August 8, 2025 • 29 mins
In this episode of The Eye-Q Podcast, I speak with retina specialist Dr. Krishna Mukkamala about the impact of diabetes on vision. We cover five major ways diabetes can silently damage your eyes, the most commonly overlooked symptom, and how early intervention can prevent permanent blindness. Whether you're managing diabetes or supporting someone who is, this episode offers vital insights to help protect long-term eye health.
Dr. Krishna Mukkamala is a fellowship-trained vitreo-retinal surgeon with a background in Biomedical Engineering and a passion for precision medicine and compassionate care. A graduate of Virginia Commonwealth University and a member of the Alpha Omega Alpha Honor Medical Society, he completed his ophthalmology training at the New York Eye and Ear Infirmary and advanced fellowship at Vitreous Retina Macula Consultants of New York and Columbia University. In addition to treating complex retinal conditions, Dr. Mukkamala has authored over 15 peer-reviewed publications, contributed to clinical trials, and written on Age-Related Macular Degeneration. Based in Atlanta, he also revived the Atlanta Ophthalmological Society to foster a professional community and education among local eye care providers.
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(00:00):
Diabetes is essentially elevatedblood sugar in your blood
vessels. And with hypertension, the
higher flow through the blood vessels further damages the
blood vessels. And three, when there's
increased lipid, it makes essentially blood more dirty.
Think of it that way. And by reducing the sugar, by
reducing the lipid and by reducing the flow and damaging
(00:22):
the blood vessels, it really reduces the complications
diabetes has. So that's the triad of how to
minimize complications. Welcome to the IQ podcast.
I'm Doctor Ronnie Banik, here tohelp you boost your IQ with
powerful insights that connect your eyes, your brain, and your
whole body Wellness. This episode was recorded during
(00:44):
the Eye Health Summit, where theworld's leading experts shared
breakthrough insights in vision and holistic eye care.
Hello and welcome back. I'm Doctor Ronnie Banik, and
today I'm joined by Doctor Krishna Mukamala, who is a
highly experienced retina specialist who has devoted his
practice to helping people with diabetes restore and preserve
(01:07):
their precious eyesight. Thank you so much, Doctor
Mukamala, for joining us today. Thank you.
For having me, Doctor Bannock. Yeah, absolutely.
So let's get right into it. With diabetes, we know that as
an eye doctor, we know that it can cause so many different
issues in the back of the eye. But why did this particular area
of care interest you so much? Feel like an eye is a different
(01:29):
organ than the rest of the body because it's in many ways not a
typical part of much of your routine care at your primary
care doctor. And the truth of the matter is,
in the eye, the retina specifically, is integrally
related to the rest of the body.The reason is because the blood
vessels that feed the eye, and specifically the retina travel
through the rest of the body, and medicines you take as well
(01:52):
as conditions that you have in your body can damage the retina.
And so that that integration between the retina and the rest
of the body makes this a very interesting topic.
I understand. So for our listeners who maybe
they have diabetes or they've been diagnosed with pre diabetes
or they have a loved one with diabetes, which is so common,
just give us the overview. What are the five main ways that
(02:16):
diabetes can affect our vision? They're probably a lot more than
that, but let's talk from your from a retina perspective.
What are the five main ways thatdiabetes can affect vision that
you've seen? Sure.
I think the first and most commonly heard word is
cataracts. So many times patients who have
diabetes can develop cataracts at a slightly younger age.
The second is that they're more prone to what's called diabetic
(02:39):
retinopathy, and that's a condition where there could be
bleeding in the retina or in thevitreous cavity.
Furthermore, the damage done by the elevated blood sugar in the
blood vessels can cause some of the retinal tissues to be
swollen up. We call that macular edema.
Furthermore, you can develop various types of glaucoma, so
there are many eye conditions for which being a diabetic puts
(02:59):
you at greater risk, including even a stroke to different parts
of the eye. Let's talk a little bit more
about diabetic retinopathy. So there are different forms of
the condition, right? Different stages of the disease.
Can you share with us what are those different types and how do
we approach each of those types?Sure.
Whenever a patient enters my office for a diabetic
(03:20):
evaluation, I tell my staff thatthere's a matrix.
It's a very simple box that's two by two.
And the first question to answeris do they have diabetic
retinopathy or not? If the answer is no, it's
simple. Continue to manage your A1C, the
goal of which is 7 point or below and move on with your
life. But if you have diabetic
retinopathy, which is evidenced by little spots of blood in the
(03:43):
retina called micro aneurysms, the next question becomes is
this non proliferative or proliferative diabetic
retinopathy? The reason why that question is
so important is because proliferative diabetic
retinopathy or the more serious version can cause significant
vision loss either by forming scar tissue and detaching the
retina or by causing hemorrhage,which causes patients difficulty
(04:05):
seeing through that blood in their eye.
