MedLink Health Connections Podcast

Diabetes and Your Vision: A Clear View with Dr. Evans of Georgia Eye Clinic

• MedLink Georgia • Season 1 • Episode 12

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Diabetes can silently damage your eyes long before you notice any vision changes. In this episode, ophthalmologist Dr. Evans explains how high blood sugar affects the tiny vessels in your retina—and how early detection can help prevent permanent vision loss.

With clear analogies and expert insight, Dr. Evans walks us through the stages of diabetic eye disease, why the brain might hide signs of vision loss, and how lifestyle changes can help your body heal.

Whether you're managing diabetes or supporting someone who is, this episode offers essential, hopeful information to help protect your sight.

Speaker 1:

Welcome to the MedLink Health Connections podcast. Today we're talking about something that often goes overlooked how diabetes affects your eyes. Diabetic eye disease can creep in without warning and it's one of the leading causes of vision loss in adults. What should you be watching for? When does eye damage actually begin, and can it be stopped or even reversed? When does eye damage actually begin, and can it be stopped or even reversed? To help us understand all of this, we're joined by Dr Evans, a leading ophthalmologist at Georgia Eye Care, located in Athens, georgia, who works with patients every day to protect and preserve their vision. Whether you're managing diabetes yourself or supporting someone who is, this episode is full of insight that could make a big difference. Dr Evans, we know diabetes can affect many parts of the body, but a lot of people may not realize the eyes are one of them. To start things off, can you explain what exactly is diabetic eye disease and how is it connected to diabetes?

Speaker 2:

Yeah, absolutely. I'd love to chat a little bit about that, but first I just want to say thank you so much for having me out. This is a great honor and it's a lot of fun to talk about the eyes, and I could be here all day. We'll try to keep it short and sweet. So what is diabetic eye disease and how is it connected to diabetes? Well, you know, diabetes in general is a disease of the entire body, so anything that has blood supply is going to be affected by diabetes.

Speaker 2:

Essentially, you have all this sugar floating around in your blood and and typically the body's way of processing that sugar is by releasing insulin. That sugar is then taken up into the tissues, such as the muscle, and places where it's useful, and the body tries to get rid of that sugar as quickly as possible. Because if the sugar stays within the bloodstream too long, eventually it'll start to make changes, and a lot of these changes are not great. And in fact, one of the ways that we check for diabetes in patients is we check your A1C and basically that is a marker of how long sugar has been in your bloodstream and the changes that the sugar actually makes to the red blood cells. And so, because we know that blood cells last for about 90 days within the body, that's a good marker to determine how much blood has been in there and how many changes have occurred to these individual blood cells. And so when we check your A1c we can tell, basically over about a three month period, how high your sugars have been. So that just goes to show that sugar hanging out in the bloodstream is not a good thing.

Speaker 2:

Well, if you can imagine, obviously there's blood flow all throughout our body, but there's some tissues and some organs that require more blood flow. So heart, kidneys, liver, brain and actually a lot of people don't know this but for its size, the eye actually demands probably the highest flow or highest what's the word? Concentration, I guess of blood from the body. So in terms of its size and how much tissue it has, the amount of blood flow that's going to the choroid, which is one portion of the eye, is tremendously high. So you can imagine it going back to sort of the eye is tremendously high. So you can imagine going back to sort of the process of this disease, all this sugar in the bloodstream going to an organ that has a lot of blood flow. You're going to notice some changes very, very often, and so that's why a lot of your primary care doctors are going to say every year, our diabetics need to have an eye exam because this is the only place in the body that we can actually visualize the blood cells or the blood vessels. So you know, I don't really know what's going on in your heart. I can do some tests and I can maybe do some imaging to take a look inside your body, but with the eyes, I can literally look in with my own eyes and see what's going on at the cellular level. And so when I look in there, typically and I'm hoping to see nothing I'm hoping to see healthy blood vessels and a healthy retina.

