Episode 44 - Diabetic Retinopathy - a podcast by Rio Bravo Family Medicine Residency Program

Episode 44: Diabetic Retinopathy. 

Dr Carranza explains the effect of diabetes on the retina, domestic abuse among female doctors, jokes.

Today is March 15, 2021.

Domestic Abuse among Female Doctors

There are topics which are very sensitive, but we need to talk about them.

Such is the case of domestic abuse among doctors. Do you know what is the most important risk factor to be a victim of domestic abuse? Yes, being female, and doctors are not an exception. 

Recently, in February 2021, the British Journal of General Practice (BJGP) posted an article addressing this topic.  The aim of the article was to understand the experience of female doctors as victims of domestic abuse, the barriers they faced to find help, and the impact that domestic abuse had on their work. 

The study was limited to doctor mothers because the author had access to this group and she was a member of the online forum and a single doctor herself. 114 doctors expressed interest in the study but a total of 21 participants were interviewed. The criteria to be included in the study were being a single mother working as a doctor and having previously left an abusive relationship. 

Each interview lasted between 44 and 113 minutes and were conducted from August 2019 and March 2020. The interviews were recorded. The principal author of the study can be seen and heard in an interview on the BJGP’s podcast.  

The doctors felt that stress of domestic abuse affected their quality of work but were unable to participate in seeking help because of the social stigma. One of the barriers for seeking help included lack of confidentiality when the other partner was a doctor as well. 

One of the participants expressed that the social services did not treat her with respect when the abuser was a doctor himself. Also, the participants expressed embarrassment and shame because of their status as a doctor as she stated that doctors “should know better.”  

Another negative connotation going through domestic abuse as a doctor is that the particular individual “is not capable of taking care of the patients if she cannot take care of her personal life.” 

The barriers to find help included “owning up” to domestic abuse, not seeking help from social services and work hours. The doctors feel socially and professionally isolated because they are not able to talk about abuse and fear the consequences of reporting. 

One of the most helpful thing for victims of domestic abuse was an online social group. The author added that domestic abuse training should be taught in medical school as doctors can be victims as well.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

Question of the Month: Polyarthralgia
by Valerie Civelli (written by Claudia Carranza)  

This is match week! congrats to everyone, and we hope you matched to your dream residency.  

This is the question of the month. This is the last week you have to answer this question. We have received very interesting answers but we are hoping to receive yours. 

A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling very fatigued. You note on her chart that she was diagnosed with COVID-19 six weeks ago that did not require hospitalization. She denies any relevant past medical history. She denies trauma, bleeding, headaches, chest pain, SOB, or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation to bilateral wrist and ankle. No signs of inflammation on joints are noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? 

Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical ankle and wrist pain with fatigue for 1 month. What workup would you order? Clue: Listen carefully to the history of the patient. Send us your answer to rbresidency@clinicasierravista.org before March 22, 2021. The winner will receive a prize.

Diabetic Retinopathy 

 

A lot of us send out referrals for diabetic retinopathy screenings every day. Now we all learned about this topic in med school but it is important to do an overview as to what diabetic retinopathy entails. These will help us, providers, to be able to explain it to your patients better and also for all listeners to have a better understanding of a much-unwanted complication of diabetes. 

 

Basics on Diabetes.

 

So for all of our listeners I wanted to do a quick review on diabetes. A lot of us have heard about “high sugars” and diabetes but what is it really? It is a disease in which carbohydrates are not processed correctly in our body leading to an increase of glucose in our blood. Insulin is made in the pancreas and its job is to regulate carbs by sending them to the liver, fat, skeletal muscle. You need glucose to function and not in your blood vessels but in your organs. For the listeners, what should they look out for with regards to symptoms?

Lots of urination, also called polyuria and nocturia, increased thirst, weight loss, increased appetite, blurred vision, UTIs, fatigue, numbness and tingling of extremities. In other words, think of any symptoms you would have if honey was running through your bloodstream. 

 

Hemoglobin A1c is the number people hear when they have diabetes. I tell this to all my patients, this number is a way to measure the sugar coating of your RBCs over the last 3 months. If your cells are exposed to higher amounts of glucose then the number will be higher. Prediabetes is 5.8-6.4, and diabetes is >6.5. 

 

 

Diabetic Retinopathy (DR).  

 

The main targets of diabetes are the eyes, kidneys and nerves since the first things to get damaged are the smallest blood vessels and those feed these organs. Today you are going to tell us more about the damage diabetes can do to your eyes or as we call it Diabetic Retinopathy.

 

DR is actually one of the most important causes of visual loss worldwide and the main reason for impaired vision in patients 25-74 as the retina becomes damaged. An issue is that people will not develop symptoms until they are in late stages of DR. 1 in 5 patients with newly diagnosed diabetes will have signs of DR. 

 

In patients with diabetes, glucose runs through the circulatory system. Glucose and the protein at the walls of blood vessels react and overtime damage the collagen. Collagen keeps the blood vessels plump. When damaged, the capillaries thicken and the walls break down. 

 

The timing of your diabetes is a good predictor for DR. After 10 years 50%, 15 yrs 90% but it all really depends on your A1c. The more uncontrolled, the quickest you will have side effects and damage and will end up with DR.

 

Proliferative and non-proliferative diabetic retinopathy.  

 

Non-proliferative diabetic retinopathy is also known as “background retinopathy” meaning it just kinda sits in the background for years. 95% of people with DR have Non-Proliferative Diabetic Retinopathy (NPDR). Usually it is at an early stage and the progression is very slow. 

