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    New strategies to assess the risk of diabetes-related vision loss

    ODs must go outside the lines of traditional eye care

     

    Go outside the lines

    We can start by targeting those at highest risk for developing diabetes with messages about prevention. Consider those with a positive family history of type 2 diabetes, overweight or obesity, sedentary lifestyle, people of color, high blood pressure, over age 40 years, with low fiber and plant food intake.17

    Additional risk factors include history of gestational diabetes, use of statin therapy (especially simvistatin, atorvaststain, and rosuvistatin) or thiazide diuretics, and serum vitamin D deficiency.18-20 Agouridid, Elliott, McDonnell

    Patients can be asked or surveyed about these risk factors as part of an eye examination and recommendations can be tailored to lower risk (see Table 1).

    Regarding ocular findings that predict development of diabetes, we know that refractive shifts, dry eye, and staphylococcal lid disease are linked to chronic hyperglycemia as, of course, is any unexplained retinopathy.21

    Related: Worldwide diabetes epidemic approaches half a billion

    Additionally, long-term exposure to elevated glucose causes accelerated formation of indissoluble glyco-protein molecules in the crystalline lens called advanced glycation endproducts (AGEs), which can now be quantified easily in-office with ClearPath DS120 (Freedom Meditech) to gauge metabolic risk long before blood glucose testing establishes a diagnosis.22 Cahn

    Recently, subclinical retinal microaneurysm formation as detected by multi-spectral imaging (MSI, Annidis RHA) has been strongly linked to insulin resistance and excess insulin production in adults without known diabetes, giving us a qualitative and quantitative tool for assessing the sentinel biological abnormalities underlying the development of type 2 diabetes (see Figure 1).23

    Some of these abnormalities may also be seen via OCT angiography (OCTA). Laboratory assessment of insulin resistance and hyperinsulinemia are almost never done outside of research settings, so this represents a chance for ODs to get ahead of the curve and counsel our patients.

    Low blood levels of the dietary carotenoids lutein and zeaxanthin that form the macular pigment are associated with increased risk of diabetic retinopathy, and low macular pigment optical density (MPOD) has been linked to type 2 diabetes.24,25 Macular pigment clearly plays a role in macular degeneration, which may progress more rapidly in patients with diabetes.25,26 MPOD is also something that can be easily measured in-office (QuantifEye MPS II, ZeaVision). MPOD improvements are likely after appropriate diet and especially supplement recommendations are made by optometrists and patient adherence is confirmed by follow-up testing.

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