Speaker 2:

But typically what happens with diabetics, specifically ones that are uncontrolled, is, over time, the diabetes and the sugar inside the bloodstream starts to affect the blood vessels and it starts to affect their ability to hold in, basically, the blood. And the way that I explain this to patients is you know those garden hoses that you have that are like black and they seep fluid. You know you turn them on and it's like a way to water your garden, it's like a trickle type of thing. Well, think of it. Sort of like that You've got your blood vessel and blood is starting to kind of leak out of the blood vessels. And that's kind of another thing about the body. The body doesn't really like for blood to be in the tissues, it likes it for all of it to be inside the blood vessels. And so when the blood vessels themselves start to become kind of leaky and it leaks blood into the tissue, it becomes inflammatory and the body amounts a little bit of an inflammatory response to it.

Speaker 2:

And so it's a combination of this blood starting to seep out of the blood vessels into the surrounding tissue and in this case we're talking about the retina, because that's the portions that we can see easily when we look inside the eye.

Speaker 2:

The blood starts to kind of seep and trickle into the retina and it starts causing inflammation. Seep and trickle into the retina and it starts causing inflammation, and that inflammation can then lead to scarring and then scarring can lead to severe vision loss. And so essentially, with the scarring inside the eye, scars and I don't know if you have any scars or you've ever seen anybody with scars but scars when they first grow it's this body's attempt to repair itself. But then what happens is the scar starts to contract a little bit. And so if you've ever seen someone with a scar, you can sometimes see the tissue around it kind of contracting a little bit and when that happens in the eye it actually contracts and kind of pulls on the retina slightly and the retina at that point can then detach from the eye. So basically the progression. I know this is a very long winded answer, sorry it's okay.

Speaker 2:

But it's nice to have a little bit of background and kind of understanding of, like, what's the deal with all this sugar and how does it affect us? Right, but essentially you have sugar in the blood that causes damage to the blood cell I'm sorry, the the blood vessels and that causes the blood vessels not, it's not able to do its job very well. So blood starts to seep into the tissue and that causes inflammation. Inflammation causes contraction and other problems in the eye which we won't go into right now, and that contraction can sometimes cause retinal tears and detachments and things like that. So that's sort of the full progression of diabetic eye disease.

Speaker 2:

Now, of course, going back a little bit to, you know, blood seeping into the tissue, we know that it's not just red blood cells, right, there's lots of other things that are kind of floating along in our bloodstream. Uh, so of course we've got sugar, you know, we've got blood cells, we've got white blood cells, but we also have cholesterol, we also have a lot of other things that are necessary for our function, and but they belong either within cells or within the blood vessels themselves. And so when we have blood leaking out of the blood vessels and getting into the tissue, kind of where it's not supposed to be. The body tries to repair it, but sometimes there's stuff left behind, right, and I'm just going to call it junk, whatever's floating around in the bloodstream, let's say cholesterol, a little bit of waste, you know, because we also use our blood vessels and our cells dump waste into it, you know, to be filtered out through our kidneys and liver and whatnot.

Speaker 2:

So, it's kind of like a transport system, a highway system, and on the way here actually, I saw a wreck and you know they had cleaned it up, but I saw a bunch of junk like glass and like car parts still laying around, you know. So it's like, even after, like you know, something bad happens, the body tries to fix it, but there's always some junk left behind right. And so a lot of times in diabetic eye disease, a lot of that junk or that stuff gets left behind in the tissue and that's not very conducive to eyesight, if that makes sense. So you can imagine, your retina is a clear tissue that intercepts light and sends signals to our brain and our brain interprets that as an image. Now, if you have a bunch of junk in your retina that's blocking that light or reflecting that light and whatnot, it's going to cause a poor image.

Speaker 2:

Think of it like you got a camera and your camera's really dirty. You know you've got that clear lens up there and you've got a bunch of junk on that lens and you're not going to be able to see very well. So there's. It's kind of a multifactorial process, but essentially, you know what is diabetic eye disease. Well, it's, it's an inflammatory disease of the retina and you know how is it connected Well to diabetes. The inflammation comes from all the sugar in the bloodstream.

