 I'm Matt Ergin, you're a YouTube endocrinologist. And today we are hosting an ophthalmologist. It's our series in this November month, the activities month. I'm inviting distinguished specialists to our channel to talk about your questions. And we wanted to bring you the best in the area, the experts to answer your questions. So today I have Dr. Ronald Prenkel today. He is a ophthalmologist in Port St. Lucie, Florida. He is the founder of East Florida Institute and he's a medical director there. He has done his internship and fellowship in Harvard University. And he's a former voluntary professor of ophthalmology at Baskin-Palmer Eye Institute. And he's a distinguished alumnus Kresge Eye Institute as well. So welcome, Dr. Prenkel, how are you today? I'm doing great. Thank you for your kind introduction. Definitely. Thank you for joining us on a Sunday, taking time from your family. We really appreciate that. Before further ado, I'll go ahead and get started with our questions from our audience. And there's some interesting questions here actually. Number one is, and some of them are obvious, but I think if it was so obvious, that wouldn't be a question, right? So there's never a bad question. So we'll go ahead and start with, will all diabetics develop diabetic retinopathy? Interesting question actually, right? It's a great question. And the short answer to that is really no. And the reason for that is it depends on a number of factors. One is the duration of the disease. And certainly the longer you have diabetes, the greater the chance of you developing diabetic retinopathy. And the other factors are things that we can control, especially with your endocrinologist like Dr. Ergen, which is your blood sugar, your blood pressure and your lipids are probably the three most important things. So definitely not everybody will develop eye disease as long as their health is under control, diabetes cholesterol, blood pressure under control. So that's awesome. The next question is, who is at the most risk for diabetic retinopathy? Other than like high blood sugar, is there anything that our patients should be aware of that they may not know already? Well, I think those are the main factors. Certainly you want to maintain a healthy lifestyle as well, not only just in terms of diet, but in terms of exercise. But I think those are the principal factors that have been identified that cause worsening of this disease. Now, if you have cardiovascular disease, diabetic retinopathy is a vascular disease of the retina, which is the film that lines the back of the eye, just like the film and a camera, and people that have other vascular disease, blood vessel diseases in their body, such as heart disease, you know, may be more prone to problems. Are there any medications, for example, or other diseases that can make a diabetic more prone to develop retinopathy? Well, I mean, it's really medications that aggravate the things that we spoke about. So I think the one that comes to mind that's used with some degree of frequency are steroids, medicines like prednisone that can aggravate both your blood sugar and your blood pressure. You know, pregnancy is not a medication, but I mean, it's not something you want to avoid, but pregnancy actually can worsen diabetes too. Actually, one of the things that we recently discovered, some of the GLP-1 augurance medications, for example, that we use in epidemiology for diabetes control, like Ozempic, for example, even some other GLP-1 agents, even Trilocity, in their studies, we found that actually they increase the risk of retinopathy if they have already underlying retinopathy. So we always send patients to ophthalmologists, which is a routine thing, but if somebody says to me that they are going on the treatments for retinopathy, we, for example, try to keep these agents at bay to try to make things not aggravated, but great points. Now, what about the exercise? Is there any eye exercises that they can do to actually prevent retinopathy? That's an interesting question. Yeah, no, unfortunately, there's nothing specific, in terms of eye exercises you can do. It's a good question. Yeah, does retinopathy always lead to blindness? No, it doesn't. In fact, it's the leading cause in this country of blindness in working-aged Americans, but it definitely does not always lead to blindness. In fact, with the advances that we've had in therapies, particularly over the past decade or so that quite frankly we've been involved, we do a lot of clinical trials and have helped develop all these, this new class of medications called anti-Vegeth drugs that it has had a marked reduction in blindness. But the typical patient does not go blind. And years ago, 30 years ago when I was a resident, we used to see patients that not only went blind, but they would develop a bad form of glaucoma as well and they would get blind, painful eyes and actually some of those eyes needed to be removed. And that shouldn't happen today. What other, since you talked about this, what other common problems do you see in your practice for in people with diabetes other than the retinopathy, which is the retinal disease? What other problems like cataracts, glaucoma, RD's more common and what other things do you see? Oh yes, you hit the nail on the head right there with your question. So, diabetics are more prone to getting both cataracts as well as glaucoma. So, what's in eye visits is necessary, even if their blood sugar is not high, that's as we get older and the cataracts, glaucoma, develop and when you have diabetes that can definitely get worse, am I right? Absolutely, I mean there's a lot that we can do to prevent vision problems. And we see earlier stages before the patient is ever aware of those problems. Perfect, I guess we feel like glaucoma and stuff like that, they retinopathy really, these people will not know unless, until they come to a stage where they're almost losing their sight. So, I always emphasize my patients to please, please go see your eye doctor once a year. If everything is okay, every two years is okay. But just like diabetes, eye disease can be very insidious and hidden. So, that's perfect. The next question is interesting, which could be a long answer, but we'll try to keep it short. How does diabetic retinopathy cause vision loss? Well, another excellent question. So, if you think of the blood vessels in your eye, in your retina, that these blood vessels develop, normally the blood stays in the blood vessels, but the blood vessels in diabetics can develop weaknesses of some of the cells that keep the blood in the vessels and can also develop what we call microaneurysms, which are little tiny outpouchings of the blood vessels. And these microaneurysms leak fluid into the retina and the retina has a very specific and beautiful anatomy. And when the fluid leaks out, it distorts the anatomy of the retina and causes swelling in the retina and causes other problems. And that is how most diabetics lose vision. That's the most common way. Now, there are really two forms that we sort of classify diabetic retinopathy into. And one is just without getting into the medical terminology, one is just these leaky blood vessels. And the other one that is more serious is where new blood vessels start to grow inside the eye. And these blood vessels can then bleed into the center part of the eye where what we call the vitreous jelly that occupies four fifths of the eye. And that can then lead to