Shireen: In this episode, Dr. Mitul Mehta talks about what is diabetes retinopathy. He dives into symptoms and treatment for diabetes retinopathy and how opthamologists and other healthcare providers can better support individuals with diabetes before their presentation with the disease. Tune in to learn more about diabetic retinopathy prevention and management. 

Podcasting from Dallas, Texas. I am Shireen and this is the Yumlish podcast. Yumlish is working to empower you, to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week. 

Dr.Mehta teaches medical students, residents and fellows how to diagnose and treat diseases of the retina including diabetes mellitus, specializing in vitreoretinal surgery. He also co-founded an augmented reality visual aid company called Eyedaptic that makes devices to help people with retinal disease see better. Welcome Dr.Mehta!

Dr.Mehta: Thank you.

Shireen: So Dr. Mesa diving right in, why this, why did you decide to become a retina specialist? 

Dr.Mehta: So when you're in medical school, you have to pick a field of medicine or how you got to live the rest of your life, basically as a doctor. And so it's a really important decision to make. So you need to take it pretty seriously. So, what I did was I did the brute force method. So between my first and second year of medical school, I went home. My dad called all of his doctor buddies and I rotated everybody's office for at least half a day. And if I liked it, I went back. And so I rotated through basically every field of medicine over that summer.

And the ones I like the most were neurosurgery, urology, and ophthalmology. And then during your third years of medical school, you actually do rotations in these fields directly. So I did all those. And the one I liked the most was after Knology and within ophthalmology, the field of ophthalmology that involves the most kind of cutting edge, most delicate surgeries. The one that's probably the most important is the retina and retina is definitely the best field in all of medicine without any bias, no bias. 

Shireen: Okay. Gotcha. Gotcha. Right, right. No, I got it. What is diabetes retinopathy? Help us understand. 

Dr.Mehta: So ultimately when you think about diabetes in general, ultimately diabetes is a disease of blood vessels because the sugar damages the blood vessels, and in particular, it damages the cells in the walls of the blood vessels by damaging the support cells called the parasites.

And so when you damage the blood vessels, it damages everything. Because everything in the body needs blood to survive your oxygen. So in the retina, in particular, the retina is the nerve layer at the back of the eye. And so if you don't have nerves, you can't capture light and then you can't send that light to the brain and you can't see anything.

So when the blood vessels to the nerves that catch the light die, then it damages the vision permanently. So diabetic retinopathy is ultimately the damage to the blood vessels that causes the damage to the nerves. 

Shireen: I gotcha. And, and help us understand the science a little bit better. So you mentioned the blood sugars to help us understand the connection between blood sugars, diabetes, and then retinopathy. And what does that mean? Is that for everyone in the population? 

Dr.Mehta: Yeah, so, so diabetes is a very common disease. Now we're seeing very, very high levels. It's a pandemic at this point, and it's one of these diseases that affects such a large percentage of the population that everybody knows somebody who's diabetic pretty much. And so what diabetes does is in particular, the first talking about type two diabetes, because that's the more common. So when people have type two diabetes, what happens is people are resistant to their own natural insulin in their body. And so as a result, their body can't regulate the amount of sugar that's in their bloodstream. When the sugar gets so high, it's actually toxic to the cells in the body. And so in the retina, in particular, in, in the actual eye, it damages the blood vessels. And when it damages the blood vessels, they become leaky and you don't want them to be leaky in your eye, that eye swells the tissues. So it's just swollen like water basically. And so when they're water logged, they can't see clearly because it's like looking through basically someone shooting water on your face. And that's what we call diabetic macular edema. When it gets really bad, it actually kills the blood vessels. So now you're not actually getting blood flow to those areas so that those areas can't get oxygen because your blood carries oxygen to your tissues. And so if your blood cells are all dead, your vessels are all dead. Your capillaries are all dead, then you're not getting oxygenation to these nerve tissue in your eyes. And so then you lose vision permanently. 

Shireen: What are some clinical signs and symptoms of diabetes retinopathy that individuals with diabetes should pay attention to?

Dr.Mehta: So diabetes causes disease in many ways, not just retinopathy. So the symptoms can affect many parts of the eye of your perception of that. So one of the first things that could happen in diabetes is it can cause the lens in your eyes to become cloudy. And we call that a cataract. Diabetic cataracts in particular tend to be cataracts in younger people. Usually when you think of cataracts, you think about older people getting an age-related cataract, but diabetes causes a specific type of cataract. We call it a posterior subcapsular cataract. It's like looking through frosted glass in glam, becomes a problem. People have issues driving at night from that.

