Diabetic
Mr Ajai K Tyagi MS FRCS
Mr Ajai K Tyagi MS FRCS, obtained his Fellowship of the Royal College of Surgeons (Edinburgh) in 1994. He completed his Registrar training in general Ophthalmology at The Birmingham & Midlands Eye Centre, Birmingham. Following this he underwent sub-specialist training in Vitreoretinal Surgery at Newcastle-upon-Tyne. He also undertook an Observership at John Hopkins Hospital, Baltimore to study new techniques in managing patients with retinal and in particular macular diseases.
Mr Tyagi was appointed as Consultant Ophthalmologist at The Birmingham & Midlands Eye Centre in 2001. This is the second largest eye hospital in UK and is a dedicated teaching hospital for medical students and Ophthalmologists in training. Mr Tyagi also trains surgeons from across the globe in vitreoretinal surgery. He has a large tertiary referral base with patients being from all over the country. He has presented at various international conferences and has published research papers in prestigious medical journals.
Mr Tyagi has specialist interest in medical and surgical management of patients with vitreoretinal diseases. Few of these are:
- Intravitreal lucentis and avastin: These new drugs can restore vision in patients with macular degeneration, retinal vein occlusion and diabetic retinopathy
- Retinal detachment:He undertakes surgery for simple retinal detachments and the more complex cases associated with proliferative vitreoretinopathy, giant retinal tears, trauma etc
- Macular holes: He performs internal limiting membrane peel to improve the success of the surgery. Short acting intraocular gasses are mainly used to reduce the duration of postoperative rehabilitation. Patients who cannot posture following the surgery are adviced to have the long acting gas.
- Age related macular degeneration: He is involved in both the medical and surgical management of patients with AMD. He performs the full range of treatment options for AMD including macular translocation for patients who will not benefit from medical treatment for AMD, new intravitreal drugs such as Avastin/Lucentis (improves vision in wet AMD).
- Diabetic retinopathy: He is happy to review patients with diabetic retinopathy and will perform retinal laser treatment or vitrectomy if necessary.
- Central retinal vein occlusion: He performs vitrectomy with optic neurotomy and intravitreal steroid injection. This surgery in some cases can prevent severe loss of vision
- Branch retinal vein occlusion: If indicated, new surgeries such as vitrectomy with sheathotomy are performed by him
- Epiretinal membranes: He performs internal limiting membrane peel along with ERM peel as this additional step can improve the outcomes following vitrectomy.>
- Subluxated/dislocated lens or IOL: Surgical management carried out by him may include vitrectomy, scleral sutured IOL implant or iris fixated IOL.
- Intravitreal triamcinolone: This drug can be used for macular oedema due to various conditions such as diabetic maculopathy, vein occlusion, uveitis, post cataract surgery etc.
- Retinal laser treatment: He performs laser treatment for patients with diabetic retinopathy, retinal tears etc.
- Ocular Trauma: He is keen to manage patients with ocular trauma and perform surgery if necessary.
Diabetic Eye Related Conditions
Diabetes is very common, affecting approximately 1 in 25 patients in the developed world. In the UK up to 9% of the whole NHS budget is used to treat diabetes and its related complications.
The condition can start in childhood or later in life. It can affect many different parts of the body, but particularly the eye.
How does diabetes affect the eye?
Diabetes can affect the eye in various ways. The most serious effects however are through problems in the retina. This problem is called diabetic retinopathy.
Diabetic retinopathy occurs as a consequence of diabetes and can result in loss of vision either through leaky blood vessels causing swelling of the retina or by causing the production of abnormal blood vessels which result in bleeding within the eye and scaring of the retina.
Screening is essential to detect vision threatening stages prior to loss of vision.
Having diabetes does not mean that a person will have eye problems, but it is important that regular eye examinations are carried out to ensure that any potential problems are diagnosed early. Sight loss from diabetes can usually be prevented if retinopathy is diagnosed and treated early. After diagnosis the condition can be graded by a person’s eye specialist depending on its severity.
Treatment
The most important aspect of management of diabetes is to ensure that good cooperation exists between each patient and the team of health professionals who are involved in managing their care. The general practitioner is key to proper management of all systemic medical factors. However, the ophthalmologist as a diabetic retinopathy screener in addition to directly managing retinal problems should provide support to the GP by helping to communicate the value of good systemic medical management. Strategies for treatment combine optimization of systemic risk factors such as blood glucose control, blood pressure management, reducing blood lipid levels.
Evidence for the value of controlling these factors includes:
Glycaemic Control:- Diabetes Control and Complications Trial (DCCT) demonstrated a 26% reduction in the risk of developing macular oedema where there was intensive insulin treatment
Blood Pressure Control:- UK Prospective Diabetes Study (UKPDS) reported a 47% reduction in loss of vision from macular oedema in Type II diabetics where there was tight blood pressure control
Blood Lipid Control:- The DCCT and the ETDRS studies have demonstrated positive correlations between lipid profiles and the development of macular oedema in patients with type I Diabetes.
Smoking:- This is a well recognized risk factor for diabetic micro- and macrovascular problems. No diabetic should smoke.
Local Ophthalmic Treatment
The Cathedral Eye Clinic follows the Early Treatment of Diabetic Retinopathy Study (ETDRS) guidelines when managing diabetics with laser photocoagulation. This study sponsored by the US National Eye Institute has shown that early laser intervention when clinically significant macular oedema is present can reduce the risk of moderate visual loss by 50%.
In addition to the ETDRS study guidelines the institute advocates using larger spot sizes with longer durations and lower energy profiles. This is in response to more recent studies demonstrating effectiveness of this technique while minimising any side-effects of the laser treatment. (Roider J et al, 2000, BJO 84(1):40-47)
