The following lecture on "The Eyes and Diabetes" was given at the American Foundation for the Blind Center on Vision Loss in Dallas, by Michelle Brochner, MD, an ophthalmologist and member of the Center on Vision Loss advisory board.
The lecture was given as part of a series sponsored at the Center by Kappa Kappa Gamma.
Hi, everybody. Some faces look familiar. I appreciate the introduction. A couple things. Yes, I was a swimmer in a previous life. And a little about me. I was a swimmer at the University of Texas, as they say THE University of Texas. And I swam on a scholarship and then graduated, went to medical school in Texas and then before that had gotten a degree in biology and in nursing. So I was also a nurse. And as a nurse I saw a lot of diabetes. I worked in the emergency rooms, worked in home health, and actually worked my way through medical school as a nurse before ER even came out. With that idea.
And then from there I went into trauma surgery, and then ocular plastics and eye surgery. So I decided to set up a practice here in Dallas. And one of my passions is eye education and diabetes, glaucoma, macular degeneration in general. And I got invited to join the Board of Directors here, and I really have been impressed. And I'm very happy that they allowed me to participate. It's a great passion.
As far as my practice, I end up speaking now all over Dallas, all over the country, predominantly about educating folks, and educating them so they can understand why doctors harp on you all the time about different things. Instead of just telling you, we need to make you understand in a sense that you understand the reason why—it's not that we're just telling you to do it "because."
And I'm a very visual person so I use a lot of analogies. So if anybody doesn't understand anything, I would ask that they raise their hand or just kind of flag me down. And I'll try to reanalyze what I'm saying.
Today I'm going to do diabetes. I give this lecture probably in my office twenty times a day. I could probably do it in my sleep. But if I can just reach three people a day, I think it will save vision phenomenally in this country.
Diabetes will steal your vision and you won't even know it. Yes, your doctors tell you about your diabetes. Yes, you need to be under control.
What I'm going to show you today and I'm going to try to talk through some of the photos too, so bear with me because I know some people in here are a little visually challenged. I want you to understand the reasoning behind it, and I want you to understand the impact.
Your eyes get impacted first, before your heart, before your kidneys, before anything else with your diabetes.
Okay. So I'm going to start with that and we'll go from there. All right. As he said, I am an ophthalmologist, that's sixteen years of school, after high school. All right, the bridge of knowledge of your diabetes and your vision. So my goal has been to help you understand why we harp at you, "Get your blood sugar below 130. Get your hemoglobin A1c below 6.0."
If some of you don't know what your blood sugar is, you need to know. If you say, "Well, my doctors take care of that." Well, no, they don't. Yes, they're there to guide you, but you need to be informed in this day and era. You need to know what your blood sugar is first thing in the morning. You need to know what your hemoglobin A1c is.
A hemoglobin A1c is a predictor or an actual number of what your blood sugar's been over the past three months.
We know from research that 6.5 and below will preserve your vision, 6.0 will almost guarantee that you won't be affected. And that's an average of 130 or below for your blood sugar every day. That's two hours after a meal, and that's usually first thing in the morning.
Okay. Let's talk about what it does to your eyes. The dreaded word: diabetic retinopathy. Well, what does that mean to you? Sounds like a bunch of mumbo jumbo after the word diabetic.
Retinopathy is the retina. And what is the retina? The retina is the lining in the back of your eye. If you think of your eye as a tennis ball and the inside lining as wallpaper, that wallpaper is what controls your vision as far as what it projects. So if there's damage there, your vision's going to be impacted and the message doesn't get sent.
What happens in diabetes, if your blood sugar goes above 130 on a repeated basis, you start to get little hemorrhages, small little red dots in the wallpaper. It gets progressive. If you don't bring your sugar down, it starts to form these little yellow "exudates," or deposits in the wallpaper.
The black and white photograph over here shows leakage. The white is all the leaking of the dye out of the blood vessels. What happens, if you think about the walls in your house, you've pipes in the walls in your house. And when those pipes get old or let's say they get weakened they start to leak. The same thing happens in diabetes. If your blood sugar goes over 130, it weakens your pipes and they start to weep. And weeping—you don't feel it. You don't know that it's happening.
