Melanie Cole (Host): Diabetes is an important health problem and it could carry with it ocular complications. These complications associated with diabetes are progressively and rapidly becoming the world’s most significant cause of morbidity and are preventable with early detection and timely treatment. My guest today is Dr. Shilpa Register. She’s a Clinical Assistant Professor in the Department of Ophthalmology at UAB Medicine. Welcome to the show, Dr. Register. So, tell us about some of the ocular complications associated with diabetes.

Dr. Shilpa Register (Guest): Well ,thank you, Melanie. You know, with diabetes, there are actually a lot of complications. I think the first thing that most people think about is the diabetic retinopathy that comes from the systemic consequences but, in addition, there’s higher likelihood of infections, greater instance of cataracts, and a variety of other ocular related issues including vision, fluctuations, and things of that nature that really are clues for patients to see their eye care provider to ensure that they’re receiving the care that they need and ensure that we can catch things pretty early.

Melanie: Is there a strong relationship between chronic hyperglycemia if they’re having trouble controlling their blood glucose and the development of diabetic retinopathy?

Dr. Register: There is. You know the higher, the less control that a patient is and the longer that they’ve had diabetes, the more likelihood they have of diabetic retinopathy. So, we have, many times, patients who are only been diagnosed and on treatment for less than two or three years and have significant diabetic retinopathy because of the swings in their blood glucose. And then, we have others that can go 10-15 years without having some complications. So, I think the key for us and what I tell patients a lot of the time is that steady, constant control. So, not having those spikes throughout the day really will definitely help.

Melanie: Speak about some of the current therapies including metabolic control or glycemic control.

Dr. Register: So, as far as current therapies for optometrists and ophthalmologists, we definitely, when we see our patients, we try to ensure that we coordinate care with the endocrinologist then ensure that we’ve got a good A1C and a good understanding of how long they’ve had diabetes and how well it’s been controlled. On our end, a lot of the treatment is based on the grade and the stage of the diabetic retinopathy. Many times, it’s monitoring patients but depending on the severity, there is sometimes the need for intravitreal injections as well as other surgical treatment for our patients. You know, what I think the key that I always tell my patients is, if you can see a difference in your vision, then it likely is a little bit too late. So, a lot of it, for me, goes into kind of prevention and ensuring that they are getting checked even if they’re not having any kind of symptoms so that if we’re starting to see some bleeding in the back of the eye, that we can go ahead and work with the healthcare team to ensure that we’re getting their blood sugar back down to where we need it to be.

Melanie: And, speak about the intravitreal medication or injections for a minute. When are those indicated?

Dr. Register: So, intravitreal injections are indicated both for diabetic macular edema as well as proliferative diabetic retinopathy. The diabetic macular edema can really happen at any stage of the retinopathy and that’s swelling of the macula or fluid accumulation that sometimes can affect the patient’s vision but often times doesn’t. The proliferative diabetic retinopathy is more later-stage retinopathy. So, you have two different classifications: non-proliferative and proliferative. With the proliferative diabetic retinopathy, you have hypoxia to the retina as well as new blood vessel growth. And those new blood vessels, they are quite weak so they tend to bleed. With that bleeding comes loss of vision. The intravitreal injections that our ophthalmologists do will help to reduce that bleeding and hopefully improve their vision back to where at least it was. And then, that’s coordinated with the endocrinologist and the medical management should hopefully get us to a better point.

Melanie: Are those temporary or do they have to be redone?

Dr. Register: Typically, they do need to be redone. It really just depends on how well the patient is controlled.

Melanie: Are there complications such as elevated intraocular pressure or infection? Can those occur with intravitreal steroids?

Dr. Register: You know, with IV steroids, yes, most definitely your pressure can go up and infection is always a risk with any kind of surgical procedure, anything that you’re putting in the eye. With diabetics, that’s a little bit higher because their healing rate isn’t as good. We definitely, when we do the intravitreal injections, we do some topical antibiotics and sometimes oral antibiotics as well just prophylactically, but I typically haven’t seen very many complications.

Melanie: So, then, speak about cataracts and glaucoma as ocular manifestations of diabetes and where do they come in.