So that's the first question. And the second question is there
or is there not presidents of diabetic macular edema, diabetic
macular edema, to break that down means that in the center
part of your retina called the macula.
And to explain that word, I callit the downtown of the retina,
just as Atlanta, where I reside in the very center has a
(04:26):
downtown and we have a very large suburbs.
The reality is the downtown has a very high density of
population. And in the same way, the macula
has a dense high density of photoreceptor cells.
And in that area, the blood vessels can leak and the water
in the blood vessels can leak into the surrounding tissues,
making it more difficult to see.And if you have proliferative
(04:50):
diabetic retinopathy or if you have macular edema, those
generally require treatment. And that's why identifying those
as critical to making a treatment course.
That's excellent information. I know oftentimes people will go
to the eye doctor for their annual checkups.
Is it any different for diabetics?
For example, the frequency of how soon they should be seen?
(05:11):
Or let's say someone's been justdiagnosed with diabetes, it's a
new diagnosis. When do they need to be seen by
an ophthalmologist? That's a great question.
And what I would say is that anydiabetic should be examined at
the minimum annually, either their optometrist or their
ophthalmologist. I think it's mandatory, and
(05:31):
that's why many times the primary care doctor recommends
that. So that way their eye gets a
good check up. Now, there are many things that
we look at in that kind of exam #1 is that we'll look at the
vision and the glasses and the eye pressure.
Those are standard and basic things, but in addition to that,
it would be very important that your eye care provider looks
specifically at your retina because that's the major area
(05:53):
that can be affected by diabetes.
And that exam might include one of three things.
One would be a dilated eye exam.That's where they place eye
drops in your eyes, so that way they can look deep into your
retina #2 it might include fundus photography, which is a
photo taken of your retina to look for some of the subtle
findings that may not be as easily visible by just looking
(06:13):
in. And the third is an Oct.
Think of it much like a microscope.
Microscope you can see some large items, but looking through
a microscope you can see fine detail.
And an Oct is a noninvasive device that looks specifically
at the macula to look for any macular edema.
So those would be 3 standard tests that might be considered.
(06:34):
And if you don't have diabetic retinopathy, I think it's quite
typical to be examined once a year.
But based on the level of diabetic retinopathy, your eye
care provider may recommend morefrequent visits.
And a few small caveats to that might be if you're pregnant,
because pregnancy can cause changes in your blood sugar with
changes in hormones, and so yourdoctor might recommend more
(06:56):
frequent examinations. Got it.
Thank you for that information. Now, is there a difference
between having someone having type 1 diabetes in which perhaps
they're not making enough insulin and they have to be on
insulin or some derivative of insulin, and type 2 diabetes
where their body makes insulin, but perhaps their cells are not
able to take in the glucose, so we call that insulin resistance.
(07:19):
So is there a difference betweenwhen these patients should be
seen a type 1 diabetic versus a type 2 diabetic?
That's a great question and I would say the answer generally
speaking is no in in the sense that in both cases, the net
effect is that the elevated level of blood sugar can damage
the blood vessels. And this is an example that I
give that I think many patients understand very clearly.
(07:42):
Let's say you took the PVC pipe that you might have for plumbing
in your home and you poured acidin it.
You would expect that acid wouldcorrode the blood vessels.
I think everybody would have thesame answer.
And I tell patients that's exactly what diabetes does.
In diabetes, what happens is that due to lack of insulin or
(08:02):
due to insensitivity of the tissues to insulin, there's an
elevated amount of blood sugar that's running through the blood
vessels. And that blood sugar in effect
damages the blood vessels, causing those blood vessels to
become weak, much like pouring acid down a pipe.
And a few observations I will make, however, is that
unfortunately, type 1 diabetics,individuals who don't produce
(08:24):
insulin become diabetic at a relatively young age and for
that reason end up with diabeticcomplications also at a younger
age. And I think it's very critical
for them because when you're younger, you have so many other
responsibilities. You have work, you have so many
other types of physicians that you see.
So it becomes increasingly difficult to fit an eye doctor
into your schedule. But it's all the more important
(08:46):
because you have a lifelong vision to preserve in terms of
the retina. And we want to make sure that
these individuals are well caredfor.