Speaker 1:

What are the most common eye problems caused by diabetes?

Speaker 2:

So I think we need to kind of think about problems. So there's problems for me, you know, as your ophthalmologist, and there's problems for you as the patient. Sometimes those sync up. The unfortunate part about diabetes sometimes is the early changes that occur in diabetes. Patients don't often know about Because obviously you can't look inside your eye and tell that something's going on right. But your ophthalmologist can look in there and can see blood leakage, like we talked about, and can see a leakage of that blood into the retina. We can see some of that junk that we talked about, the extracellular material that kind of accumulates after the body's trying to clean up all of this blood that's spilling out. We can see that in the retina and deposits and typically at that stage most of the time patients don't really know what's going on, for one of two reasons. One, if the changes are small enough, it doesn't create a significant amount of vision loss where patients don't really notice. But also, we were born with a spare eye, right, we all have two eyes, and so a lot of times the brain is very, very good at ignoring problems that occur in one eye, if that makes sense. I have patients all the time that come in who are nearly blind in one eye. But they had no idea, because the brain is just that good at helping us adapt. And you know, because, if you can imagine, we still have to function, we still have to live and survive, and so our brain just gets us there the most efficiently possible. So so that's the difficulty about diabetes and about managing eye disease, and that's why it's so important to have a yearly checkup. So that's what I would consider my problem. You know, when you come in and I take a look inside the eye and I can see little spots of blood and some of the early changes of diabetes, they're problems, but they're not necessarily major problems for the patient at that moment, if that makes sense, because to them it's not going to make that much of a difference. But that's often the time where we can really spend our time counseling with the patient and talking about how we can reverse these changes. So there are a lot of reversible changes that occur in diabetes in the early stages in the eye, and then eventually, once it gets into that inflammatory phase that we talked about, that's when a lot of irreversible changes start. So you know, once the inflammation sets in and you start having scarring and contraction and other changes. That's oftentimes irreversible, so let's talk a little bit about that for a moment. Irreversible so let's talk a little bit about that for a moment. We talked about how inflammation leads to scarring and scarring can lead to contraction, and contraction can lead to tearing of tissue.

Speaker 2:

What we haven't talked about is the fact that, because the sugar in the bloodstream causes those blood vessels not to work very effectively, the blood vessels original job, which is delivering nutrients and oxygen to the tissue, is dampened or hindered, if that makes sense. And so you have all of this retinal tissue that's looking for more blood, but what's happening is these blood vessels are not supplying it effectively because it's leaking out. Or, you know, oftentimes patients with diabetes also suffer from high blood pressure and high cholesterol, and so you've got these. You know, oftentimes patients with diabetes also suffer from high blood pressure and high cholesterol, and so you've got these you know, very poor blood vessels that are not delivering oxygen very well, not delivering the nutrients very well, and so you've got this tissue out there that's starving for oxygen. Well, when that happens in the body, tissues activate sort of a pathway that releases what we call the vascular endothelial growth factor, or VEGF, which is what we call it, and that recruits new blood vessels to that area. So it's kind of like they send up a little beacon and blood vessels start to grow towards it. Now this can be very important in some cases.

Speaker 2:

Within the body I mean, I think that there probably is an important aspect of this but inside the eye, new blood vessel growth, or what we call neovascularization, can be a real problem because often those new blood vessels grow in a very haphazard manner. It's not very kind of laid out. Well. You know, when we're growing as a fetus, there's kind of like a plan. You know, our DNA sort of puts out this master plan and it tells like where the blood vessels to grow and everything grows according to how, like it, best functions. But when the body is in this sort of repair mode, it tries to do things as quickly and quickly as possible. It's just like I don't care where the blood comes from, I just need it. And so when these new blood vessels grow, like I said, usually it's kind of haphazard. Usually they're not formed very well and often those new blood vessels themselves will clot and kind of stop functioning for whatever reason, and sometimes because this chemical is being released.

