Ocular Abnormality- Diabetes

Front 1

What is Diabetes Mellitus?

Back 1

• Ametabolic disorder

• Defective Insulin secretion/action/both

• Effects include long-term organ dysfunction & failure

Front 2

When was the earliest known record of diabetes?

Back 2

1550BC

Front 3

What is the worldwide (Global Reporton Diabetes, WHO, 2016) for 1980?

Back 3

108 million diabetics (4.7%)

Front 4

What is the worldwide (Global Reporton Diabetes, WHO, 2016) for 2014?

Back 4

422 Million diabetics (8.5%)

Front 5

Name the current 7 countries with more than 10 million diabetics.

Back 5

• China

• India

• USA

• Brazil

• Russian Federation

• Mexico

• Indonesia

Front 6

How many people in the UK have diabetes?

Back 6

>1 in 16 people in UK have diabetes (diagnosed/undiagnosed)

• 3.5 million diagnosed diabetics

• 549000 people with undiagnosed diabetes

Front 7

What is diabetes a minor cause of?

Back 7

• Blindness

• Kidney failure

• Heart attacks

• Strokes

• Limb amputation

Front 8

How much of the NHS budget is spent on diabetes?

Back 8

10%

£10 billion

Front 9

What is the function of the pancreas?

Back 9

Dual function:

• Exocrine- (95% tissue)

• Endocrine

Front 10

What is the Exocrine function of the pancreas?

Back 10

Aids digestion-secretes enzymes digest proteins, fats & carbohydrates

Front 11

What is the endocrine function of the pancreas?

Back 11

• Regulates blood glucose

• Islet cells release hormones in to blood stream

Front 12

What does insulin do?

Back 12

Lowers blood sugar

Front 13

What does glucogon do?

Back 13

Raises blood sugar

Front 14

What does somastatin do?

Back 14

Controls sugar/salt

Front 15

Name the cells in a pancreas?

Back 15

• Islets of Langerhans (<5%)

• Alpha Cells (Glucagon,75%)

• Beta Cells (Insulin, 20%)

• Delta Cells (Somastatin, 5%)

Front 16

What is blood regulation essential for?

Back 16

For normal brain, kidney and liver function.

Front 17

Insulin release is stimulated by what?

Back 17

High blood glucose

• Muscles, red blood & fat cells absorbs glucose from the bloodstream

• decrease in Glucose

Front 18

What stimulates the release of glucagon?

Back 18

Low blood glucose

• Acts on liver to release glucose into blood stream

• Induces liver to synthesise glucose from other nutrients & breakdown ofenergy stores

Front 19

What is Glycogen?

Back 19

stored form of glucose (in muscles/liver)

• Useful store of energy for exercise

Front 20

Glucagon release stimulates what?

Back 20

Glucagon release stimulates breakdown of Glycogen 》 Glucose

Front 21

What are the 2 types of Diabtes Mellitus?

Back 21

Insulin Deficiency (Type 1)

Insulin Resistance (Type2)

Front 22

What is type 1 diabetes?

Back 22

• Destruction of pancreatic Betacells

• Depletion of insulin stores

• Variable rate of cell destruction

• Symptoms present when majority of cells are destroyed

Front 23

What is type 2 diabetes?

Back 23

• Inefficient response to Insulin (absorption)

• Results in increased demand for insulin production

• Increased insulin demand outweighs supply

• Eventual impaired insulin production

Front 24

What is Hyper-glycaemia

Back 24

• High blood glucose (fasting blood glucose >7mmol/L

Front 25

What causes Hyper-glycaemia?

Back 25

• Absent/defective insulin

• >>Carbohydrates

• Missing diabetic medication/insulin dose

• Stress

• Poor health/infection

Front 26

What are the symptoms of Hyper-glycaemia?

Back 26

Inceased:

• urination

• thirst

• fatigue

• hunger

Front 27

What Is Hypo-glycaemia?

Back 27

Low blood glucose (<4mmol/L)

Front 28

What causes hypo-glycaemia?

Back 28

• >dose diabetic medication

• Delayed meal, Exercise

Front 29

What are the symptoms of hypo-glycaemia?

