4/18/19 Diabetes and Low Vision Rehabilitation: Past, Present, and Future Tina Mac Donald, OD, CDE, FAAO Western University of Health Sciences Eye Care Institute-Century City 2080 Century Park East, Ste., 800 Los Angeles, CA 90067 310.277.0120 tmacdonald@westernu.edu WADE Conference April 27, 2019 Disclosure to Participants Notice of Requirements for Successful Completion: For successful completion, participants are required to be in attendance in the full activity and complete the program evaluation at the conclusion of the educational event. Presenter Conflicts of Interest/Financial Relationships Disclosures: No conflicts exist. Disclosure of Relevant Financial Relationships and Mechanism to Identify and Resolve Conflicts of Interest: No conflicts of interest. Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity. Off-label Use: Participants will be notified by speakers to any product used for a purpose other than that for which it was approved by the Food and Drug Administration. Objectives • List the stages of Diabetic Retinopathy and other Ocular Complications. • Demonstrate familiarity with the terms and descriptions of Vision Impairment and Blindness and describe the significance of those terms. • Why is the Interdisciplinary relationship between Optometrists and Diabetes Educators important for those with Vision Loss? • List tools and adaptive techniques to help those with Diabetes and Vision Loss. 1
4/18/19 What Is (Low) Vision Rehabilitation Low vision services are provided to individuals with reduced visual acuity or visual field deficit that is not correctable by conventional spectacles, contact lenses or surgery. Even individuals with severe to total vision loss can maintain an active and independent lifestyle. The practice of low vision rehabilitation helps to maximize a visually impaired person's function, independence, and overall health. These services help patients move beyond the belief that "nothing more can be done" for their vision loss. Vision Impairment can be difficult for the person experiencing it as well the people that they interact with. Chronic Complications of Diabetes Heart and blood vessel disease, stroke, kidney failure, amputations, nerve damage, and Vision Loss 2
4/18/19 Statistics on Low Vision and Blindness • 25.2 million Americans are visually impaired • The number of Americans who report some form of visual impairment is expected to double by 2030 • Of those with Legally Blind Status, 76% have some useable vision Issues of Diabetes and Low Vision • Diabetes is the leading cause of blindness in those of working age • -95% of Type 1 and 60-80% of Type 2 will show signs of Diabetic Retinopathy in 15 years • 25% of all Diabetics have some form of retinopathy Diabetic Retinopathy in Pre- Diabetes? • Diabetic retinopathy has been found in nearly 8 percent with pre-diabetes ( Diabetes Prevention Program (DPP) 3
4/18/19 Dilated Exams Type First DFE Follow-up 1 5 Years after onset Yearly 2 time of diagnosis Yearly* * Or as indicated by the clinical findings (American Academy of Ophthalmology, AOA ) According to the Centers for Disease Control (CDC), every 15 minutes someone with diabetes loses their vision to diabetic eye disease 50% of all blindness could be prevented Diabetic Retinal Disease • Diabetic Retinopathy and/or Diabetic Macular Edema • Most common microvascular complication of Diabetes • Often asymptomatic early on • Vision Loss primarily due to DME, Vitreous hemorrhage, or tractional retinal detachment 4
4/18/19 Diabetic Retinal Disease • Occurs in well defined stages (vision does not always correlate with stage) • DME may appear at any stage (break down of blood retinal barrier that causes fluid at macula) Diabetic Retinopathy Study and Early Treatment of Diabetic Retinopathy Study Standardized classification of levels of Diabetic Retinopathy Nonproliferative Diabetic Retinopathy (NPDR) • Mild- at least one retinal microaneurysm, but less than Arlie House photo 2A • Moderate- Hemorrhages/Microaneurysms more than above in one 2-3 quadrants, Venous Beading, soft exudates (cotton wool spots), and intra retinal microvascular abnormalities may be present 5