The only way that you know this is if you know what your blood sugar is. If your blood sugar is over 130, your pipes are probably weeping. From weeping it goes to leaking and leaking is the blood. You don't feel it. Your vision does not get impacted at this time at all. Then it turns to actual hard deposits or what I like to term as rust. Then your pipe is going to burst. And if that pipe bursts, you still may not feel it and you still may not be able to detect it in your vision. You still may be seeing twenty twenty. But, after that happens, the next thing is what we call "the big bleed." And with that in mind, it starts to really bleed and it can fill the eye up with blood in thirty seconds if one of your bigger vessels breaks. And if that happens, that is complete blindness. And I'm talking total darkness.
So in this first picture, this is progression of diabetic damage. There are little bleeders, a little bit more. You can see that there are little black holes here where the bleeding has actually damaged the wallpaper. Here you start to see some little microaneurysms which are pouching of the actual pipes. And then you're going to see swelling which is this darker color right in the center.
Now the macula is a part of the retina. It's like the engine of the retina. And it's what tells you colors. It's what tells you how to thread a needle. It's fine vision. And those are the most sensitive cells. And they're right in the center here. Now, when you start to leak, well what happens? Well, see this white? It's like cob webbing. It's severe diabetic damage. If your sugar is over 140 on a regular basis and you start to bounce—two hundreds and three hundreds,—this accelerates and all that leakage starts to gather and form cobwebs. Okay? Just like spider webs. Doesn't that look like a spider web?
And what happens is it attaches to that wallpaper and it's so sticky and gooey that it pulls the wall off. So it literally pulls your wallpaper down. And that's a retinal...that causes a retinal detachment.
It's very hard to go into the eye and clean this up. It's fibrosis of the retina and finally a retinal detachment leading to vision loss. It's very hard to reattach it after that and you will not recover all your vision even if they reattach most of it.
[Doctor reads caption on next slide.] "New vessels pull on the vitreous and lead to bleeding and scarring of the retina." Well, what does that mean? Well, with this also the eye's panicking. So what it does, is it tries to form new pipes. With new pipes it actually cuts off the blood supply to the eye trying to get it there. There are too many superhighways. Kind of like the hifi downtown? Try to get into downtown?
So the eye starts to die. Now this is an overall picture. And I really like this picture. It's put out by the American Academy of Ophthalmology. And this first picture shows a gorgeous orange. Nice color. No bleeding. No little red dots. The blood vessels look really good. There's not blackening of the center. This is a normal eye. No diabetic retinopathy.
But this is a diabetic that's keeping their sugars controlled. You move over here, you can see a little exudate, right here this yellow. It's a little leakage, what I called the weeping. You move over here, what do you see there? There's a little bleeding. Then this is my patient that's bouncing 160, 180, 200. More microaneurysms, a little proliferation. More exudates.
I'm telling them, "You will lose your vision." I have three people in my practice that have lost their vision and that's all I want. I don't want any more. And I tell them. The first one is thirty-four years old with four kids. Didn't listen to me and he's blind now.
Okay. The second one listened to me. He only lost his vision in one eye.
Here you can see more exudates. More swelling. It's turning black. Even blacker. Okay? Now if you come down here you can see there's the white cob webbing forming. And this picture here is all red. Why do you think it's all red? That's all blood. The whole eye's full of blood. Okay?
Now, can you live in total darkness. It is very difficult to live in total darkness. If you have a choice, I probably would not want to live in total darkness. It's possible. You can do it. But it is harder and harder the older you get.
And so what I say is be pro-active not inactive. Now. We will help you keep your eyesight. But you have to also keep an eye on your diabetes with us. We have to work as a team.
This is my vision checklist that I use. And I go over this, like I said, every day. MONITOR AND RECORD YOUR BLOOD SUGARS. I cannot stress this enough. You know I get it every day: "Well, you know, my blood sugar's the same every day."
"Well, how do you know that?"
"Well, I don't. My doctor tells me that."
"Well, how does he know or how does she know?"
"Well, they just do."
"Well, how do they magically know if they're not testing your blood sugar every day?"