Speaker 2:

The VEGF that we talked about is being released all throughout the retina and the vitreous, which is like the center part of the eye. Blood vessels start to grow everywhere. You know, not only are they growing into the retina, they start growing into the center of the eye and it becomes a major issue because those blood vessels themselves then cause scarring and inflammation. They're not functioning very well either because there's blood in them with sugar and so they start to contract and it further pulls on the retina and so it causes lots of problems. Sometimes you can see those blood vessels grow into the drain of the eye.

Speaker 2:

Okay, we have a drain which is called the trabecular meshwork and that drain is responsible for all of the eye. Okay, we have a drain which is called the trabecular meshwork and that drain is responsible for all of the fluid that's produced in the eye. It drains it back into the body, basically back into the bloodstream, and so you can imagine, if all of these little blood vessels are growing into the drain of the eye, then that drain is not going to function well and that leads to high pressures in the eye, just like if you put a bunch of spaghetti in the kitchen sink and you turn the water on, that water level is going to rise, and that's what happens in the eye, and that will lead to something else we could talk about, which is glaucoma. So there's something called neovascular glaucoma, which is because of, if you break it down, neovascular new blood vessels glaucoma, which is an optic neuropathy often associated with high pressures in the eye. So you have that's a major problem in some of my end-stage diabetic retinopathy patients, where blood vessels are growing and causing high pressures in the eye, and all that pressure is causing severe trauma to the optic nerve, and so that's just one of the ways that pressure is causing severe trauma to the optic nerve, and so that's just one of the ways that diabetic retinopathy can lead to blindness. We talked a little bit about retinal tears and detachments that occur due to scarring and inflammation.

Speaker 2:

Sometimes, and most often, we actually I don't know why I forgot about this, but a lot of times I'll be called to the emergency room because there's a diabetic patient who's uncontrolled and their sugars have been kind of high and all of a sudden they just went blind in one eye and in my mind there's a lot of different things that could be happening.

Speaker 2:

You can still get blood clots and just you know, standard sort of things that happen, you know, but most commonly in my uncontrolled diabetics is going back to that leakage of blood. And so what happens is these blood vessels, they, they break open and blood starts flowing into the center of the eye. And if you, if you kind of think of the eye as like a globe or a snow globe, there's a lot of fluid in the middle and you release a little bit of blood in there and all of a sudden it's going to look like you just shook up that snow globe and you're not going to be able to see through it, and so that's a very common thing. We call it a vitreous hemorrhage, and that is one of the most common reasons for an uncontrolled diabetic to have sudden vision loss diabetic to have sudden vision loss.

Speaker 2:

So lots of problems Typically, you know, typically your ophthalmologist can detect these things early on if you're getting kind of routine care and your ophthalmologist will work really closely with your primary doctor to kind of help you kind of manage this. You know, because the thing that people don't understand is that because we can see inside the eye and I can actually visualize your blood vessels, if everything's looking good inside the eye, then chances are it's looking good elsewhere, right? So the places that I can't see, such as your heart, kidneys, you know, lungs, whatever, they all have blood vessels and those blood vessels are the same as the ones in the eye. So this is just kind of like you know you're trying to diagnose a problem with your car. You just got to pop the hood, you know, look under there, see what you see. And that's kind of what we do in ophthalmology, and so that's why it's so important to get an eye exam once a year.

Speaker 1:

Are these hemorrhages reversible?