And so when glare is an issue and bright lights are really, really bothering people when the diabetic typically that's associated with. Other problems that diabetes can cause is because of ischemia or lack of blood flow. I was talking about before it can cause new blood vessels to grow and those new blood vessels can grow in any part of the eye. But if it grows in the front of the eye, it can block the drainage canals in the eye that help us regulate our pressure in the eye. And so when the eye pressure gets too high, that can be very painful. I, and that's what some people will see. They'll say pain halos around lights because their cornea, the front part of the eye, becomes so swollen that it has all these cysts in it. And so they can see halos around lights. They can get nausea from that. It can make you very sick and it can cause the vision to get dark because you're not getting blood flow to your eye. Because their eye pressure is higher than their blood pressure. That's in your eye that gets back to the retina.

You know, people who have diabetic retinopathy, or chronic diabetic retinopathy, what has happened for a long time, it can cause you to lose what we call contrast sensitivity. So similar colors may not be as easy to differentiate. So it is an orange and a pink kind of thing, or like different shades of gray. You may not be able to see the subtle differences in color, or you may mean more light just to see something because things are dimmer or colors seem kind of watching. Or it can affect the central vision. And like I said, with diabetic macular edema, it can basically just make things seem blurry. And that's what people typically start to see, bring it some more advanced.

It could actually start to bleed in your eyes because you've got vessels. Like I said, become weak, but walls become weak and they bleed. And so your eye can be completely full of blood. So you can see a whole lot of floaters. You can see blood clots floating around in your. Um, and so, you know, I see people like that pretty much, many times a week who come in with new vitreous hemorrhages, we call that 

Shireen: What sort of treatments exist for this?

Dr.Mehta: So there's lots of treatments for diabetic retinopathy nowadays, the most common treatment that we're doing, or first and foremost, we're controlling the blood. If the blood sugar and blood pressure and cholesterol control, remember these are all the blood vessel problems we want to control because people who have diabetes, don't just have diabetes. They often also have high blood pressure and high cholesterol, and all of those also damage your blood vessels. So we have to control all those things. So first and foremost, that's the first thing we have to do if we want to control our sugar, blood pressure and cholesterol. So after we do that, When they actually have diabetic retinopathy, sometimes we'll do treatments of injecting lasers, start doing lasers and do injections of medication in the eye.

So these medications have been used for the last 15 years or so and with these medications, we can actually reduce the swelling that's in the. We can reduce the growth of new blood vessels that are going to bleed in the eye and we can improve the vision with these injections as well. And the lasers can work to reduce the incidence of problems happening again in the future.

So sometimes things are so bad when people get to something called proliferative diabetic retinopathy, we have to do something called a fat pen laser photocoagulation or PRP. So there's panretinal photocoagulation. What we actually do is we sacrifice the peripheral. We can kill it off with a laser to prevent people from growing new blood vessels in the center of their vision, and basically ripping the retina apart with these new blood vessels, because those can be pretty bad.

We can prevent that with this laser, but you lose a lot of vision by doing that. You lose your peripheral vision and night vision from those laser procedures. And sometimes it gets to the point where we have to do surgery. So the eyes are full of blood, you can't see through blood. So sometimes if the injections don't cause the blood to go away, we have to go inside of the eye and remove all the blood from the eye and that can help people see better.

Shireen: Now you talked about controlling the blood sugar levels before doing the injections or even the laser. What sort of levels do they need to be brought down to if we're looking at A1C, what sort of numbers are you looking for to bring down to before you can, sort of look at some of these other options?

Dr.Mehta: So in terms of A1C, the best data we have is from a study that was done a long time ago, and that showed having an A1C less than 7.0 will reduce your risk of developing that proliferative diabetic retinopathy, where you need that laser. So we want less than seven is our, is our overall goal, but really ideally we want less than 6.4 so we can prevent any and Oregon.

So that's really kind of the ideal scenario because when people are less than 6.4, but not actually having the effects of diabetes, but less than seven is a good goal to start with, to get people out of the dangerous part for diabetic, uncontrolled diabetes that sits above nine. 

Shireen: From what I gathered, then what you're trying to do is bring them down below that, um, in that 6.47 sort of range in order to do the surgery or even the injections, for instance, you need them sort of at that controlled level before you can do that.

Dr.Mehta: Well, we'll do the injections right away  because we want to get the effect to work immediately. But the thing is that if somebody is living at nine, it doesn't matter how many injections I give them. I can't really control them now. Well, if their blood sugar is not controlled, ultimately they're just going to have end organ damage. Even if I can reduce the factor that's being released, they're still going to have damage. You must understand the role of ophthalmologists and all of this and caring for patients with diabetes.

