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Interactive Learning : HealthCast Transcripts

Episode 18 : Eye Disease: A Consequence of Vascular Disease and Diabetes

Release Date: June 4, 2007

Dr. David Meyerson: Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's HealthCast. We're very excited to bring you excellent, easy to understand science on all topics relating to heart and blood vessel diseases as a public service. As a public education forum, the Vascular Disease Foundation is made up of representatives of the premiere medical and science advisory groups in the country that relate to vascular diseases. These are groups that use peer-reviewed science to verify that the information that you're getting is nationally recognized as the very best and most reliable data available.

Prior episodes of this series have dealt with exactly who patients are that get vascular disease, how we diagnose vascular disease. We've talked about carotid artery disease, the narrowing of the arteries in the neck that nourish the brain that can cause stroke and threaten strokes that we call TIA's or transient ischemic attacks. We've talked about coronary arterial disease, narrowings of the arteries that nourish the heart muscle that can cause angina, the chest pain you get when too little blood supply and oxygen get to your heart muscle and causes heart attacks. We've also talked about abdominal aortic aneurysms. These are the bulging and weakenings of the major blood vessel of the abdomen, the aorta, which can cause life threatening blood loss. Finally, we've spoken about peripheral arterial disease, narrowings or blockages in the arteries that nourish your legs which can limit your ability to walk, they cause pain and ulcers of the legs and in extreme situations, can even cause one to risk amputation. These are largely preventable diseases and once developed, they are very treatable diseases and the early recognition and treatments can prevent your disability, promote your physical well-being and help you maintain the healthiest and most active lifestyle you possibly can. We've used the analogy in the past of the sixty-year- old house. If the plumber told you that certain of the pipes in the basement were corroded and clogged, it wouldn't surprise you for a moment that the pipes on the first and second floor were also at risk.

Certain conditions, as we told you in the past, contribute to the development of vascular disease more than almost any other risk factor. One such is diabetes. This is not only a disease, diabetes is not just a disease of high blood sugar, that's too simple a way at looking at this. It is a disease of the small blood vessels throughout the body. Blindness and sight impairment are worries of every single diabetic person, so keeping on our target at VDF of giving you information that prevents disease, prevents disease, let's look at the prevention of that special vascular disease, diabetic retinopathy. With me today in studio is Dr. Stuart Dankner. He is a pediatric ophthalmologist in Baltimore, Maryland. He is the past president of the Maryland Society for Sight and he is an expert on diabetic retinopathy. He deals mostly in children and the fascinating information that you'll hear from him today has to do with how we can prevent this disease, early, early, early. Prevention is the name of the game. Dr. Dankner, thank you so much for being in the studio today with us for VDF HealthCast.

Dr. Stuart Dankner: It was my pleasure and if I can call you David and you call me Stuart that would be great.

Dr. David Meyerson: That works beautifully.

Dr. Stuart Dankner: Okay.

Dr. David Meyerson: Our audience knows that we get kind of informal at times and I think they're more comfortable that way as well. So, how does a pediatric ophthalmologist get into the framework of talking about diabetes and diabetic retinopathy? First, let's talk a little bit about, for our adult listeners, diabetic retinopathy is a key cause of blindness.

Dr. Stuart Dankner: Correct.

Dr. David Meyerson: And every diabetic person is worried about this, aren't they?

Dr. Stuart Dankner: That's correct.

Dr. David Meyerson: Or they should be.

Dr. Stuart Dankner: Right. We find that in the adult population, people are usually pretty well educated once they've been given the diagnosis of diabetes that one of the things that they really need to do on a regular basis is to have yearly eye exams, also they're very well aware that their blood level of sugar is a key factor, but also hemoglobin A1C is a very key factor and people have --

Dr. David Meyerson: And these are issues, if you haven't heard these words before, we're going to come back to these in a few minutes.

Dr. Stuart Dankner: Correct.

Dr. David Meyerson: But let me just mention, Dr. Dankner -- Stuart, is an ophthalmologist. There are scant few physicians that have the ability to actually see, to actually visualize vascular disease. Now a surgeon will visualize vascular disease when he's doing a bypass or she's doing a bypass on the arteries of your legs or maybe your heart, but Dr. Dankner has the ability. Ophthalmologists can look right into the retina and you can actually see small blood vessels and their diseases.