Testing it once a month or once every three months is great. But if you truly have diabetes which means you are on medication, you should be checking your sugar every morning, ...minimum of every morning, and recording it to follow the trend.
Why? One reason is, you need to communicate with your doctor.
You know, I have a patient whose blood sugar started climbing. They were doing so great. They were at 120 128 125, doing great.
All of a sudden, their blood sugar started climbing to 166 and they were eating everything right. They were exercising. They didn't know why. Well, they were having a urinary tract infection, their kidneys were infected. And what that showed them was an early sign.
So when your sugar starts to rise, it can show you an infection before you actually know you have it which can save your life.
It also showed this person, okay, let me look at my diet, which is the thing you need to look at first. I have some patients that can eat a little bit of potatoes, some that can't eat any. Some that can eat some white tortillas once in a while, some that can't do that. Some that can eat rice, some that can't.
Most of my diabetics, I give them five rules.
Stay off the white flour meaning white bread, white rice, white pasta and go to wheat.
Exercise minimum twenty minutes a day—meaning even for a thirty minute show on TV if you get up on the commercials, you'll get a walk around for fifteen minutes, if you just get a walk around on the commercials.
So any excuse I hear, "oh it's too cold. It's too hot" doesn't cut it. I can figure out a way for you to do five minutes of exercise which will fool your body into burning your calories and burning your sugar.
Second of all, eating knowledge and understanding. Comes back to my other rule. Okay. What makes your sugar go up? Well, does orange juice make your sugar go up? That's what you take when your sugar goes low, right?
Well, think about it. If you eat an orange, it's the same thing as drinking orange juice. So your sugar's going to go up. So I would stay away from oranges. Only if you need them. So berries are good, blueberries raspberries, bananas, half a banana, half an apple. Those fruits are good for you. They're fiber and they're good for you. And they don't crank your sugar up over two hundred. Oranges will.
Now exercise. Like I said, cleared by your doctor.
Audience Question: How does coffee impact your insulin?
Brochner: It's different for every person. But it's a stimulant. And it can actually mess with your insulin. It can actually make you need more. Some people will need more. And actually some people might need less.
Audience Question: So when the doctor tells you that, speaking about the insulin that you take, or the insulin that your body's already producing?
Brochner: It can be both, actually. There's no way to tell. And the way to tell that, and this is what I tell people. There's no way to tell what your body's producing and what you're putting into your body. The only thing you're going to know, ... if you're on a sliding scale you'll know how much you're putting in But you don't know what your body's making. The way to tell that is eat the same thing.
I know it sounds really crazy, but eat the same thing for three days. And I mean exactly the same thing.
Take your sugars two hours after a meal. Take your sugar first thing in the morning, and when you introduce the coffee, note the time that you drink the coffee and then see what your blood sugar is two hours after.
And record it over the next three days and see what it does because everybody's different. Okay?
Audience: Thank you.
Brochner: You're welcome.
Next. ALWAYS GET YOUR VISION CHECKED WITH A FULL DILATED MEDICAL EXAM.
Now optometrists are great. They get the basic knowledge down. But if you are a complicated diabetic, you need to be seeing an ophthalmologist every six months. My patients, until they're controlled, they see me every six months.
Once they prove to me that their hemoglobin A1c stays below 6.0 and they're at 130 and they're doing what they're supposed to be doing, then I let them out a little bit more. I give them ten months. If they prove that to me, it's a year. The minute they slip and I send a letter to their doctor, within twenty-four hours of them seeing me, so we're all on the same page.
Life is precious and so is your vision. You know, I don't know if I could go a day without seeing a smiling face and if I was to lose my vision, that would impact me directly. So vision is precious. We pay money to get our teeth fixed. We pay money to see doctors. We pay money to go to Walmart. But how valuable is your vision? And that's my biggest message. Any questions?
Audience Question: Most of the medication you see on TV and stuff like that, it'll say don't take it if you have glaucoma.
Audience Question: And my ophthalmologist told me that the glaucomas that diabetics have is different from that glaucoma. And you can take the medication and it wouldn't hurt you.
Brochner: I agree to disagree with that ophthalmologist at this point. It really depends on what type of glaucoma you have. You can have diabetes and have—there are twelve different types of glaucoma. You can have diabetes and have a different type of glaucoma.
