What every tech should What every tech should know about Diabetesknow about Diabetes

Lynn Lawrence, CPOT, ABOCLynn Lawrence, CPOT, ABOC

Tech vs RobotTech vs Robot Are you a robot?Are you a robot? Do you know how to thoroughly screen a Do you know how to thoroughly screen a

patient?patient? Are you informed or educated? Are you informed or educated? Are you an instrument monkey?Are you an instrument monkey? Can you educate your patients on their Can you educate your patients on their

conditions or do you expect your doctor to conditions or do you expect your doctor to perform that function?perform that function?

Is O.D. chair time valuable? Is O.D. chair time valuable?

US Statistics about DiabetesUS Statistics about Diabetes

• • 5th leading cause of death in U.S.5th leading cause of death in U.S. • • Approximately 2,700 Americans are diagnosed withApproximately 2,700 Americans are diagnosed with diabetes each daydiabetes each day • • Leading cause of adult blindness, end-stage kidneyLeading cause of adult blindness, end-stage kidney disease and lower extremity amputationsdisease and lower extremity amputations • • 60%-70% of people with diabetes have mild to severe60%-70% of people with diabetes have mild to severe forms of nervous system damageforms of nervous system damage • • $1 of every $10 of health care spending is spent on$1 of every $10 of health care spending is spent on diabetesdiabetes

Source: American Diabetes AssociationSource: American Diabetes Association

OverviewOverview DefinitionsDefinitions What is DiabetesWhat is Diabetes Types of DiabetesTypes of Diabetes Screening PatientsScreening Patients Established PatientsEstablished Patients Patient EducationPatient Education Test ResultsTest Results Diabetic RetinopathyDiabetic Retinopathy PhotographyPhotography Return/follow up visitsReturn/follow up visits

DefinitionsDefinitions Insulin – a hormone that controls blood Insulin – a hormone that controls blood

sugar…blood sugar can affect arteries, sugar…blood sugar can affect arteries, leading to heart diseaseleading to heart disease

Plaque – deposits of fat, cholesterolPlaque – deposits of fat, cholesterol Lipids – fat like substance in bloodLipids – fat like substance in blood Atherosclerosis – hardening of arteriesAtherosclerosis – hardening of arteries Angina – chest tightness and painAngina – chest tightness and pain Blood clot (embolus) – mass of blood cellsBlood clot (embolus) – mass of blood cells Stroke – damage to arteries to brainStroke – damage to arteries to brain

DefinitionsDefinitions Insulin is a Insulin is a hormone produced by the pancreas that produced by the pancreas that

regulates the level of regulates the level of glucoseglucose glucose, , a simple sugar that provides energy, in the a simple sugar that provides energy, in the

blood. blood. The human body requires a steady amount of The human body requires a steady amount of

glucose throughout the day, and that glucose glucose throughout the day, and that glucose comes from the foods people eat. Obviously, comes from the foods people eat. Obviously, though, people don't spend the entire day eating a though, people don't spend the entire day eating a bit of food at a time to maintain a steady stream of bit of food at a time to maintain a steady stream of glucose. This is where glucose. This is where insulininsulin comes into play. comes into play.

What is Diabetes Mellitus?What is Diabetes Mellitus? DM is a chronic disease with long term macrovascular and DM is a chronic disease with long term macrovascular and

microvascular complicationsmicrovascular complications Type 1 (body is not producing enough insulin) with medsType 1 (body is not producing enough insulin) with meds Type 2 (90%) can be controlled without medsType 2 (90%) can be controlled without meds Insulin resistant DM…growing concernsInsulin resistant DM…growing concerns Approx 26% of pt’s with type 1 and 36% of type 2 pt’s have Approx 26% of pt’s with type 1 and 36% of type 2 pt’s have

never had their eyes checkednever had their eyes checked Affects 20.8M Americans (7% of pop)…6M undiagnosedAffects 20.8M Americans (7% of pop)…6M undiagnosed Leading cause of death, disability/blindness ages 20-75 in USLeading cause of death, disability/blindness ages 20-75 in US Responsible for 10% of all new cases of blindness annuallyResponsible for 10% of all new cases of blindness annually Blood glucose over 250 is called hyperglycemiaBlood glucose over 250 is called hyperglycemia

ADA DefinitionADA Definition

A disease that affects the body’s ability to A disease that affects the body’s ability to produce or respond to insulin, a hormone produce or respond to insulin, a hormone that allows blood glucose (blood sugar) to that allows blood glucose (blood sugar) to enter the cells of the body and be used for enter the cells of the body and be used for energy.energy.