Dr. Stuart Dankner: Correct. And it's interesting; the eye is very unique in several ways. One is that the eye is really part of the brain. People aren't always aware of that, but there's an optic nerve in the back of the eye that's actually, it consists of brain tissue and it's connected to the brain. The second unique thing is without doing invasive testing like you often have to do to evaluate blood vessels in the body, a very simple test is just to dilate the pupils with drops and we can actually visualize the tiny blood vessels in the back of the eye because they're right in front of us. They say that the eye is a window to the rest of the body because it often shows other conditions in the body that could be present just by looking at the nature and the condition of the tiny blood vessels.

Dr. David Meyerson: Now they use the term neovascularization for diabetes and that is the growth of new tuffs of tiny blood vessels and these blood vessels can ultimately bleed and cause blindness. Is that right?

Dr. Stuart Dankner: That's absolutely correct. Now, new blood vessels unto themselves are not a bad thing. Often in areas where regeneration has to occur, new blood vessels are the reason why our tissue comes back to health. However, in the eye, when there is damage from either glucose or the fluid change in the eye, in the back of the eye, these new blood vessels that are stimulated to grow really not good new blood vessels. They cannot only grow actively, but they can bleed as you said and that can cause hemorrhage in the back of the eye and in the vitreous which is the jelly of the eye and these new blood vessels can actually cause traction or pulling of the retina. It's almost like wallpaper being pulled off the way.

Dr. David Meyerson: So you can get not only blindness from the blood, but you can also pull the retina away from its moorings, if you will.

Dr. Stuart Dankner: Exactly. And these new blood vessels, not only do they pull the retina and cause traction and not only do they bleed, but they also leak and they leak fluid and that fluid can involve the macula which is where central vision is and most diabetics when they lose their vision, it's actually because of what we call macula edema which is swelling or fluid in the central portion of the eye.

Dr. David Meyerson: So again, for our adult listeners and our adult diabetics, they should really be getting ophthalmologic evaluations yearly and there are some very straightforward therapies, I want to get into hemoglobin A1C in just a minute --

Dr. Stuart Dankner: Yes.

Dr. David Meyerson: -- but tell us about, they actually do laser procedures to cauterize these little vascular tuffs and it prevents them from bleeding?

Dr. Stuart Dankner: Correct. Laser is being used in so many areas of medicine now, it's high technology and here in Maryland, we have been very blessed to have a senior ophthalmologist, his name is Arnold Petts, and not only did he do very early work on retinopathy, prematurity of the eye in babies who were born premature who had eye disease, but he was one of the first people in the country who started using laser therapy for diabetics and a certain type of argon laser for that. So, and he's still here and he's active in the community and is quite a guy in terms of what he's contributed to our field. But laser can actually prevent some of these new blood vessels from not only being activated and expanding, but can also seal the leaking blood vessels.

Dr. David Meyerson: So even once they've shown a tendency to ooze, if you will, --

Dr. Stuart Dankner: Yes.

Dr. David Meyerson: -- that the laser can still be effective --

Dr. Stuart Dankner: That's right.

Dr. David Meyerson: -- and preserve what sight is remaining.

Dr. Stuart Dankner: And I know you made note of the words prevention, prevention, prevention and that's where laser comes in and if it's detected early, the diabetic change in the back of the eye detected early, the message throughout this interview I think is going to be the earlier the detection, the better cure rate and the better the visual prognosis.

Dr. David Meyerson: Just so that you know where I'm going in my own mind in this interview, I want to stay on adult issues for just a minute more and then we're going to take prevention back to its roots, back to the pediatric population because the seeds of disease can often be seen decades before the disease develops and if the seeds are there and we can stop the seeds of disease from growing, I think we can benefit a lot of people later on down the line. Wouldn't you say?

Dr. Stuart Dankner: I absolutely agree with you and I think that should be the thrust of the message we got across.