Diabetes affects your risk of getting glaucoma. Glaucoma is a disease that attacks the nerve that connects your eye to your brain. And what happens is, that is usually open angle glaucoma meaning that the flow of fluid through your eye that keeps the pressure in your eye is not effected as much as somebody else who has what we call narrow angle glaucoma. And that kind of glaucoma is their pipes get shut down if they take decongestants or cold medicines. And that can throw them into a different type of glaucoma.
I have diabetes patients who have closed angle glaucoma. And so those medications do affect it. So to answer your question directly, I would say I would not risk it until you ask your ophthalmologist which type of glaucoma you have because I have people that do have open angle glaucoma that have taken a cold medicine and their pressures have risen in their eye. And the goal is bringing their pressures down in their eye to save that nerve. And when you raise that pressure, even if it's just one or two points with a cold medicine, that can impact you. Do you see what I'm saying?
Brochner: So it really depends on what type of glaucoma you have and it really depends on what your body does with those cold medicines.
I tell all my patients with diabetes, if you're going to take over-the-counter cold medicines, I need you to call me and ask me first. If you are at risk for glaucoma and I've told you that you are at risk for glaucoma because I check all my patients that have diabetes for glaucoma, and it's in your chart that you are at risk, I would tell them, if you have to use it, let me know.
I'd like you to come in and let me check your pressure and see if your body responds differently. And I do that for all my patients, because I've seen too many times where they have open angle glaucoma and their pressure still has risen from the cold medicine.
So I would say I disagree with that blanket statement. But you may have the type of glaucoma where it's okay for you to take cold medicines. Does that answer your question? Okay. Anybody else? Yes, sir?
Audience question: Yes, I was going to ask, can you drink a beer every now and then if you have diabetes?
Brochner: Good question. Because I don't want to destroy your fun, I was going to go over that a little bit.
You know, your body, think about your body and how it handles the food you eat. Our society eats its biggest meal at dinner. Well, that's kind of backwards. If you're diabetic, you need to have your biggest meal of the day at lunch. And if you work, it's hard to have a beer at lunch. So I would say, a beer at night, no. I would say on the weekend, a beer at lunchtime, yes. But with that knowledge, if I'm going to have that beer, if I'm going to have that, I know I need to go walk that night to burn those calories. It's a tradeoff.
Light beer is your friend. There are certain beers where the carbohydrates are lower and the sugars are lower and I would try to keep toward those. If the flavor of the beer is what you like, I would try to find one with the lowest carbohydrates and the lowest sugar content. If you swear by Heineken or Coors and you have to have a beer then you need to look at your lifestyle and say "Okay. I'm going to have a beer at lunch on Saturday with, you know, the knowledge that I'm going to need to walk twenty minutes that night." And what I tell also (I'm going to tie this in), the biggest meal needs to be lunch. I'm not saying go live this life that's boring. Nothing fun. I can't eat any of the good food. I'm saying if I'm going to eat the good foods, when I took my sugar that morning, it'd better be 130 or below. And if it's going to be, if I'm going to cheat, as we say, as I say to my patients, if you're going to cheat, cheat at lunch not at dinner.
Dinner, your metabolism is slowing down. It should be your smallest meal of the day. Okay? So that when you wake up the next morning, you're not behind the eight ball already. And, you know, you don't wake up with "Oh wow, my sugar's at 300, I guess I shouldn't have had that beer at nine o'clock at night."
You see what I'm saying? Anything else? Yes, ma'am.
Audience Question: So, the information you just gave, you're basing that on if a person has maybe an eight to five schedule?
Audience question: So what if you're a night person?
Brochner: Right. A night person? Okay.
If you're a night person, it's more of a challenge because we know that working night shifts adversely affects your body as a diabetic.
It's very hard. And I can't tell my patients "Try to get on the day shift." They look at me like I'm crazy. You know? What you have to do is you have to flip your day, and you have to do it consciously. So if let's say you sleep during the day which is your night. Then you're going to have to have, when you wake up, that's your breakfast. Okay? So let's say you wake up at six to work the seven shift. Have your breakfast. Your lunch is going to be one or two in the morning. You're going to have that be your biggest meal because you're still up and movin' and groovin'.