Two types: Type 1 and Type 2Two types: Type 1 and Type 2 55thth deadliest disease in the United States deadliest disease in the United States

(2005)(2005)

Two Categories of DRTwo Categories of DR Non-proliferativeNon-proliferative

Mild, moderate, severeMild, moderate, severe Cause by a development of microaneurysms in the Cause by a development of microaneurysms in the

capillary wallscapillary walls Venous bleeding, hard exudates, diabetic retinal edema Venous bleeding, hard exudates, diabetic retinal edema

(DRE)(DRE) Proliferative diabetic retinopathy (PDR)Proliferative diabetic retinopathy (PDR)

Occurs in 25% of Type 1 usually after 15yrs c DMOccurs in 25% of Type 1 usually after 15yrs c DM Most severe form…result from persistent and profound Most severe form…result from persistent and profound

retinal ischemia leading to neovascularization of retina retinal ischemia leading to neovascularization of retina and optic nerve retinal/vitreous hemorrhages, and retinal and optic nerve retinal/vitreous hemorrhages, and retinal scarring and fibrosis end in traction retinal detachmentscarring and fibrosis end in traction retinal detachment

Type 1 Type 1

Previously called insulin dependent Previously called insulin dependent diabetes (IDDM) or juvenile diabetesdiabetes (IDDM) or juvenile diabetes Insulin…helps to keep Body Mass IndexInsulin…helps to keep Body Mass Index

Injections are required for insulinInjections are required for insulin Body destroys pancreatic beta cells, the Body destroys pancreatic beta cells, the

only cells that make the hormone insulinonly cells that make the hormone insulin Beta cells…Beta cells…are in the pancreas are in the pancreas

Type 2Type 2

Previously called non-insulin dependent Previously called non-insulin dependent diabetes (NIDDM) or adult on-set diabetesdiabetes (NIDDM) or adult on-set diabetes

Associated with older-age, obesity, family Associated with older-age, obesity, family Hx, gestational, physical inactivityHx, gestational, physical inactivity

The pancreas makes insulin, but the body The pancreas makes insulin, but the body cells have trouble using it properlycells have trouble using it properly

Lifestyle changes can aid in treatmentLifestyle changes can aid in treatment

ContinueContinue

Diabetic eye disease is an Diabetic eye disease is an end-organ end-organ response to a systemic medical condition. response to a systemic medical condition. All structures of the eye and many aspects All structures of the eye and many aspects of visual function are susceptible to the of visual function are susceptible to the deleterious effects of DMdeleterious effects of DM

End Organ: a place where the blood End Organ: a place where the blood vessels loop through or terminatevessels loop through or terminate

SymptomsSymptoms Urinating more often, Urinating more often,

especially at nightespecially at night Blurred visionBlurred vision Fatigue or low energyFatigue or low energy Increased thirstIncreased thirst Increased hungerIncreased hunger Dry skinDry skin Slow healing woundsSlow healing wounds

What role does your office play?What role does your office play?

Optometrist are often the first health care Optometrist are often the first health care practitioners to examine patient’s with practitioners to examine patient’s with undiagnosed diabetes mellitus (DM) or undiagnosed diabetes mellitus (DM) or ocular manifestations of DMocular manifestations of DM

Timely diagnosis and appropriate referral Timely diagnosis and appropriate referral and interventionand intervention

Technician’s RoleTechnician’s Role

Provide the doctor with information in Provide the doctor with information in understanding the patient’s current conditionunderstanding the patient’s current condition

Identify any recent episodes involving vision Identify any recent episodes involving vision or overall healthor overall health

Understand and properly administer Understand and properly administer appropriate testappropriate test

Identify patient’s sign’s and symptoms of DMIdentify patient’s sign’s and symptoms of DM Understand the different modes of Understand the different modes of

interventionintervention Education and referralsEducation and referrals

Risk FactorsRisk Factors SugarSugar

travels through the blood and attaches to part of red blood travels through the blood and attaches to part of red blood cells called hemoglobin (carries oxygen to lung)cells called hemoglobin (carries oxygen to lung)

High blood sugarHigh blood sugar High blood sugar can cause damage to the arteries by High blood sugar can cause damage to the arteries by

affecting proteins in the artery wallsaffecting proteins in the artery walls Insulin resistance can lead to high blood pressure and Insulin resistance can lead to high blood pressure and

increased cholesterol levels through a complex metabolic increased cholesterol levels through a complex metabolic processprocess

