Diabetes and Low Vision Rehabilitation: Past, Present, and Future - - PDF document

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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.

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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

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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)

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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
• f Diabetes
• Often asymptomatic early on
• Vision Loss primarily due to DME,

Vitreous hemorrhage, or tractional retinal detachment

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Diabetic Retinal Disease

• Occurs in well defined stages (vision does

not always correlate with stage)

• DME may appear at any stage (break down
• f 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

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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

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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
• f 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

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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

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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

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• 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

• n 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)

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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

• ther 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

• r other pertinent information can be attached.

Low Vision Definitions

• Visually Impaired
• Partially Sighted
• Legally Blind
• Functionally Blind

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Vision Aids may help patients psychologically by improving mood

• A study of 584 low vision patients found

that people who used optical aids, either traditional or electronic, suffered measurably less depression than those who did not have such help. (nytimes.com/2004/04/06/health/

06EYE.html)

Specific Functional Needs of the Person with Diabetes

Visually impaired persons with diabetes have specific functional needs that must be addressed in the low vision examination. Many of these are crucial to their health and safety.

Common Tasks for People with Diabetes

• Reading Labels (food, medicine bottles)
• Checking Blood Glucose levels/ Blood Pressure
• Administration of Insulin and other medication
• Foot care
• Things pertaining to color vision/ contrast
• Driving (especially at night- post PRP- prior to

Anti VEGF, glare anytime)

• Night Vision (anytime post PRP-prior to Anti

VEGF)

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Case Study

• D.R.
• 52 year old Caucasian male
• POHx: Patient reports that vision had decreased
• ver the last several years. OAG x 7 years.
• PMHx: Type 2 Diabetes x 15 years.
• FOHx: unremarkable
• FMHx: unremarkable
• Allergies: PCN
• Meds: 70/30 insulin 12 units am, 12 units pm

Xalatan, hs

• Blood Sugar reading- Patient measures 3-4x

per day. Last reading was 130 mg/dl before eating breakfast.

• HbA1c- 6.0

Goals

• Golfing
• Glare
• Measuring Blood sugar and administering

insulin

• Administering eye gtts.

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Acuity

• OD-PR (sc): 10/100
• OS-PR (sc): 10/100
• OD-BVA: Plano DS
• OS-BVA: Plano DS
• Near VA
• OD: 5M (33 point, 7cm) @ 20 cm (8”)
• OS: 5M @ 20 cm
• Ocular Health
• SLE:

Lids/ Lashes- clean, OU Conj.- 1+ injection Cornea- 1+ arcus, OU. Iris- blue, flat, OU Lens- 2-3+ brunescence, OU Vitreous- 2+ syneresis, OU Visual Field: full, OU

• GAT

OD: 15 mmHg OS: 17 mmHg @ 10:21 pm Pupils equal, round, 2+ reactive to light, OU

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Posterior Segment

C/D: 0.5 round OD, 0.5 V x .6 H OS media: clear margins: distinct, OU rim: P&H macula: scarring and focal laser marks

• Post. Pole: PRP, OU

My Recommendations

Goal 1) Golfing Plano grey sun lens (U22 fade to clear with UV 400. +12.50 round seg. Add to see the scorecard. 6x telescope to view the green from a distance, to read the “lay” of the green and to inspect hazards

U-series Filters

NoIR makes 25 colors in the UVShields

• RP patients tend to like Yellowish-Amber
• Diabetic Retinopathy tend towards Plum,

Grey, Green, and Amber

• Glaucoma tends toward Grey and Green

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Corning CPF Filters

• The CPF 450 yellow is good for Macular

Degeneration and Optic Atrophy.

• Orange 511 is useful for Macular Degeneration,

Glaucoma, and Cataracts. The CPF 450 yellow is good for Macular Degeneration and Optic Atrophy.

• The CPF 527 is an orange amber tint that is useful

for patients with greater photophobia, for instance those with Diabetic Retinopathy and Retinitis Pigmentosa

• Patients with Retinitis Pigmentosa and Albinism

may prefer CPF 550 which is orange-red in color.

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Specwell Monocular Telescopes

• Intended for distance spotting tasks
• Used for mobility
• Used for student
• Power options: 2x up to 20x
• A neon green ball was most visible to D.K. and he

was instructed to paint his putter black and to mark the “sweet spot of his clubs with yellow electrical tape.

• Finally, D.K. signed up for lessons with a PGA

professional familiar with the needs of a visually impaired golfer.

• Since D.K. does have legally blind status, USGA

modifications apply.