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طاهری نادر دکترداخلی متخصص

غدد تخصص فوقRefrence:ADA(2012) and

William textbook of endocrinology

Global Prevalence of Diabetes

An epidemic of T2DM is under way in both developed and developing countries.

The number of people with diabetes will rise

from 171 million in 2000 to 366 million in 2030.

Classification of diabetes

The classification of diabetes includes four clinical classes:

Type 1 diabetes: results from beta -cell destruction, usually leading to absolute insulin deficiency

Type 2 diabetes (90% of diabetic cases globally): results from a progressive insulin secretory defect on the background of insulin resistance.

genetic defects in beta-cell function, or in insulin action,

diseases of the exocrine pancreas (such as cystic fibrosis),

and drug- induced (such as in the treatment of HIV/AIDS or after organ transplantation

Gestational diabetes mellitus (GDM: diabetes diagnosed during pregnancy)

Diagnosis of diabetes

For decades, the diagnosis of diabetes was based on

the fasting plasma glucose (FPG)

or the 2-h value in the 75-g oral glucose tolerance test (OGTT).

Diagnosis of diabetes In 2009, an International Committee that

included representatives of the ADA, the International Diabetes Federation

(IDF), and the European Association for the

Study of Diabetes (EASD)

recommended the use of the A1C test to diagnose diabetes.

Diagnosis of diabetes The A1C has several advantages to the

FPG and OGTT, including

greater convenience, and less day-to-day perturbations But, these advantages must be balanced

by greater cost, and the limited availability of A1C testing

in certain regions of the developing world,

Diagnosis of diabetes

The diagnosis of diabetes must employ glucose criteria exclusively,

in conditions with abnormal red cell turnover, such as pregnancy, recent blood loss or transfusion, or some anemias.

Criteria for the diagnosis of Diabetes

FPG > or = 126 mg/dl, or 2-h plasma glucose > or = 200 mg/dl,

during an the 75-g OGTT.

or In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, A random plasma glucose > or = 200 mg/dl.

Or A1C > or = 6.5% .

Criteria for the diagnosis of Prediabetes

Prediabetes definded as

FPG > or = 100–125 mg/dl (IFG)

Or 2-h plasma glucose in the 75-g OGTT > or = 140–199 mg/dl (IGT)

Or A1C > or = 5.7–6.4%.

Prediabetes

Individuals with IFG and/or IGT have the relatively high risk for

the future development of diabetes

and cardiovascular disease (CVD).

Prediabetes IFG and IGT are associated

with obesity (especially abdominal or visceral obesity)

high triglycerides and/or low HDL cholesterol,

and hypertension.

Screening in asymptomatic patients

Testing for type 2 diabetes in asymptomatic people, considered in

adults of any age, who are overweight or obese

and have one additional risk factor for diabetes.

In those without these risk factors, testing begin at age 45 years.

Risk factors of type 2 diabetes

physical inactivity first-degree relative with diabetes high-risk race/ethnicity women who delivered a baby weighing 9

lb or past history of GDM women with polycystic ovarian syndrome Hypertension A1C > or = 5.7%,

Risk factors of type 2 diabetes

HDL cholesterol level < 35 mg/dl Triglyceride level > 250mg/dl clinical conditions associated with insulin

resistance (e.g., severe obesity, acanthosis nigricans)

History of CVD

Screening in asymptomatic patients

If tests are normal, repeat testing carried out at least at 3-year intervals .

Monitoring for the development of diabetes in those with prediabetes performed every year.

To test for diabetes A1C, FPG, or 2-h 75-g OGTT can be used.

Diabetes Complications diabetes associated with microvascular

pathology in: the retina (retinopathy)

renal glomerulus (nephropathy),

peripheral nerve (neuropathy).

and accelerated atherosclerotic macrovascular disease in the heart, brain, and lower extremities.

Diabetic retinopathy A highly specific vascular complication of

both type 1 and type 2 diabetes,

The most frequent cause of new cases of blindness among adults, aged 20–74 years.