High blood pressureHigh blood pressure Can cause arteries to become less elastic raises blood Can cause arteries to become less elastic raises blood

pressurepressure

ContributorsContributors

Eating too much food or sugary liquidsEating too much food or sugary liquids Not exercisingNot exercising Not taking diabetic medsNot taking diabetic meds IllnessIllness InfectionsInfections Stress Stress Weight Weight (can contribute,, but not the (can contribute,, but not the

deciding factor)deciding factor)

Patient Screening ChecklistPatient Screening Checklist If the patient has diabetes:If the patient has diabetes:

Ask Case Hx questions specifically about Ask Case Hx questions specifically about • What is your AlCWhat is your AlC(4.3-5.5)(4.3-5.5), latest BP, latest BP(120/80), (120/80), and cholesterol levels and cholesterol levels

((<100)<100)??• When was the last time you were tested?When was the last time you were tested?• What are you using to manage your diabetes?What are you using to manage your diabetes?• Is your glucose under control?Is your glucose under control?• Has your vision been stable since your last visit?Has your vision been stable since your last visit?• How do you feel today?How do you feel today?• Are you taking your meds and exercising?Are you taking your meds and exercising?• Is the patient a new or established pt?Is the patient a new or established pt?

Is the patient “New” or “Established”?Is the patient “New” or “Established”?

Cont…Screening a New PatientCont…Screening a New Patient

What should you look for:What should you look for: Is the patient African American (37.3%) or Is the patient African American (37.3%) or

Hispanic (42.9%)? Native Americans…Hispanic (42.9%)? Native Americans… Is the patient at risk for hypertension?Is the patient at risk for hypertension? Is the patient large waist up?Is the patient large waist up? Check blood pressure Check blood pressure

• Systolic – pressure when heart is pumpingSystolic – pressure when heart is pumping• Diastolic – blood force against artery between heart Diastolic – blood force against artery between heart

beatsbeats Last cholesterol check Last cholesterol check (HDL, LDL, and (HDL, LDL, and

triglycerides)triglycerides)

Cont….DM Established PatientsCont….DM Established Patients Ocular Exam Includes:Ocular Exam Includes:

Significant Case HistorySignificant Case History Vision (BCA)Vision (BCA) IOP…biomicroscopyIOP…biomicroscopy Blood PressureBlood Pressure Visual Field (Amsler Grid, HVT, etc…)Visual Field (Amsler Grid, HVT, etc…) Ocular motilityOcular motility Fundus Examination (new non-mydriatic technology Fundus Examination (new non-mydriatic technology

documentation, retinal imaging)documentation, retinal imaging) Caution if contraindications are requiredCaution if contraindications are required Color Vision TestingColor Vision Testing Confrontation FieldsConfrontation Fields Contrast Sensitivity TestingContrast Sensitivity Testing

• Those items in red should be done prior to seeing docThose items in red should be done prior to seeing doc

A1C (glycohemoglobin)A1C (glycohemoglobin) A1C test gives a perspective on diabetes managementA1C test gives a perspective on diabetes management Lower A1C levels helps to reduce and prevent diabetes complicationsLower A1C levels helps to reduce and prevent diabetes complications Directly relates to the average glucose concentration (mean blood glucose) Directly relates to the average glucose concentration (mean blood glucose)

in the body over the life span of red circulating red blood cells (RBC)in the body over the life span of red circulating red blood cells (RBC) Red blood cells live approximately 90-120 daysRed blood cells live approximately 90-120 days 1 percent rise in HbA1c increases retinopathy by 44%1 percent rise in HbA1c increases retinopathy by 44% The A1C test measures your average blood glucose control for the past 2 to The A1C test measures your average blood glucose control for the past 2 to

3 months. 4.3 – 5.5 is normal…Under 6% acceptable3 months. 4.3 – 5.5 is normal…Under 6% acceptable It is determined by measuring the percentage of glycated hemoglobin, or It is determined by measuring the percentage of glycated hemoglobin, or

HbA1c, in the blood. HbA1c, in the blood. Check your A1C twice year at a minimum, or more frequently when Check your A1C twice year at a minimum, or more frequently when

necessary. necessary. It does not replace daily self-testing of blood glucose.It does not replace daily self-testing of blood glucose. Story of ophthalmic techStory of ophthalmic tech