Every patient gets a dilated fundus exam. Every year. This can help us screen for diabetic retinopathy and screen for what level of diabetic retinopathy and optometrists or a general ophthalmologist can do this. If they do a dilated exam, meaning they put the drops in your people, make your pupils very large, and this is the way they can actually see into the retina. Sometimes they'll take photos to make it easier for them to look at the retina, but they need to look. And if you don't look, you're not going to see it. So this needs to be checked every year because sometimes people can move very fast and they can get real bad, very fast, especially type one. Type twos tend to be a little slower than type ones, but I've seen type one type two diabetics get worse within a year to the point where they need it. 

Shireen: So how can ophthalmologists and just other clinicians in a patient's care team, help with diabetes, retinopathy prevention, and really what can be done to better identify at-risk patients before disease development?

Dr.Mehta: So the thing is, if people are going to the regular doctor, as they're getting their blood sugar checked, then we can have an idea of who's going to be at. So if you're a diabetic, but with medication, your A1C is 5.6 or low sixes. The chances are of you developing end organ damage, meaning diabetic disease, kidney disease, heart disease, loss of the neuro function in your hands and feet is lower.

So the first and foremost is we have to have the regular primary care doctor or endocrinologist in some cases be on top of controlling the blood sugar. And so having the blood sugar, the blood pressure and the cholesterol controlled, that's the first step. 

Shireen: Anything in particular that can be done for that the patient can do for, uh, to prevent disease development?

Dr.Mehta: So they just have to control their sugar, you know, and the first and foremost, part of controlling your sugars diet, because diet is the medication you take many times. It doesn't matter the manufacturer of that medication because if you're going to eat it. It's just going to happen. Right. So you have to control what it is you're eating to reduce your glucose levels.

And so that's, you know, a whole thing that ended up itself as a whole field of medicine. That's all dedicated to nutrition. And a lot of what you guys are doing here in Yumlish is doing that. And that's really important. That's why I'm so happy to be part of this. 

Shireen: Yeah, of course. No, thank you for the work that you're doing, you know, uh, help us understand the scope of the problem of the general sort of diabetes population. How many would you say have this sort of complication or diabetes retinopathy? Help us understand sort of just so we can frame how big the problem is. 

Dr.Mehta: So it's variable depending on where you are and the culture of the people who live in that area, the demographics, where there are some areas of the country where diabetic retinopathy and diabetes in general, diabetes is 40 to 50% of the population that certain populations and diabetic retinopathy is a large percentage of those people. And these are populations where diet is very different from populations where things are better. Frankly, people eat a lot more carbs. They're more sedentary in terms of their lifestyle. They have genetic predispositions for diabetes, and so it can be a major, major problem in certain parts of the country and communities all over the country.

And we're seeing this a lot in a lot of ethnic populations. And the United States, because they're not used to the food that is made here and the process nature of the food that's here. And so the constitution is just, aren't designed to process that food at this level of, of, of carbohydrates. And so they just can't can't do that well with that.

Shireen: And, and so if you had to scope out just an average estimate for the population. How widespread would you say it is in the diabetes population? 

Dr.Mehta: Okay. Diabetic retinopathy. So diabetic retinopathy is something that eventually we see in almost every diabetic. The question is, what percentage of the population needs treatment? I don't know the number on that.  but ultimately, if you live long enough, you're going to get diabetic retinopathy. If you have diabetes, even 5% of people who are perfectly controlled, their diabetes will eventually need surgery for the diabetic disease. So even if you do everything perfectly, right, some people will still need surgery. And that that's getting to the far end of the spectrum of what treatment 

Shireen: And that's why it is so important to get those eye exams. So if you are someone who has diabetes, getting those eye exams done yearly is going to be very, very important to just make sure your eyes are good. You're getting the dilated exam done and everything is, everything is fine. And ideally the patient doesn't have to visit you.

And so with that, you know, Dr. Mehta  we're toward the end of the episode, how can our listeners connect with you and just really learn more about you?

Dr.Mehta: So, yeah, so I'm at the University of California, Irvine and Southern California. So you can either go to our website, uci.edu, if you go to eye.uci.edu that'll get you to the Gavin Herbert eye Institute where I work, or you can look me up. Uh, you can contact us to make an appointment if you're in the area, but also call 9 4 9 UCI 2020 or 949-824-2020 if you want to make an appointment and come see one of us

Shireen: Well, thank you so much for your time, doctor for helping us understand exactly what diabetes retinopathy is, and how we can do a few things and really stay on top of this. You really take a preventative approach to work this. So thank you so much for your time. 

Dr.Mehta: It was a pleasure and thank you for having. 

Shireen: Absolutely. And for our listeners out there, head over to our social media after this episode, head over to our Facebook or Instagram and let us know. What did you learn from today's episode one break, takeaway, head over again to Facebook or Instagram, and we will see you there after the episode with that document.

Dr.Mehta: Thank you so much. Thank you.

Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn. For tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspectives. You can also visit our website Yumlish.com for more recipes advice and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first. Stay well.

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