Speaker 2:

So, yeah, typically hemorrhages in the eye. So so, yes, right, the body is very good at cleaning up its mess. Um, what the body's not great at is if the original factor, the original thing that caused that mess, keeps going on, right. So that's why you see patients that have, like, let's say, a stroke, and sometimes you know things don't get better, but sometimes they do. Sometimes you know things don't get better, but sometimes they do. Sure, right, and it's just the body's way of repairing itself. And but you know, of course, if, whatever reason, you had that stroke let's say your blood pressure was crazy high If you don't fix that problem, well, guess what? The body's not going to be great at repairing itself. Sure, you know, you have to kind of get rid of that original sort of what we call the etiology or the cause of that problem. And so a lot of times we see patients that come in with early changes in their eye and just some hemorrhages and blood leaking into the retina. As long as we can get that sugar under control and get that information to your primary doctor so they can better closely manage it.

Speaker 2:

And you know the patients, there's a lot of work to do. You know, it's not just on the doctors, right? I mean, the patients have to eat right and exercise and really change their lifestyle to get back to a point where their body is better able to repair itself. It is a lot, well, you know, and it's I think of things often. I try to break it down and make it simple. But one of the biggest things we say as doctors, we're always talking about a healthy diet and exercise. Um, and it really is the key to everything, Um, you, you always hear, like, for example, patients go to physical therapy after they have, like, a knee replacement or something like that. It's just work, it's exercise right, you're trying to get the body moving again, you're trying to strengthen your muscles and you're trying to put yourself in the best possible position to get healthy again. Okay, well, guess what? Your body is better able to do that when you are healthy. You know what I mean.

Speaker 2:

So if you, if you take two people, one, one person who is very unhealthy, very poor lifestyle, the, the level of nutrients that they're taking into their body are very poor, the level of nutrients that they're taking into their body are very poor, okay, versus someone who's active and healthy, that's eating a high level of nutrition and you give them the same injury. Well, guess who's going to heal faster? Obviously, it's going to be the healthy person, and it's easy for us to visualize that. But think about your body, all the healing that it's doing on its own. So you get a little hemorrhage in your retina, okay.

Speaker 2:

But I've got a super healthy person over here and I've got a very unhealthy person over here. They both have hemorrhages in their retina. Who's going to be able to clear and clean up that hemorrhage better? It's going to be the healthy person, right? And so I think sometimes we think of healing and reversible damage and all of this at more of a sort of meta level, like, oh, I hurt my knee, I need to heal, but your body's doing a lot of this at a cellular level too, right? And so that's really where the work happens. And if your body is not equipped to do that because of poor nutrition and poor health and all of that, then the same problem is going to keep happening. But you're also never going to get over that first insult. That makes sense.

Speaker 1:

What are some of these like lifestyle changes that you can kind of do to help with that?

Speaker 2:

Yeah, no, well. So this is kind of like the Sunday school answers, you know, like there's always answers that you can give when someone asks you a question, you can instantly like be right, right. So whenever someone asks me that question, I'm always going to say, well, okay. Well, you know, eat better, right, that's always going to be the answer, no matter what. So when I was in medical school, that was an easy one. Like doctors would always try to ask me super difficult questions. I'm like, well, you know, let's focus on eating healthy, and it's like my turn's over next guy. But so lifestyle changes. So, number one absolutely nutrition, that's all it is right. A Absolutely nutrition, that's all it is right.

Speaker 2:

A lot of times in diabetics and diabetes, we're just overloading the body's capacity to deal with all the sugar, and so and sugar is not just, you know, cakes and bonbons and stuff like that you know our body breaks down a lot of food into sugar, and so and this is something that you know I won't get into because I'm not the nutritionist and I'm, you know, I don't know all about that but there are certain foods that will raise your blood sugar a lot higher, and patients often know what. They are right. They know what spikes their blood sugar and it's not always the same for everyone. It's not always the same for everyone. Funny enough, but, um, but we need to give the body a break and and try to allow it time to repair itself and eat better, right? Um, exercise. So we know for a fact that when we exercise, it makes it much easier for our muscles and other tissues to take in that sugar from the bloodstream, and so we're getting that sugar out of the bloodstream into the surrounding tissues to lower our blood sugar levels as quickly as possible. And so every moment and you know, the more that you are working out and using your muscles, the lower your blood sugar is going to be. That's great. And so those are like the two main things, right?