Risk Factors Cont…Risk Factors Cont… Smoking Smoking damages the lining of arteries allows damages the lining of arteries allows

build up of plaque and raise blood pressurebuild up of plaque and raise blood pressure

Inactivity make it harder for the heart to do its Inactivity make it harder for the heart to do its work…work…lack of activity lack of activity aids in the formation of aids in the formation of plaqueplaque

Over-weightOver-weight makes it harder for the body to use makes it harder for the body to use insulin and makes the heart work harderinsulin and makes the heart work harder

Helpful Screening InfoHelpful Screening Info Foot painFoot pain Dizziness spellsDizziness spells Heavy sweatingHeavy sweating Weakness, faintnessWeakness, faintness Nausea, vomitingNausea, vomiting Pain or pressure in back, Pain or pressure in back,

neck, jaw or armneck, jaw or arm Eating habitsEating habits Does patient track blood Does patient track blood

sugar?sugar? Supplement useSupplement use Is the patient vision stable?Is the patient vision stable? LethargicLethargic

Blurred visionBlurred vision Inflamed gumsInflamed gums Teeth painTeeth pain Clammy/Pale skinClammy/Pale skin ThirstThirst HepatitisHepatitis HTNHTN Medications are used Medications are used

to treat what defectto treat what defect Does the pt know Does the pt know

about DM?about DM? Alcohol useAlcohol use

Risk FactorsRisk Factors Obesity (120% over desirable body wt or 27% over Obesity (120% over desirable body wt or 27% over

body mass index)…for every 20lbs over wt…5% body mass index)…for every 20lbs over wt…5% higher risk for DMhigher risk for DM

First degree relative with diabetesFirst degree relative with diabetes African Am, Hispanic, Native Am, AsianAfrican Am, Hispanic, Native Am, Asian Delivered baby over 9lbsDelivered baby over 9lbs Hypertensive (BP over 140/90)Hypertensive (BP over 140/90) Cholesterol HDL lvl less than 35 or triglyceride lvl Cholesterol HDL lvl less than 35 or triglyceride lvl

greater than 250mg/dlgreater than 250mg/dl Has had Impaired Glucose Tolerance or Impaired Has had Impaired Glucose Tolerance or Impaired

Fasting Glucose on previous testingFasting Glucose on previous testing

Effects of SmokingEffects of Smoking

Vasoconstriction Vasoconstriction Venous dilationVenous dilation OxidationOxidation Free radicals…Antioxidants are Free radicals…Antioxidants are

substances in the blood that may protect substances in the blood that may protect cells from the damage caused by cells from the damage caused by unstable unstable molecules molecules known as known as free radicalsfree radicals

Slows healing processSlows healing process

ABCs to remember!ABCs to remember!

Recommended twice a year if controlled Recommended twice a year if controlled AA1C – covers 120 days 1C – covers 120 days BBlood Pressurelood Pressure CCholesterol holesterol

TriglyceridesTriglycerides Under 150Under 150

Blood Pressurenormal adultUnder 130/80

CholesterolLDL >100HDL < 40m/50w

A1CUnder 7% eAG *154

AB

C

Normal BodyNormal Body When we eat our body breaks down sugars, starches, When we eat our body breaks down sugars, starches,

and other foods into glucose or blood sugar, energyand other foods into glucose or blood sugar, energy

Glucose then enters bloodstream where it is transferred Glucose then enters bloodstream where it is transferred into tissue cells in all parts of the bodyinto tissue cells in all parts of the body

Glucose is either for immediate use or for later storage in Glucose is either for immediate use or for later storage in the the liver,liver, muscle, or fat for later muscle, or fat for later

Normal glucose levels are Normal glucose levels are 4.3 – 5.5 4.3 – 5.5 (70-108mg/dl)…(70-108mg/dl)…hypo levels below 4.3…hyper above 6.0hypo levels below 4.3…hyper above 6.0

Insulin is produced in the Insulin is produced in the pancreaspancreas and regulates blood and regulates blood sugarsugar

Blood Sugar LevelsBlood Sugar Levels

For people For people withoutwithout diabetes, according to diabetes, according to experts, blood sugar levels should be: experts, blood sugar levels should be: Between 70 and 120 mg/ dL Between 70 and 120 mg/ dL

For people For people withwith type 2 diabetes: Fasting type 2 diabetes: Fasting (not eating for a period of time): up to 130 (not eating for a period of time): up to 130 mg/dLmg/dL

