access to. Access to primary care, optometry and ophthalmology. The Los Angeles Latino I studied, which had thousands of subjects in the study. Almost almost 65% of the diabetic participants had not received dilate exam at the time of enrollment. Some other information in terms of glaucoma, Medicare, Medicaid services, cover glaucoma examinations for diabetics. But again, some bears or access to care. Um, and then a lot of times patients will come to me and they will say, Well, I had an optometry examine my eye Pressure is fine and you're telling me I have glaucoma. And then I have to explain to him that you can have normal pressure and have glaucoma. So the gold standard is normal or formal visual field testing, which is unfortunate, routinely done in terms of diabetic retinopathy. Diabetic macular oedema. As I said before, the longer you have diabetes, the more likely you'll have it, you know, the more likely you'll get retinopathy. Um, a one scene systolic Blood pressure, independent predictors of progression of diabetic retinopathy. Eso from an eye perspective. We recommended target A one C of 7% or lower on increased in a onesie corresponds to an increased risk of death. Diabetic macular oedema. So it kind of leads me sort of back to this slide. Um, you know, I think a lot of patients you know will come to me will come to you, and a lot of them will have fears of blindness. And I think, um gives us as clinicians a really good opportunity number one, um, to calm those fears to remind them that it's a possibility. But a lot of these ocular conditions are very treatable. Um, very treatable by seeing us Azzam ophthalmologist early on in the disease. Course on. Of course, being mawr compliant with their diabetes treatment. So it's kind of a cute too, You know, all of us Thio get these patients to the ophthalmologist as soon as possible. So usually the recommendations for type two diabetics toe have a dilated exam, a time of diagnosis and for type ones at five years after the diagnosis. Um, just one other thing is, you know, at scripts they have a very, very good running team. A couple guys that helped training many years ago. Very good. Ethical doctors. Very skilled clinicians. Um, and I think that's it. Thank you so much, Dr Nugent. That was very informative. And I know you're not getting live feedback from the audience, but I want you to know, I was laughing out loud at some of your images and things that you said so thank you very much.