things like a retinal detachment and really serious problems. So you've got the mechanism of the leakage to store in the architecture. And then you've got the more serious one where these abnormal blood vessels can grow and bleed into the eye. I see, perfect, thank you. That was a great, short and precise answer. The next one is also another interesting one. Somebody said that I have astigmatism and farsightedness. Does it make my chances of developing diabetic eye disease any worse? Not at all. That wasn't easy answer, that was a yes. All right, okay. So the next one would be, could I develop diabetic retinopathy even though my diabetes is always well controlled? Your chance of developing it is low, but I can't say you would never develop it. There are some people that get a mild degree of diabetic retinopathy and yet develop significant leakage in the retina that really affects their vision. So you can have an early stage of retinopathy and still have your vision impacted. But if the best thing you can do is to control those variables that we discussed, particularly your blood sugar, and that's your best chance of not having any significant retinopathy. Now, what do you think about genetic variability? For example, in our tight one diabetic patients, some of them are very uncontrolled. Even after 20 years, they don't necessarily develop complications. And some of them are just a little bit uncontrolled, but they already have complications after five years. So there's a lot of studies indicating that genetic variability, but the problem with that is you don't really know what genetic makeup you have so you cannot really gamble on your health. But what do you think about that? Yeah, I mean, I think what you're saying is true, but there are not great studies yet that we have in ophthalmology that are showing which of these people are at higher risk, but there's no question. As we learn more about genes, it's gonna tell us more and more. I remember a number of years ago when this first started, one of my mentors said that when you go to your primary care physician in the future, instead of him trying to prevent things, he's gonna tell you what you're gonna get. And the genes are a very strong factor, but the environment is also an important contributor. Exactly. Since that's the only thing we can control, we have to work on that for sure. All right, so let's see the next one would be, is there any evidence? I think this is somewhat related to the previous question. Is there any evidence that retinopathy can occur in patients who are pre-diabetic? We really would see that very uncommonly. And I guess it even makes one question, the diagnosis is, are they really pre-diabetic? You know, it would have an extremely low incidence, but it wouldn't be zero. But I certainly, if you're pre-diabetic, I would not get all concerned about it, but people over the age of 40 should certainly have a routine eye exam every couple of years anyway. And if you're over 60 or 65 annually. Yeah, so what you're saying is they shouldn't be really worried that much. Of course they need to be worried about not progressing to diabetes, but they wouldn't do all of eye disease at that stage. Okay, so another question is, if one eye is affected from diabetic retinopathy, will the other eye automatically suffer from the same fate? Another good question. First, one thing to understand, and patients often ask this about a number of different eye diseases, is disease almost never travels from one eye to the other eye. They're almost like separate organs. On the other hand, the two eyes behave very similarly, but not exactly the same. So whether it's diabetic retinopathy, or cataract, or glaucoma, if you have it in one eye, you're more likely to have it in the other eye, but there can be in a number of patients in asymmetry or a significant difference between the two eyes. So just because you have it in one eye, you'll probably have it in the other eye, but the degree of it can vary quite a bit between the two eyes. Awesome, thank you. Another question, and that will be probably the last question here. They are asking what type of vision loss a patients with diabetic retinopathy will experience, and is there a rule, or is it more like peripheral vision loss versus central vision loss, or can it be either? How does that work when it comes to symptoms of diabetic retinopathy? Well, again, patients that have early diabetic retinopathy usually don't have any symptoms at all. So we have very sophisticated instrumentation in the office to detect very, very early stages of this. We not only are looking at the anatomy and the blood vessels, but we're looking at the blood flow and how that is. So would you repeat the question one more time? The question is if they're already losing vision, what kind of vision loss would that be in most cases? I think that's the essence of the question. Yeah, so in general, the vision loss that diabetics get is they get swelling from the leaky blood vessels into the very center of the retina, that that's when they notice it. So you can get leaky blood vessels with swelling in the periphery of the retina or just outside the center, and basically patients are usually unaware of this and have no symptoms. So it's when it presents right in the center, which is what we call the macula, which is the center of the retina, that's the part of the retina that is responsible for your fine vision that lets you read and lets you recognize faces. And that is what people notice is blurred vision there. What's happening out in the periphery, you generally aren't very aware of, and if you are, there's probably big time trouble that's already there if you're aware of that. So it's really your central vision, straight ahead vision is what you're gonna notice in most people first. I see, perfect. Well, thank you very much for your time, Dr. Franco. Now, what would you recommend to our diabetic patients suffering from diabetic retinopathy or the ones who never want to get to diabetic retinopathy in a nutshell, what would be your recommendation before we conclude this video today? I think number one is get routine eye exams because we can diagnose this disease early and we can prevent it. And you want to prevent problems if you can. The days when people had severe visual loss, those things can be prevented, but the patient has to go to the appointments and comply with the course of treatment. We now with the newest drugs we have, it's almost a little bit of a fountain of youth where we can take stages of diabetic retinopathy now and we can take you to an earlier stage than what you had. So we've made huge advances in this disease and stick with your endocrinologist with someone who's got a great reputation like Dr. Ergen and also stick with the ophthalmologist and by doing those two things, you have your best chance of staying out of trouble or unfortunately, if you have a problem of getting out of trouble. Awesome, thank you Dr. Franco for your time. We really appreciate it. I think you gave us great advice and I'm sure our audience already appreciated. And I think they'll have more questions and if they have more questions, we'll get together again. Thank you very much. Okay, great, thank you Dr. Ergen. Have a good evening. Thank you too. Hey guys, I hope you're enjoying this channel so far and I hope you subscribed already. If you didn't do it and if you did, watch this video right there. I think that will help you too.