After meals: less than 180 mg/dLAfter meals: less than 180 mg/dL Krispy Kremes storyKrispy Kremes story

Bodily FunctionsBodily Functions

Pancreas produces insulinPancreas produces insulin

Insulin regulates blood Insulin regulates blood sugar which is the energy sugar which is the energy glands use to produce glands use to produce hormones hormones

Hormones are the signals Hormones are the signals that tell glands what to dothat tell glands what to do

SomeSome Signs in End Organs Signs in End Organs

Eyes… Eyes… vision fluctuationsvision fluctuations

Teeth… Teeth… gum infection/blood sugargum infection/blood sugar Heart and Blood Vessels…Heart and Blood Vessels…

vascular circulationvascular circulation Nervous SystemNervous System Kidneys… Kidneys… bladder controlbladder control

Gastrointestinal…Gastrointestinal… bowel controls bowel controls

Feet… Feet… poor peripheral supportpoor peripheral support

*Ears… ringing sensation*Ears… ringing sensation

Control RoutesControl Routes

PatchPatch PumpPump OralOral InjectionInjection DietingDieting

Health Sight CounselingHealth Sight Counseling

Diabetic related ocular Diabetic related ocular complications continues to complications continues to be the most feared be the most feared complication of the diseasecomplication of the disease

Visual impairment occurs in Visual impairment occurs in 23.5% of pts over the age 23.5% of pts over the age of 50of 50

After 20 years, 40% of all After 20 years, 40% of all diabetic patients will diabetic patients will demonstrate some degree demonstrate some degree of diabetic retinopathy. of diabetic retinopathy. 20% vision threatening20% vision threatening

Ocular ComplicationsOcular Complications CataractsCataracts AMDAMD GlaucomaGlaucoma UVR retina related UVR retina related

ocular diseases ocular diseases Superoxide formation Superoxide formation

and lipid perioxidationand lipid perioxidation Contrast SensitivityContrast Sensitivity GlareGlare Color discriminationColor discrimination

Types of DiabetesTypes of Diabetes Type I…(age less than 30) destroys beta Type I…(age less than 30) destroys beta

cells in pancreas (faster in infants and cells in pancreas (faster in infants and children), children), absolute insulin deficiency, absolute insulin deficiency, needs drugsneeds drugs

Type II…most common, causes vary, 90% Type II…most common, causes vary, 90% of DM patients, most patients are of DM patients, most patients are asymptomatic and remain undiagnosed for asymptomatic and remain undiagnosed for years, years,

911 Time…don’t panic!911 Time…don’t panic! Prompt treatment… Prompt treatment… Louisiana storyLouisiana story Distress signsDistress signs

Shortness of breath or trouble breathingShortness of breath or trouble breathing Heavy sweatingHeavy sweating Tiredness, weakness, or faintnessTiredness, weakness, or faintness Nausea vomitingNausea vomiting DizzinessDizziness Pain or pressure in your chest, back, neck, jaw, Pain or pressure in your chest, back, neck, jaw,

or armor arm Awareness depravationAwareness depravation Loss of color Loss of color

Types of Diabetes Cont…Types of Diabetes Cont… Impaired Glucose Tolerance…most people have Impaired Glucose Tolerance…most people have

normal HbA1c levelsnormal HbA1c levels IRD (Insulin Resistant Diabetes)IRD (Insulin Resistant Diabetes) Gestational Diabetes…during pregnancy…4% of Gestational Diabetes…during pregnancy…4% of

pregnancies…no need to test if all criteria are pregnancies…no need to test if all criteria are met: under 25, normal wt, no 1met: under 25, normal wt, no 1stst degree relative, degree relative, not Hispanic, Native American, African AM, or not Hispanic, Native American, African AM, or Asian, during 24-28 wks…9lb indicates Asian, during 24-28 wks…9lb indicates

Other types…juvenile (genetics), age related Other types…juvenile (genetics), age related (growing baby boomers), stiff-man syndrome(growing baby boomers), stiff-man syndrome

Hypo vs Hyper glycemiaHypo vs Hyper glycemia

Low blood sugar/HypoLow blood sugar/Hypo Sudden onset symptomsSudden onset symptoms Poor coordinationPoor coordination