It is the result of capillary breakdown with leakage of fluid into retina, aneurysms at the blood vessels that can burst and show “blot and dot” hemorrhages that are small and round and can be seen on fundoscopic exam.

When it worsens, there is decreased blood flow to the retina causing ischemia of superficial retinal nerve fibers. This can also be seen in fundoscopic exam as the infamous “cotton wool spots”. Worsening capillary break down can also lead to beading of larger retinal veins. 

 

The other type of DR is the Proliferative retinopathy. The way this one occurs is that when vessels are very damaged they occlude completely and you end up with no blood supply. 

 

Our bodies are smart and usually try to fix themselves. How does the retina reacts to this lack of blood flow? It sends chemicals, like VEGF (vascular endothelial growth factor) that stimulate growth of new vessels. This process is called “neovascularization”. This sounds pretty great, right? The problem is that these new vessels are not top notch. They are abnormal, friable and prone to leaking. On top of that they grow in the wrong places. For example, if it grows in the vitreous jelly, which has framework of proteins, it tugs at these proteins and you end up with retinal detachment. These vessels can also bleed into the eye and cause vision loss. And if they grow into the iris, they can block the trabecular meshwork and cause Neovascular Glaucoma.

 

Proliferative retinopathy (PR) can advance quickly and ½ of the patients can go blind if it is left untreated.

 

 

 

Macular edema.

 

The macula is the functional center of the retina which has a high concentration of photoreceptors, it’s basically the center of high-definition and color vision. It’s the center of the retina. 

 

Macular edema it occurs in 10% of patients with diabetic retinopathy, more commonly with severe retinopathy. The leakage of capillaries and microaneurysms cause macular retina to swell with fluid. Once this swelling goes away, on fundoscopic exam you will see the “hard exudates”. These hard exudates are fatty lipids that are left behind after the swelling stops. I highly encourage all of our listeners to google the images for the findings mentioned today as they are quite impressive when you compare them to a healthy retina. 

 

I think it is best for us as physicians to recommend to our patients and try our best to work with them to control their A1c so they don’t end up with diabetic retinopathy and also have yearly eye checkups. 

 

Treatments.

 

Laser treatment is one of the options. The laser seals the leaking vessels and microaneurysms; which can be done when there is only a few and they are well defined. If the area is too large then PRP (Pan-retinal photocoagulation) can be done. What is does is that it burns thousands of spots around the peripheral retina in a way to decrease the stimulus to form new vessels. The side effects are decreased peripheral vision and night vision as you end up with less peripheral rods receptors. 

 

Another treatment is with anti-VEGF agents. These are used to treat proliferative diabetic retinopathy. They are injected into the vitreous. There are 3; Ranibizumab, bevacizumab, and aflibercept. Interesting fact; Bevacizumab is used “off-label” for retinopathy and it has to be repackaged to a strength of 1:500th of the dose used for cancer treatment. 

 

Vitrectomy. For progressive disease, vitrectomy can be performed and it is the removal of the vitreous humor. At this point the vitreous humor would be filled with blood, inflammatory cells and debris. I had read that it is usually replaced with saline but learned from an ophthalmologist that you don’t always have to replace with saline but can also be replaced with air or gas. 

Conclusion: Diabetic retinopathy is a consequence of poor glycemic control. The consequences can be serious and cause severe physical, mental and social dysfunctions in our patients. Keep an eye on your care gaps, and order an annual retinopathy screening in all your patients with diabetes. But do not limit yourself to order annual screening, always ask about vision changes in your patients, and if there is any concern about worsening vision, send your patients promptly to ophthalmology.

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For your Sanity: Jokes
by Anonymous Medical Assistants

-There is a lot of people with 20/20 vision. How come none of them warned us about corona?

-I'm beginning to think adult supervision is a myth. In fact, my vision just seems to be getting worse.

-What do you call a fish without an eye? A fsh.

-Why did the cross-eyed teacher quit her job? She couldn’t control her pupils.

 

Now we conclude our episode number 44 “Diabetic Retinopathy.” We learned that high glucose is very harmful to the retina. Let’s teach our patients the importance of glycemic control to prevent blindness. Remember to order a retinopathy screening at least once a year, or whenever your patients reports changes in their vision. This is the last week to answer our question about polyarthralgia and fatigue in a 49 year-old-female who has a key element in her history. Send us your answer this week and you will receive a prize. Remember, even without trying, every night you go to bed being wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Claudia Carranza, Steven Saito, Udayveer Brar, Valerie Civelli, and anonymous Medical Assistants. Audio edition: Suraj Amrutia. See you next week! 

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References:

Donovan, Emily; Miriam Santer; Sara Morgan; Gavin Daker-White; and Merlin Willcox, Domestic abuse among female doctors: thematic analysis of qualitative interviews in the UK, British Journal of General Practice, February 8, 2021; BJGP.2020.0795. DOI: https://doi.org/10.3399/BJGP.2020.0795. 

 

Fraser, Claire E; Donald J D'Amico; et al, Diabetic retinopathy: Prevention and treatment, UpToDate, Last updated: Oct 29, 2019, accessed on March 4, 2021. https://www.uptodate.com/contents/diabetic-retinopathy-prevention-and-treatment

Root, Timothy, MD, OphthoBook, Chapter 4: Retina (47-53), published on July 20, 2009.

 

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