Dr. David Meyerson: So for our diabetic population who have kidney disease more than the rest of the population, they have heart and blood vessel disease more than the rest of the population, we talk about careful control of blood sugar. And let's talk for a minute about an idea that I promise to bring to the microphones a couple minutes ago and that is this hemoglobin A1C. Now, if I were to take -- if I had a camera and I took a picture of you at this very moment, a snapshot, that would be the same as if I took a blood sample from your arm right now and did a blood glucose.

Dr. Stuart Dankner: Correct.

Dr. David Meyerson: It's one little moment in time.

Dr. Stuart Dankner: Uh-huh [affirmative].

Dr. David Meyerson: Tell us then, if you will, what about the hemoglobin A1C? What prospective does that give us? Now again, we talk -- hemoglobin, it sounds like we're talking about a different blood disease or a blood issue entirely, but what we're really talking about is what window does the hemoglobin A1C give us about blood sugar control?

Dr. Stuart Dankner: I think the biggest, in my field, one of the biggest contributing factors and new technologies has been the ability to very easily identify this protein, this hemoglobin A1C, because by identifying this, it gives you more than that snapshot. What it gives you is a reflection or an indication of how well the glucose is or is not controlled over the previous three months.

Dr. David Meyerson: So it's almost like the news crew following you for three months as opposed to-- and giving you that information as opposed to giving you just one snapshot of information.

Dr. Stuart Dankner: Absolutely.

Dr. David Meyerson: It really tells you longitudinally how well are we controlling the blood sugar.

Dr. Stuart Dankner: That's very, very true and control is a very, very significant thing right now. We know statistically from patient studies that have been done, that control is a major factor in preventing the advancement of this disease and that can often lead to legal blindness, but now we know that we can advise patients that the better they have their control, the earlier any change is detected in the back of the eye that they often can have a very successful visual prognosis for this and one of the things I know we don't intend to do in these interviews, but we really are not out to scare the public, especially those who have diabetes, but to give them hope now that with the technology that we have, there are ways to really prevent this disease if people take it upon themselves to care about what they're doing and how they can prevent it, making sure they see their diabetic doctor and their eye doctor on a regular basis.

Dr. David Meyerson: I couldn't have said it better. We are all about trying to assess what is the risk in a nice calm prospective manner and say here are the tools that you can use to minimize your long-term risk and truthfully prevent disease. I mean, that's the goal of these HealthCasts and again, so that the public listening who are diabetics know that if you think you're doing something to benefit the blood vessels of the eye, at the very same time, the very same things, the very same close control of diabetes and all of the other things that we talk about are the very same things that would benefit the blood vessels in your kidney, the blood vessels in your brain, the blood vessels in your heart. Again, this is that sixty- year-old house that we give the analogy to and blood vessels -- something you do for the plumbing in one place is probably going to help plumbing in the other place and if there was something that we can do when the house was only three or four or five years old that could prevent the pipes from ever corroding, now wouldn't that be a great thing? And plumbers could be busy building new houses as opposed to having to repair the old ones.

Dr. Stuart Dankner: That's right.

Dr. David Meyerson: So let's talk a little bit about this epidemic of obesity in children that I hear about and why blindness in children may ultimately become a real issue. Again, as we said before, often we see the seeds of future disease before the disease develop. How do we get there?

Dr. Stuart Dankner: Well, more and more in my practice over the years, and this has been almost now twenty-nine years in practice, we found more and more obese patients coming in at young ages. I mean, we're talking about two-year-old children, two and three-year-old children coming in who are grossly overweight. And besides the other health problems that they have, we're now finding again statistically that these children are going to be at a lot higher risk for developing the type II diabetes, which is -- used to be called adult onset diabetes and now really has become both childhood and adult onset because of the fact that obesity is directly correlated with a higher incidence of diabetes.

Dr. David Meyerson: And the sooner that the diabetes develops, then the sooner the blood, small blood vessels all over the body become effected.