Difficulty maintaining balanceDifficulty maintaining balance Angry, moody temperAngry, moody temper Pale skin, colorationPale skin, coloration Confusion/disorientationConfusion/disorientation Sudden hungerSudden hunger Unnatural sweatingUnnatural sweating TremblingTrembling May result in unconsciousnessMay result in unconsciousness Eat high sugar foods/ no diet Eat high sugar foods/ no diet

drinksdrinks

High blood sugar/HyperHigh blood sugar/Hyper Gradual onset of symptomsGradual onset of symptoms SleepinessSleepiness Excessive thirstExcessive thirst Frequent urinationFrequent urination Flushed skin colorFlushed skin color Nausea, vomitingNausea, vomiting Fruity/wine like smelling breathFruity/wine like smelling breath Heavy breathingHeavy breathing May result in unconsciousnessMay result in unconsciousness If you are not sure if hypo or If you are not sure if hypo or

hyper, give a sugar containing hyper, give a sugar containing drinkdrink

Symptoms of DM1Symptoms of DM1 Polydipsia…abnormal amt of water intakePolydipsia…abnormal amt of water intake Polyphagia…excessive eating…ck emotional statusPolyphagia…excessive eating…ck emotional status Polyuria…release of large amts of urinePolyuria…release of large amts of urine Unexplained weight lossUnexplained weight loss Dry mouth…means pt has a dry mouth Dry mouth…means pt has a dry mouth Pruritus…anal itching Pruritus…anal itching Leg cramps or pain…Leg cramps or pain… Delayed healing in skin wounds, genitalia, or urinary Delayed healing in skin wounds, genitalia, or urinary

tracttract Absolute dependency on exogenous insulin to prevent Absolute dependency on exogenous insulin to prevent

ketoacidosis (ketoacidosis ((key-toe-ass-i-DOE-sis) is a serious condition that can (key-toe-ass-i-DOE-sis) is a serious condition that can lead to diabetic coma (passing out for a long time) or even death. lead to diabetic coma (passing out for a long time) or even death. Ketoacidosis may happen to people with type 1 diabetes) Ketoacidosis may happen to people with type 1 diabetes)

Peripheral neuropathy…loss tactile sensationPeripheral neuropathy…loss tactile sensation

Ocular ManifestationsOcular Manifestations Approx 5% develop glaucoma..Approx 5% develop glaucoma.. Pre-mature cataracts are 2-4 times more likelyPre-mature cataracts are 2-4 times more likely Retinopathy…bleeding inside of eyeRetinopathy…bleeding inside of eye Macular defects…central field lossMacular defects…central field loss Unstable VA’s…fluctuating hormones…Unstable VA’s…fluctuating hormones… Neovascularization on IrisNeovascularization on Iris Loss of corneal sensitivity…Descemet’s membrane wrinkling Loss of corneal sensitivity…Descemet’s membrane wrinkling

and delay healing (contact lens wearers)and delay healing (contact lens wearers) Sluggish pupillary reflexesSluggish pupillary reflexes Tear film deficiencies resulting in dry eyeTear film deficiencies resulting in dry eye Iris de-pigmentationIris de-pigmentation Tritan color deficiencies (blue)…short wave length/high Tritan color deficiencies (blue)…short wave length/high

energyenergy 25 times higher incidence of open angle glaucoma25 times higher incidence of open angle glaucoma

Neovascularization on IrisNeovascularization on Iris

Blood vessels Blood vessels growing in places growing in places where they don’t where they don’t normally grownormally grow

Explain picture!

Cystoid Macula EdemaCystoid Macula Edema Documented as “CME”…or Documented as “CME”…or

swelling of the swelling of the macula, , typically occurs as a result of typically occurs as a result of disease, injury or more rarely, disease, injury or more rarely, eye surgery.  Fluid collects eye surgery.  Fluid collects within the layers of the macula, within the layers of the macula, causing blurred, distorted causing blurred, distorted central vision.  CME rarely central vision.  CME rarely causes a permanent loss of causes a permanent loss of vision, but the recovery is often vision, but the recovery is often a slow, gradual process.  The a slow, gradual process.  The majority of patients recover in majority of patients recover in 2 to 15 months.   2 to 15 months.  