All patients with T1DM and more than 60% of patients with T2DM develop some degree of retinopathy after 20 years.

The primary end-point to evaluate the relationship between glucose levels and diabetic complications is retinopathy.

International Classification of Diabetic Retinopathy

no apparent retinopathy (no abnormalities),

mild NPDR (microaneurysms only),

moderate NPDR (more than microaneurysms only but less than severe NPDR),

International Classification of Diabetic Retinopathy

severe NPDR (any of the following: more than 20 intraretinal hemorrhages in

each of four quadrants,

definite venous beading in two or more quadrants,

prominent intraretinal microvascular abnormalities in one or more quadrants,

and no PDR

International Classification of Diabetic Retinopathy

and PDR :

one or more of retinal neovascularization,

vitreous hemorrhage,

or preretinal hemorrhage

Risk factor for retinopathy

Duration of diabetes Quality of Glycemic control Hypertesion Renal disease Anemia Elevated serum lipid levels

Risk factor for retinopathy Duration of diabetes: closely associated with the onset and

severity of diabetic retinopathy.

Diabetic retinopathy is rare in prepubescent patients with T1DM,

but all patients with T1DM and more than 60% of patients with T2DM develop some degree of retinopathy after 20 years.

Quality of diabetes control

The DCCT showed: Tight glucose control

reduced the development of retinopathy by 27%.

Also, reduced the progression of retinopathy by 76%,

But not prevent retinopathy completely.

Hypertension

Patients with DM and hypertension are

more likely to develop retinopathy and diffuse macular edema,

and more severe levels of retinopathy (PDR)

and more rapid progression of retinopathy

when compared with diabetic patients who do not have hypertension.

Renal Disease ( proteinuria )

The presence and severity of diabetic retinopathy

are indicators of the risk of gross proteinuria,

and, conversely, proteinuria predicts PDR.

Renal Disease ( proteinuria )

In a patient with long history of DM

and where retinopathy has been previously stable,

Rapidly progressive retinopathy

Suggest the need for renal evaluation .

conclusion

To reduce the risk or slow the progression of retinopathy:

optimize glycemic control.

and optimize blood pressure control.

Vision loss

results from: persistent vitreous hemorrhage, traction retinal detachment, or severe macular edema.

The most common cause of vision loss from diabetes, is macular disease and macular edema.

Other Ocular Manifestations of Diabetes

Mononeuropathies of the third, fourth, or sixth cranial nerves can arise in association with diabetes;

Mononeuropathies may be the initial presenting sign of new-onset diabetes,

even in patients not claim a history of diabetes

Other Ocular Manifestations of Diabetes

Diabetes-induced third-, fourth-, and sixth-nerve palsies are

usually self-limited

and resolve spontaneously in 2 to 6 months.

Palsies can recur or subsequently develop in the contralateral eye .

Other Ocular Manifestations of Diabetes

Diabetic papilleddema must distinguished from other causes of disc swelling such as

increased intracranial pressure, pseudopapilledema, toxic optic neuropathies, neoplasms of the optic nerve, and hypertension.

Other Ocular Manifestations of Diabetes

Optic disc pallor can occur following spontaneous remission of

proliferative retinopathy or remission of panretinal laser

photocoagulation

Neovascularization of the iris

neovascular glaucoma

Other Ocular Manifestations of Diabetes

The cornea of the diabetic person is

more susceptible to injury

slower to heal after injury

and more prone to infectious corneal ulcers,

Other Ocular Manifestations of Diabetes

Open-angle glaucoma is 1.4 times more common in the diabetic population

Cataracts are 1.6 times more common in people with diabetes

Cataracts can occur earlier in life and progress more rapidly in the presence of diabetes.

All patients with diabetes should have dilated ocular examinations by an

experienced ophthalmologist

and diabetic patients should be under the direct care of an ophthalmologist

at least by the time severe diabetic retinopathy or diabetic macular edema is present.