And then right before you go to sleep it should be a small meal. You see what I'm saying? Just flip it. Kind of have to look at it as where am I maximally going to burn my calories, my sugar and my carbs? It's when I'm up. I'm in the middle of the day. okay? Go ahead.
Audience question: And how do the white products you mentioned before impact your blood sugar? Things such as rice, white bread, potatoes?
Brochner: Basically I tell my folks, when they first come in and they've just been diagnosed I say "Okay. You're overwhelmed. You haven't made it to your diabetes education nutrition class yet. These are the fast and hard rules. No white flour meaning white bread white rice white pasta. The reason why is we know that white flour is a complex carbohydrate. It cranks your blood sugar up. Your body, when it hits your system, the sugar just goes straight through the roof. We know with wheat products, because it's higher fiber, lower carbs, lower sugar, it doesn't do that. It keeps you stable. White flour is very processed and we think that's part of the problem. So anything white will crank your sugar exponentially high. Potatoes do the same thing. Oranges do the same thing.
Now everybody's a little different. You know, I don't want to make a blanket statement.
Audience Question: Do eye exercises help?
Brochner: No. I wish. I'd have everybody do them. Yes, ma'am?
Audience Question: What if you get up in the morning and your blood sugar is normal, what if you decide not to eat breakfast?
Brochner: No. No.
This is what happens. If your body thinks that you're starving and that means by not putting anything into the tank, okay, into your body, it's going to store and your sugar's going to crank up even higher. What you have, and I tell you, I have diabetics "oh I starve myself, doc, and my sugar's going higher." Because their body thinks that you are starving and it's going to save—hold on to everything it has. And it's going to crank your sugar up even higher because it thinks that you need the energy, okay, and the sugar. So your liver releases all this and your sugar is going higher and higher.
Breakfast. As a diabetic that is so important to have. Whether it's just a piece of wheat bread and a cup of coffee or a bowl of oatmeal. But breakfast is so important. Because you're already doing great by waking up, "Oh wow!! My blood sugar is 92. Oh great, at lunch I can cheat maybe." You know? So well, I'm just saying, you know, you didn't wake up with it at 200. Okay. And you're like "Oh I'm already behind the eight ball. I'm going to have to be really good today." You know. So blood sugar 90. Skipping breakfast. No. Skipping your insulin. Absolutely horrible because your insulin just doesn't protect you at that point. What you're injecting into your body covers you no matter what anybody tells you. Short-acting, long-acting, it's still in your system. It's going to help you throughout the day.
And what you're doing, is you're yo-yoing your body. "Oh I'm not going to eat because my sugar's 90. And I'm not going to take my insulin." That impacts you at lunch, at dinner. And it's even going to impact you the next day. What we're going for is rolling hills not mountains and valleys. All right. One more.
Audience question: All right. You said lunch should be our largest meal. What do you recommend for exercise? This is just your personal thing.
Brochner: My personal thing. Well, if I was a diabetic, and I was doing pretty good, I personally think after you eat your last, your dinner or your supper, if you can, I think walking twenty minutes. That's a good start. After your last meal of the evening, if you walk for twenty minutes it fools your metabolism into "Oh, wow! She's still going. I need to burn. I need to burn what she's put in there." So your metabolism is still going even by the time you lay down and go to sleep.
Now sometimes that's hard for people 'cause they are, they've walked and now they're all revved and they can't sleep. But I usually tell people twenty minutes of walking after your dinner. You know, get your spouse, your friends and just walk twenty minutes. That to me is better for you than getting up at six in the morning and just knocking out twenty miles. But some form of exercise. Aerobic, twenty minutes. Doesn't have to sweat, you know. Don't have to just knock it out but just walk. And usually most of my clientele does a twenty minute walk.
Some of them can't do it except at lunchtime. So they'll have their biggest meal at lunch. And that's their first thirty minutes. Then they'll go walk thirty minutes. So, you know, it's kind of personalized. But twenty minutes in the evening is usually when most of my people do it.
[End of lecture]