Macula PuckerMacula Pucker

Swelling in the Swelling in the maculamacula

Guide for AdultsGuide for Adults Blood Sugar ControlBlood Sugar Control

AlC less than 6% but if over 7% serious AlC less than 6% but if over 7% serious Blood sugar before meals 90-130 mg/dlBlood sugar before meals 90-130 mg/dl Peak blood sugar after meals <180mg/dlPeak blood sugar after meals <180mg/dl

Blood PressureBlood Pressure Normal 120/80 but <130/80 mmHgNormal 120/80 but <130/80 mmHg

LipidsLipids LDL >100 mg/dlLDL >100 mg/dl Triglycerides >150 mg/dlTriglycerides >150 mg/dl HDL HDL greater than 40 mg/dl for men 50mg/dl for womengreater than 40 mg/dl for men 50mg/dl for women

CarbohydratesCarbohydrates

Everyone has food boundariesEveryone has food boundaries All carbs are broken down in to glucoseAll carbs are broken down in to glucose Carbs are the body’s main source of foodCarbs are the body’s main source of food All carbs provide the same number of All carbs provide the same number of

caloriescalories Carbs are stored in the liver and used as Carbs are stored in the liver and used as

fuel reservesfuel reserves Extra carbs are stored as fat for later useExtra carbs are stored as fat for later use

SymptomsSymptoms

Casual plasma glucose of greater than or Casual plasma glucose of greater than or equal to 200mg/dl…no regard to last mealequal to 200mg/dl…no regard to last meal

Fasting plasma glucose greater than or Fasting plasma glucose greater than or equal to 126mg/dl…no meal 8 hrsequal to 126mg/dl…no meal 8 hrs

Two hour plasma glucose greater than or Two hour plasma glucose greater than or equal to 200mg/dl during an oral glucose equal to 200mg/dl during an oral glucose tolerance test using a 75-g glucose tolerance test using a 75-g glucose challenge (WHO) challenge (WHO)

What causes low blood sugarWhat causes low blood sugar

Blood sugar below 70 is called Blood sugar below 70 is called hypoglycemiahypoglycemia Delayed mealsDelayed meals Not eating enoughNot eating enough Too much medicationToo much medication Unplanned strenuous activityUnplanned strenuous activity Drinking alcohol on an empty stomachDrinking alcohol on an empty stomach If the patient is unconscious call 911If the patient is unconscious call 911

Symptoms of HypoglycemiaSymptoms of Hypoglycemia

Weakness Weakness Fast hear beatFast hear beat ShakinessShakiness Irritability or anxietyIrritability or anxiety Blurred visionBlurred vision Headache Headache Sweating Sweating Light-headedness Light-headedness

Diabetic RetinopathyDiabetic Retinopathy

Ruptured micro-Ruptured micro-aneurysmsaneurysms

Inter-retinal Inter-retinal hemorrhageshemorrhages

Hemorrhages in NFLHemorrhages in NFL New vessel growthNew vessel growth Venous bleedingVenous bleeding Lamellar holes Lamellar holes ExudatesExudates

Angiogram

PhotographyPhotography

Non-proliferative Non-proliferative Diabetic RetinopathyDiabetic Retinopathy

Proliferative Diabetic Proliferative Diabetic RetinopathyRetinopathy

Macula EdemaMacula Edema ExudatesExudates

SurgerySurgery

Severe irreversible Severe irreversible vision loss, peripheral vision loss, peripheral visual field lossvisual field loss

Laser Laser photocoagulationphotocoagulation

Helpful HintsHelpful Hints

Manage blood sugar within recommended rangeManage blood sugar within recommended range Aids in blood pressure/cholesterol levelsAids in blood pressure/cholesterol levels

Manage cholesterolManage cholesterol Eat less fat, fried foods, more fish, vegetables, lean Eat less fat, fried foods, more fish, vegetables, lean

meatmeat Manage by measuring blood pressure regularlyManage by measuring blood pressure regularly Treatment PRNTreatment PRN Lose weightLose weight Exercise 10 min per day at least 3 days a wkExercise 10 min per day at least 3 days a wk Foot care inspect for cracks, blisters, soresFoot care inspect for cracks, blisters, sores

Caution when you are ill!Caution when you are ill!

Check blood sugar @ Check blood sugar @ 4hrs4hrs

Keep a diary of foodKeep a diary of food Common illnesses that Common illnesses that

have serious have serious complications in complications in patients with diabetes:patients with diabetes: The fluThe flu Vomiting Vomiting DiarrheaDiarrhea

See your HCP if:See your HCP if: You have fever <101FYou have fever <101F Cold or flu last too longCold or flu last too long Nausea, diarrhea, or Nausea, diarrhea, or

vomiting last longer vomiting last longer than 4 hrsthan 4 hrs

Shakiness, light-Shakiness, light-headness, sweating, headness, sweating, or rapid heartbeat last or rapid heartbeat last for more than 4 hrsfor more than 4 hrs