Back 29

• Sweating, fatigue, dizzy

• Pale, weak, hunger

• Confusion, Convulsions ,Coma (extreme)

Front 30

What is Keto-acidosis?

Back 30

Very raised blood glucose

(>15mmol/L T1>>>T2)

Front 31

What causes Keto-acidosis?

Back 31

• Missed insulin injections/faulty insulin pump or pen

• Infection, Alcohol, Drugs, extreme or prolonged stress

• Prior to T1 diagnosis

Front 32

What are the symptoms of Keto-acidosis?

Back 32

• Vomiting, Dehydration, Sweet smelling breath (peardrops)

• Hyperventilation, Tachycardia

• Confusion, disorientation, Coma & Death

Front 33

Diabetes classification

Back 33

• Type 1- usually early onset (approx.10%)

• Type 2- usually later onset (approx.90%)

• Adults - 56% Males, 44% Females

Front 34

Describe Type 1 diabetes.

Back 34

• No association with body weight

• Ketones may be present at diagnosis

• Usually symptomatic

• Requires insulin management

• Cannot be prevented

Front 35

Describe Type 2 diabetes.

Back 35

• Often weight associated

• High BP/cholesterol at diagnosis

• May be asymptomatic

• Maybe controlled with diet/medication,

some may need insulin

• Maybe prevented (education)

Front 36

What are the risk factors associated with type 1 diabetes?

Back 36

• Debated

• Viral exposure

• Geography (Northern climates)

• Ethnicity (<China,>USA Caucasians)

• Family history

• Other auto-immune conditions

Front 37

What are the risk factors associated with type 2 diabetes?

Back 37

• Family history

• Ethnicity, Age>40y/o

• BMI>30, Poor diet

• Smoking, Sedentary

• Previous gestational diabetes or large baby

• High BP/Cholesterol, Poly-Cystic Ovary Syndrome

Front 38

What is Gestational diabetes?

Back 38

• Diabetes in 2nd/3rd trimester (usually resolves post natal)

• Foetal growth demands increased insulin demand (2nd trimester)

Front 39

What are the risk factors of gestational diabetes?

Back 39

• Maternal obesity, Family history ofdiabetes

• Previous history of gestational diabetes or large baby (>10lb)

• Ethnicity: South Asian, African-Caribbean, Middle Eastern

Front 40

What drugs are used to treat diabetes?

Back 40

• Biguanides (e.g. Metformin)

• Sulphonylureas (e.g. Glicazide, Tolbutamide)

Front 41

What types of insulin are there?

Back 41

• Animal (<common)

• Human (synthetic match)

• Analogues (c. 1990’s)

Front 42

Speed of action of insulin?

Back 42

• Short/rapidacting: 0-5h

• Long acting: back ground cover 12-24h

• Ultra-long : up to 42 hours

Front 43

Name the 3 chronic complications associated with diabetes.

Back 43

Macro-vascular disease

Microvascular disease

Front 44

What is Macro-vascular disease?

Back 44

• a disease of any large (macro) blood vessels in the body.

• Increased risk of CVD, M.I & Stroke

• Arterial wall chronic inflammation& damage

• General atherosclerosis (arterial narrowing)

• Lipid rich atheroma formation (prone to rupture)

• Increased platelet adhesion 》vascular occlusion

Front 45

Name the 3 components of Microvascular disease?

Back 45

• Retinopathy (DiabetesII)

• Neuropathy-nerve fibre damage from disrupted vascular supply

• Nephropathy-changes in kidney structure affect function leading to leakage of proteins into urine

Front 46

What sensory neuropathy?

Back 46

• Reduced touch/temperature and pain sensation (tingling, numbness, burning shooting pains)

• Minor injuries may be ignored (e.g. progress to foot ulcers)

Front 47

What is autonomic neuropathy?

Back 47

Reduced supply to organs e.g. bladder, stomach

Front 48

What is motor neuropathy?

Back 48

Muscle weakness, wasting leg twitch, cramps.

Front 49

What is kidney disease Nephropathy?

Back 49

Slow destruction of small arteries involved in waste filtration.

Can affect both type 1&2

Front 50

What are the signs and symptoms for kidney disease Nephropathy?