Dr. Stuart Dankner: Exactly correct. And over fifty percent of people who are diagnosed with the type II diabetes, over fifty percent who are diagnosed before age thirty, within twenty years after their initial diagnosis and I'll make this a little more clear in a minute, but within twenty years after they have been diagnosed with diabetes, they can assuredly know that they're going to have diabetic retinopathy and that's a startling statistic because it means if you have a five-year-old who is obese from age three and by five to seven years of age, he starts to show early signs of the diabetic retinopathy, you can rest assured that within twenty years after that, meaning age twenty-five to thirty, he's going to be proliferative diabetic retinopathy that can lead to blindness and that's a very scary thought knowing that an obese child isn't just going to have a problem keeping his weight down and how he looks, but he potentially could go blind at a much younger age in life than he would be if he wasn't obese or she for that matter.

Dr. David Meyerson: And a substantial amount of this is preventable and treatable disease.

Dr. Stuart Dankner: Correct.

Dr. David Meyerson: Tell me a little bit about where the National Eye Institute comes into this picture.

Dr. Stuart Dankner: The National Eye Institute has a program called Healthy Vision 2010 and that particular program, I've been involved --

Dr. David Meyerson: That's only three years away.

Dr. Stuart Dankner: That's only three years away and they're going to have to rename it pretty soon, but that particular program is to go out into communities and to try to figure out ways that we can decrease or maybe even eliminate preventable eye disease that can lead to blindness and I'm particularly interested in the childhood aspect of this and that's why I sit on the committee for this, but a program – a pilot program has been developed here in Baltimore, the first city in the United States to have a program like this in which the Maryland Society for Sight, which is a nonprofit organization here in Maryland that does vision screening of both children and adults, but also visually screen head-start children from ages three to four and they see about a thousand children a year in Baltimore City. It's not a lot, but that's in this pilot program that they're going to earmark and what they're going to do is, they're going to identify children at ages three and four who have the potential risk of obesity, meaning all the children and they're going to consult with the children, the parents, and the educators at that level. They will be giving animated DVD's to the families. They will be giving out colorful handouts for the children to read with their parents. This is not a scare tactic for children. This is to teach children how to keep, how to maintain healthier diets because we want parents and the kids to know that this is not only a good way of keeping your weight down and eating good foods which is good for the rest of your body, but it's a good way of keeping your eyes healthy. And in fact, the name of the program is called Eat Right for Healthy Sight because that's exactly what the intention is, to train, educate children and parents at the younger ages before it actually reaches a level where it's too late to do anything about and it's basically going to target the obesity of this.

Dr. David Meyerson: I sit on the Governor's Council for the Prevention of Heart Disease and Stroke and I know that we often talk about how do we bring behavior changes to a younger and younger population and it seems that this is a -- just an outstanding methodology because again, not only will you be preventing hopefully ophthalmologic diseases and blindness, but you'll also be delaying the onset of diabetes if that's possible and you'll be preventing the kidney disease and the blood pressure problems and the heart disease and the stroke that comes along -- and the lower extremity, the peripheral vascular disease, that come along with this disease, so this is getting on the change of habit before the habit is not changeable. This is at the level when the children are still, they can absorb a foreign language like it was nothing --

Dr. Stuart Dankner: Yes.

Dr. David Meyerson: -- they can learn things quicker than any other time in their life and it sounds like this program has the ability to really change behaviors if -- and not only for the children, but once -- there's nothing like doing something for a child that gets the adult to do something right.

Dr. Stuart Dankner: Correct.

Dr. David Meyerson: And from my ear, this sounds like a program that not only is going to benefit the children, but it's going to benefit the entire family as well and I applaud this enormously.

Dr. Stuart Dankner: Thank you. Part of assessing this program during its inclusion will be to not only look at -- not only give out questionnaires to the parents to assess the success of the program in terms of whether it changed diet habits in their children and with them, but also to look at BMIs, body mass indexes, in order to evaluate whether there's actually been a difference in terms of the child's overall weight during the course of the year or two of the program. If I could, just for a second, give you a quote from a Dr. Vargis [phonetic], Ileanna [phonetic] Vargis who's a pediatric endocrinologist at Children's Hospital, New York Presbyterian, and she said, "Diet and exercise. It seems so simple, but clearly the message isn't getting out because there are so many obese children and children with diabetes. It may be too late to help teenagers or even junior high school kids who have developed type II diabetes. There is hope for the younger kids though. Children at early ages now, can still make the lifestyle changes needed if we start working on it now. The first line of defense is for kids to eat right and to exercise."