4/18/19 Nonproliferative Diabetic Retinopathy (NPDR) • Severe- any One of the following: Hemorrhages/Microaneurysms >or = 2A in 4 quadrants • Definite Venous beading in 2 or more quadrants • Prominent Intra retinal abnormalities (= or > photo 8A in at least one quadrant) Nonproliferative Diabetic Retinopathy (NPDR) • Very Severe- Two or more criteria for severe • Over a 75% chance of developing Proliferative Diabetic Retinopathy in one year Proliferative Diabetic Retinopathy (PDR) • Most sight threatening form of Diabetic Retinopathy • Neovascularization, fibrous proliferation, pre-retinal hemorrhage, vitreous hemorrhage 6
4/18/19 PDR • PDR is characterized by Neovascularization • High Risk PDR- characterized by 3 or 4 - presence of pre-retinal or vitreous hemorrhage -presence of new vessels - presence of new vessels on or near the disc (NVD) - presence of moderate or severe new vessels Diabetic Macular Edema (DME) • Retinal thickening within 2 disc diameters of the center of the macula • Clinically Significant Macular Edema (introduced by the ETDRS) signifies an increased risk of moderate vision loss. CSME • Thickening of the retina < or = 500 microns (1/3 disc diameter from the center of the macula) • Hard exudates < or = 500 microns (1/3 disc diameter from the center of the macula) with thickening of adjacent retina • A zone of zones of retinal thickening > or = 1 disc area in size any portion of which is < or = 1 disc diameter from the center of the macula 7
4/18/19 DME • Non-Central Involved retinal thickening in the macula that does not involve the center subfield zone that is 1mm in diameter • Center involved- does involve the central subfield zone Non-Retinal Changes • Loss of Acuity • Changes in Refraction • Changes in Color Vision • Accommodative Dysfunction • Eye Movement Abnormalities • Pupillary Reflex changes • Conjunctival Changes Non-Retinal Changes • Tear Film Abnormalities • Corneal Issues • Lens changes (cataracts) • Vitreous degeneration • Optic Disc changes • Open Angle Glaucoma 8
4/18/19 AOA Clinical Practice Guidelines: Eye Care of the Patient with Diabetes Mellitus • Evidence-based • National Clearing House • https://www.aoa.org/Documents/EBO/ EyeCareOfThePatientWithDiabetesMellitus %20CPG3.pdf Retinopathy Risk tools History of Vision Impairment • Ancient Times- blind babies abandon • Prior to the Middle Ages- Sold into slavery • Middle Ages- Alms houses • 1784 : The first "school for the blind" was established in France in 1784 • 1809 : Louis Braille born 9
4/18/19 • 1943: The federal vocational rehabilitation act was amended specifically to include the blind • 1975: Congress passed the first law requiring that public schools accept handicapped students in "the least restrictive environment." • Effective communication and collaboration with the rest of the diabetes care team results in optimum patient care and decreased overall costs A study conducted by the Center for the Partially Sighted showed that regular input and guidance had a positive impact on patients’ HbA1c levels, even in visually impaired individuals. (Thompson P. Psychological Counseling and Support Groups. http://lowvision.org/ en/Our_Services_Psychological_Counseling_And_Support_Groups) 10
4/18/19 Collaborating with Optometrists The best way to establish good working relationships is through personal contact. Start by sending a letter of introduction and requesting a face-to-face meeting. Mention that you’ll be following up with a phone call. This can prevent awkwardness, because the other health care provider will already be somewhat familiar with you. During the meeting, be sure to ask how the provider best receives information. Many busy professionals ask staff members to file report letters that come in the mail, and may never read them until the patient comes in for a visit. A “to the point” e-mail or voicemail may be equally or even more effective. Additionally, professionals are now requesting e-mail referrals, where photos or other pertinent information can be attached. Low Vision Definitions • Visually Impaired • Partially Sighted • Legally Blind • Functionally Blind 11
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