Back 50

• Swollen feet/ankles, Dark urine

• Breathlessness, Fatigue, Nausea, vomiting

Front 51

How to control/manage kidney disease Nephropathy?

Back 51

Early stages:

• Diet, exercise

• Tight diabetic & BP control

• ACE inhibitors - protect kidney function and BP

Late/End stages:

• Macro-albuminuria- indicates kidney failure

• Kidney dialysis / transplant

Front 52

What is this?

Back 52

Xanthelasma

Front 53

What is Xanthelasma?

Back 53

• Assymptomatic

• Yellow plaque

• Usually superior lid

• Altered and elevated lipid metabolism

• Poor diet

• Poorly controlled diabetes

Front 54

How do you treat/manage Xanthelasma?

Back 54

• Refer for blood lipid profile

• Cardiovascular work up

• Cosmetic removal

Front 55

What is this?

Back 55

Orbital Mucormycosis

Front 56

What is Orbital Mucormycosis?

Back 56

• Fungal infection of facial sinus/orbit

• Associated with poor diabetic control & ketoacidosis

• Rare/fatal condition

• Immediate referral

Front 57

What are the corneal manifestations of diabetes?

Back 57

• Slow wound healing- Recurrent corneal erosions

• Corneal hypo-anaesthesia- sensory neuropathy

• >Dry eye- neuropathy &/or vascular changes to lacrimal gland

• Descemet’s membrane- vertical wrinkles may present prior to Type 2 diagnosis

• Impact on contact lens wear

Front 58

What are the ciliary body and iris issues with diabetes?

Back 58

• Uveitis

• Iris pigment epithelial loss

Front 59

What can happen to he rx with px with diabetes?

Back 59

• Myopia is greater in diabetics- possible increased lens thickness

• Fluctuating refractive error- poorly controlled glucose levels

Front 60

What is this?

Back 60

Cataracts in diabetics

Bilateral ‘Snowflake’ opacities

Front 61

Cataracts in diabetics.

Back 61

• Significantly > risk in diabetics but presents at earlier age

• Appears as normal cataract in diabetics, faster progression

• >Cortical changes

Front 62

What is this?

Back 62

Vitreous-Asteroid Hyalosis

Front 63

What is Vitreous-Asteroid Hyalosis?

Back 63

• Small white / yellow ‘shiny’ vitreous opacities

• Ca2+ & phosphate deposits

>Prevalence in diabetics & high BP/Cholesterol

Front 64

What causes Primary Open Angle Glaucoma diabetic px's?

Back 64

• Microvascular damage impairs blood flow to anterior optic nerve

• Raised BP affects vascular perfusion of optic nerve

• >IOP sensitivity compared to non-diabetics

• Diabetics show> severe field loss

Front 65

What causes Primary Angle Closure Glaucoma in diabetics?

Back 65

• <common

• Increased lens thickness (sorbitol overload)

• Neuropathy of pupil nerves

• Usually highly symptomatic

• AC angle & IOP check essential

• Acute attacks will require immediate referral

Front 66

What is this?

Back 66

Diabetic papillopathy

• Rare, Unilateral/Bilateral

• Can affect type 1& 2

• No proven link with diabetic control

• Assymptomatic 》mild VA loss (slow progression)

Front 67

Name the non-retinal ocular manifestations of diabetes.

Back 67

• Xanthelasma

• Orbital Mucormycosis

• Cornea, ciliary body and iris issues

• Refractive shift:

- sustained changes

- transient changes

• Cataracts- snowflake, getting them earlier

• Vitreous asteroid Hyalosis- higher prevalence

• Primary Open Angle Glaucoma

• Primary Angle Closure Glaucoma

• Diabetic papillopathy

• III N Palsy

• VI N Palsy

Front 68

What is III N Palsy?

Back 68

• Microvascular ischaemia

• Eye is ‘down & out’

• Ptosis (may mask diplopia)

• Pain (unknown origin)

• Majority ‘pupil sparing’

• Spontaneous recovery by 3/12

Front 69

What is VI N Palsy?

Back 69

• Defective lateral rectus

• Affected eye cannot abduct

• Horizontal diplopia