Dr. Register: So, I’ll start with cataracts because there’s definitely a correlation with cataracts and diabetes. With the systemic effects of diabetes, most of our patients will get cataracts earlier and usually more severe. That’s just more due to their overall health and their ability to kind of process the antioxidants as well. So, with diabetics, they do get cataracts earlier. They also are at a little bit of higher risk for postoperative infections as well in cataract surgery. So, with cataract surgery, we really need to make sure that our diabetics are in the best control that they possibly can be so that one, when we go in for the cataract surgery, everything goes well and that there aren’t any other risks for infection as well as neovascular glaucoma is a risk. And so, that’s the risk post cataract surgery but it’s also a risk kind of in general. So, that’s a different type of glaucoma than kind of I would say your typically open angle glaucoma. The neovascular glaucoma is due to new blood vessel growth again and so that goes hand in hand with that proliferative retinopathy or inability to get enough oxygen to the tissues as it needs to. So, those are kind of your two major risks that also go hand in hand with the diabetes.

Melanie: And, speak about the current therapy for glaucoma neuropathy and for cataract. What are you doing?

Dr. Register: So, for cataracts, typically, cataract surgery is our number one thing and it really depends on, for my diabetics, in particular, if they’re under good control is number one. But, then, also for cataracts in general, it depends on how that cataract is affecting their daily activities. So, we want to make sure that it’s visually significant, that it’s interfering with driving or distance or something of that nature, as well as sometimes cataract can cause your pressure to go up. So, there are a lot of different things that we look at. We discuss the risks and benefits with patients and the cataract surgery typically takes, for the patient, it will take a few hours technically from pre-op to when it’s done. But it’s an outpatient procedure and then we do all of the postoperative care as well. For glaucoma, we usually will do some topical drops, glaucoma drops to the patient. There’s a variety of different types of drops, so depending on the patient’s anatomy, depending on their race, their risk factors, their compliance, we can mix up a different set of glaucoma meds that really will keep that pressure under control. For glaucoma patients, we watch them anywhere from every three months to every six months depending on how severe the glaucoma is and how compliant the patient is. For diabetes, for retinopathy, we watch patients anywhere from every three months to every week depending on, again, how bad that retinopathy is. So, you know, I think that the key for me is coordination of care among all our professionals and ensuring that when you’ve got a patient on a chair, that you’re checking them and make sure they are getting their annual eye exam. When I see my patients, I make sure that they are always getting their annual physical, that they’re getting their lab work done, that they’ve seen their endocrinologist, that if they need to see a podiatrist or a dentist, that they’ve done that as well, and coordinate with the pharmacist as well. So, I think with so many different healthcare providers that are interacting with this one patient with diabetes, if we can all be really cognizant of making sure that we’re asking these questions, then hopefully we can ensure that the patient is receiving that preventive care because prevention is really number one. And, I think fairly recently the CDC estimated that over half of patients with diabetes weren’t even receiving any annual eye exam and that early detection can really reduce the risk of blindness by almost 95%. So, it’s a huge difference that we can make in our population.

Melanie: In the last few minutes, Dr. Register, how can a community physician refer a patient to UAB Medicine?

Dr. Register: So, a community physician can refer a patient over to us a couple of different ways. If you go to the website, UAB Medicine website, there is a provider phone number there that puts you in touch with a staff member who can decide which area or which location might be most convenient for your patient and ensure that we take their insurance. They can always call Callahan Hospital directly as well and make an appointment at 325-8620, I believe. And, I know for Callahan at least, we have several locations. So, we have a location out in Bessemer, location out on 280. We’re in St. Vincent’s and then our downtown location as well. So, we’re hoping to make it convenient for all of our patients to be able to get the care that they need.


Melanie: Tell us about your team. Why is UAB so great to work with?

Dr. Register: Well, UAB has so many great things. I think one is we are a very supportive team of providers. I think everybody thinks for their patients first and foremost which makes a big difference I think in clinical care and our commitment to our patients. You know, we’re kind of there, in my mind I’m there 24/7 for my patients, even though technically it may be on the books less than that. But, you know, we’re able to really coordinate across all of the different providers as well and so having that ability to talk to an endocrinologist and call them if I needed to for a patient or get labwork or any other kind of medical record, it’s very, very easy within the UAB system. We have a lot of continuing education. We have a lot of grand rounds and a lot of places that allow us to stay up-to-date with the newest trends that are going on as well as just the newest statistics to ensure that we’re ready for whatever diseases that are going to be coming our way.

Melanie: Thank you so much for being with us today, Dr. Register. A community physician can refer a patient to UAB Callahan Eye Hospital by calling the 844-UAB-EYES. That's 844-325-8620. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That's uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.