Dr. David Meyerson: That is, it's so true, but somehow it's so hard to teach. Where do we involve the school system in this and the after school programs? Is it a funding issue? Is it a we're not thinking about this well anymore? Where's the issue?

Dr. Stuart Dankner: I think the issue rests with our public health system. I think that in this country, although we preach prevention and you know you and I and people we know well in the medical profession spend a lot of our time talking about prevention.

Dr. David Meyerson: You were saying financially we only give it lip service.

Dr. Stuart Dankner: Exactly. And I think that there has to be a real public health educational program that really makes -- has an impact. And whatever your political slant is, a significant amount of funds, much more than is available right now, really has to be placed in priorities like disease prevention and I think it would make a tremendous difference to people if they were educated about these issues because I think they would change their habits. I think the government has been somewhat lax and we know from funding and grant money that's been cut so much in the past, we really -- they need to now really take up this issue and really address it otherwise there's going to be a tremendous cost to the medical health system. Besides the disability and the loss of life, there's going to be a tremendous economic disadvantage to our government and to us if this continues on the way it is.

Dr. David Meyerson: And so you're suggesting that you spend a dollar now and it saves eight or ten dollars in disease treatment later on.

Dr. Stuart Dankner: Right. It's always been proven to be true and in this case, it would be absolutely true.

Dr. David Meyerson: And one of the things that I have chatted about from time to time is for example, if I was a healthcare insurer and if I was responsible for your health for the next fifty or seventy-five years, then I would be giving you medicines that work well if you needed medications, but I would be doing all the preventive therapies that are so important and I would be giving benefits for people who showed a tendency towards exercising, eating right and not smoking. Where does smoking and second hand smoke come in with this blood vessel disease for kids?

Dr. Stuart Dankner: Definitely a higher incidence. There are other factors like high blood pressure and we know that for sure and certainly lack of exercise, but smoking is a very key factor in terms of the progression of diabetic retinopathy and stopping smoking or never getting started with it is another way to minimize the progression of this disease along with the other factors that we mentioned.

Dr. David Meyerson: Now I've also heard that children with -- children of parents who smoke develop asthma more often than children who don't, they get sick more often, but do you think that this would also -- those who become diabetic would also have worsening retinopathy at an earlier age with second hand smoke?

Dr. Stuart Dankner: This may be somewhat hypothetical, but from everything that I read, I think would make a significant difference if parents didn't smoke and I think the second hand smoke is a real concern and I think more and more it's been proven to be a concern.

Dr. David Meyerson: Stuart, let me ask you then in the minute or two we have left, what would be the wrap up message that you would like to give to family of young children, the people who are diabetic, people whose kids are likely to become diabetic if they're not ultra-careful. Tell it to them again in the last minute here.

Dr. Stuart Dankner: I guess the word will go out to parents and the message is, we have a responsibility as parents and not to be professorial here, but we have a responsibility as parents to our kids to be able to do the things that we can control meaning their health, their diet, whether or not they become obese because if we don't take it upon ourselves to do these things for our children who really don't have much say in the matter when they're so young, we will be not only shortening the life span of our children as they get older, for sure, we will also be causing them to be visually disabled when it's totally unnecessary and it's not undoable to be able to make sure that your children eat a healthy diet, that they don't become obese that you monitor their weight gain carefully, and that you make sure that they have exercise. It sounds so simple, but it's doable.

Dr. David Meyerson: It seems imminently doable and the one thing that I like most about this is that I've often been able to motivate patients to do things for themselves, but it's even easier to motivate them to do for their children. All of us would want for our children that which we have not been able to do for ourselves. This is a legacy that we can give our children.

Dr. Stuart Dankner: I agree.

Dr. David Meyerson: You've been listening to Dr. Stuart Dankner, he's a pediatric ophthalmologist in Baltimore, Maryland, a past president of the Maryland Society for Sight. For Vascular Disease Foundation, for Dr. Stuart Dankner, for my sidekick and engineer, Dr. Kerry Stewart, I'm Dr. David Meyerson, thank you so much for listening, till next time.

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