Confusion/cant thinkConfusion/cant think

Tell Your PatientTell Your Patient

Drink plenty of non-caloric fluidsDrink plenty of non-caloric fluids Take your medication as prescribedTake your medication as prescribed Follow a meal planFollow a meal plan Exercise per Dr. instructionsExercise per Dr. instructions Check blood sugar before meals and bedCheck blood sugar before meals and bed Check your urine for ketonesCheck your urine for ketones Don’t do anything that may cause your Don’t do anything that may cause your

sugar level to become wacked outsugar level to become wacked out

5 categories of DM medications5 categories of DM medications

SulfonylureasSulfonylureas – stimulate the pancreas to produce more – stimulate the pancreas to produce more insulininsulin

MeglitinidesMeglitinides also stimulate the pancreas also stimulate the pancreas

BiguanidesBiguanides keep the liver from releasing too much keep the liver from releasing too much

Alpha-glucosidaseAlpha-glucosidase inhibitors slow the digestion inhibitors slow the digestion

ThiazolidinedionesThiazolidinediones makes muscle more sensitive to makes muscle more sensitive to insulininsulin

Contact Pt’s PHCPContact Pt’s PHCP

Send the findings to the Send the findings to the patient’s Primary Health patient’s Primary Health Care ProviderCare Provider

ReviewReview

What is DiabetesWhat is Diabetes Types of DiabetesTypes of Diabetes Screening PatientsScreening Patients Established PatientsEstablished Patients Diabetic MedsDiabetic Meds Test ResultsTest Results Diabetic RetinopathyDiabetic Retinopathy PhotographyPhotography Return/follow up visitsReturn/follow up visits

ADA TestADA Test

1. What are some risk factors for DM?1. What are some risk factors for DM? 2. Why is the A1C test important for managing 2. Why is the A1C test important for managing

blood sugar?blood sugar? 3. What ethnic groups is more at risk?3. What ethnic groups is more at risk? 4. What is considered a big baby for DM?4. What is considered a big baby for DM? 5. What is the ideal range for the A1C result5. What is the ideal range for the A1C result

ADA Test Cont…ADA Test Cont… 6. Name ocular complications assoc with 6. Name ocular complications assoc with

DM?DM? 7. Why is BP a concern for DM patients?7. Why is BP a concern for DM patients? 8. What is diabetes?8. What is diabetes? 9. What are the two different types of 9. What are the two different types of

diabetes?diabetes? 10. How is blood sugar measured?10. How is blood sugar measured?

Helpful ResourcesHelpful Resources Diabetes Education ResourcesDiabetes Education Resources American Association of American Association of

Diabetes Educators Diabetes Educators www.diabeteseducator.org1-800-338-3633 1-800-338-3633

American Diabetes AssociationAmerican Diabetes Association www.diabetes.org1-800-DIABETES (1-800-342-1-800-DIABETES (1-800-342-2383) 2383)

American Dietetic Association American Dietetic Association www.eatright.orgwww.eatright.org1-800-877-1600 1-800-877-1600

American Heart AssociationAmerican Heart Association www.americanheart.orgwww.americanheart.org1-800-AHA-USA1 (1-800-242-1-800-AHA-USA1 (1-800-242-8721) 8721)

Centers for Disease Control and Centers for Disease Control and Prevention Prevention www.cdc.gov/diabeteswww.cdc.gov/diabetes1-800-CDC-INFO (1-800-232-1-800-CDC-INFO (1-800-232-4636) 4636)

MerckMerckMedicusMedicus™™www.merckmedicus.comwww.merckmedicus.com1-800-489-5119 1-800-489-5119

National Diabetes Education National Diabetes Education ProgramProgramwww.ndep.nih.govwww.ndep.nih.gov1-800-438-53831-800-438-5383

National Diabetes Information National Diabetes Information ClearinghouseClearinghousewww.diabetes.niddk.nih.govwww.diabetes.niddk.nih.gov1-800-860-8747 1-800-860-8747

Credit for Reference MaterialsCredit for Reference Materials

Give reference materialsGive reference materials Credit for the information in the lecture goes Credit for the information in the lecture goes

to the AOA’s Clinical Practice Guidelinesto the AOA’s Clinical Practice Guidelines American Diabetes AssociationAmerican Diabetes Association National Institute of Eye HealthNational Institute of Eye Health Merck Patient Education on DiabetesMerck Patient Education on Diabetes

QuestionsQuestions

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