Speaker 2:

And then, of course, you know, there's patients who are in transition, who are working really hard to get their blood sugars under control. They're working really hard to take their medications and to exercise and to eat, right? One simple thing and again, I know this is self-serving because I'm an ophthalmologist but just go see your doctor, right? That's a lifestyle change, right? Because there's so many people who don't want to go see doctors at all and we can't help if we don't see you. And a lot of times, you know, burying our head in the sand and saying I don't have any problems and I don't see any doctors, I don't take any medicines like, doesn't necessarily mean that you're healthy. Whether or not you're healthy is really just an objective fact. You know it's there or not. Seeing your doctor can just kind of help you manage those issues.

Speaker 1:

Okay, and so, with that being said, what are some ways that you work with other healthcare providers to support patients with diabetes?

Speaker 2:

Well, the biggest thing is a patient will come into the office and say, hey, my primary doctor said I needed to see you, and so there I'll typically kind of take a few moments to sort of talk about diabetes in the eye sort of what we did here, but just a little bit more abbreviated and talk about why it's important.

Speaker 2:

And then the biggest thing is just communicating with the primary care doctor, letting them know that, hey, this is what I saw, and not every little change inside the eye requires a whole lot of intervention on my part. Sometimes, you know, if I see just a couple little hemorrhages, that's something that I can just manage and watch, especially if that patient is being taken care of by a primary doctor who's following them closely to make sure that their blood sugars are headed in the right direction, then I feel a little bit more comfortable, kind of letting them go for a while and just monitoring things. But certainly if it's a patient whom I feel like is maybe not managing their disease very well, then that's something I'm going to communicate to their primary doctor so they can be a little bit more aggressive in getting those sugars under control.

Speaker 1:

Do you have any final words to say? Anything we might have missed.

Speaker 2:

I think that I always have more to say. That's my problem, you know. I think that you know diabetes.

Speaker 2:

When I was, when I was in medical school, I remember being in a room full of doctors and we all always talked about like what's the one disease that would be the most challenging for you to get. And we're talking about doctors who have managed some of the most challenging things. You know, inner city, Atlanta, Just very, very challenging things, and almost always diabetes. You know, kind of rose to the top. It is just such a very difficult disease to manage. It's just such a very difficult disease to manage. But I think the final word would be to help empower patients to know that there are so many tools out there that can help you. There's a lot of doctors who want to help you and this can be something that can be managed, you know, and just sort of take the take back that control of your life and and make these decisions to help improve your outcomes and your life and your quality of life, you know. So that's the biggest thing is that you can do it and it's not the end.

Speaker 1:

You know this diagnosis of yours, you know there's so much more that wraps up our conversation on diabetic eye disease, a condition that affects millions, but with the right care and early action, it doesn't have to steal your sight. A big thank you to Dr Evans for joining us and helping shed light on how diabetes can impact vision and what you can do to protect it. If you or someone you love has diabetes, don't wait to schedule that annual eye exam. It's a simple but powerful step in protecting your long-term health. And if you need support managing your diabetes, medlink Georgia is here to help. Our diabetes education program offers personalized guidance on nutrition, blood sugar management and healthy lifestyle changes. Visit MedLinkGAorg to learn more or schedule an appointment.

Speaker 1:

Thanks for tuning in to the MedLink Health Connections podcast. We'll see you next time. Thank you for tuning in to the MedLink Health Connections podcast. We hope you found today's episode informative and inspiring. If you enjoyed the show, please subscribe, rate and leave a review on your favorite podcast platform. Remember, the information shared in this podcast is for educational purposes only and should not replace professional medical advice. Always consult with your healthcare provider for any medical concerns. Stay connected with us on social media and visit our website at medlinkgaorg for more resources and updates. Until next time, stay healthy and take care.