And oftentimes as a type 1 diabetic, you might be diagnosed
in anywhere in your first to second decade and you might see
complications as soon as ten years after that if the sugar is
not well controlled. In type 2 diabetics, we
(09:09):
oftentimes see it within roughlyfive to seven years after being
diagnosed, particularly if it's not well controlled.
And that control you mentioned having a hemoglobin of less than
7 is ideal. Do you have any more specific
guidance? Like for example, should type 1
diabetics strive to have becausethey have diabetes for a longer
period of their life, should they have stricter control?
(09:29):
Does it really matter? That's a great question.
Generally speaking among our retina colleagues, I don't know
if there is any other advice beyond keeping the A1C7 or below
because the thought process is that A1C and A1C for your
listeners basically is an average of your blood sugars
over the last three months. And the goal A1C for a diabetic
(09:50):
whether type one or type 2 is roughly 7.
Now there may be individual parameters based on other
conditions the patients has thatthe endocrinologist of the
diabetes provider would give, but an A1C or 7 is thought to
reduce the likelihood of end organ damage.
And many times I have a difficult conversation with my
patients because in spite of controlling their A1C at 7:00 or
(10:12):
below, the eye condition doesn'treverse.
So they wonder, they come to me with an elevated A1CI initiate
treatment. They do their part, but the
retinal condition may not alwaysimprove to their satisfaction.
And I tell them that many times if it's been poorly controlled
or if it's been, if you've been diabetic for a very long time,
you still have to deal with those retinal issues even though
(10:33):
the patient's doing their part. And that's why I think it's
important to start early in terms of eye examinations.
The earlier you start, the milder the complications will be
and the easier they will be to treat and reverse.
And I give them the example of aCliff.
As you walk towards the edge of the Cliff, the moment you fall
off the Cliff, it's hard to bring you back up and our goal
(10:54):
is to find you 100 feet away from the Cliff, so you never
even get close. And that's the benefit of going
through preventative eye examinations early in the
journey. So I wanted to just bring up
there was a large study done years ago called the Diabetes
Control and Complications trial.And in that trial, some patients
had very elevated A1 CS and theygot their A1 CS down very
(11:16):
quickly and actually their diabetic retinopathy worsened.
So what you're saying is people get frustrated because they may
have a high A1C, they get it down, but their eye issues don't
immediately respond. Do you have any thoughts about
why that may happen? That's a great question and I'm
going to add one additional level of complexity to your
discussion that applies in our modern day.
(11:37):
You may be aware that many of our patients in the recent last
five years have been taking whatare called GLP 1 agonists.
And these are medicines branded names such as Ozempic and Mogovy
who have been tremendously effective at reducing blood
sugar levels as well as helping patients lose weight.
And we see the exact same phenomenon in these individuals.
(11:58):
And in fact, if you look at the light labels from any of these
medicines, which are typically in the form of injections they
say may worsen your eyesight or your retinal disease.
And many times I think what happens is that the body has a
tremendous way of auto regulating.
Auto regulating essentially means that the bodies, blood
vessels and the different tissues become accustomed to a
(12:20):
certain level of life. Think of it where for example,
let's say you're used to making $1,000,000 a year, whatever that
number is, and then all of a sudden your income drops by 50
or 100%. You have a very difficult time
adjusting to that. And in the same way, even though
the blood sugar levels elevated,the body has auto regulated in a
way that adjusts to that. And when there's a significant
(12:41):
reduction, even though that's generally a good thing for the
overall body, it has a difficulttime coping and then resetting
its level. Now what I tell patients in this
situation is that even though yes, we see increased diabetic
retinopathy in the transient phase or the intermittent time
period after which your sugar has dropped, it's still an
important thing to do. And the reason is because we
(13:05):
have very good treatments for diabetic retinopathy and macular
edema, and these typically include injections into the
white part of your eye called intravitreal injections.
You may see many advertisements for different brands on TV.
And we have lasers that can be performed in surgery.
Now, the goal is to control the majority of disease in the
office with either injections orlaser and to avoid surgery, but
(13:27):
that option also exists. Having said that, I personally,
as a retina specialist, don't have any treatments to save your
brain from a stroke, your heart from a heart attack, or your
kidneys from dialysis. And I think that's one of the
key things about reducing the A1C is that there's many organs
to control besides the eye. And that's why I'm OK with
patients taking this class of medications, as long as they
(13:49):
follow up with me to monitor their eyes.
Thank you for sharing that because I know so many people
out there may be on these drugs or even compounded drugs or
various other forms of the drugs.
It's very common in our population these days.
So let's say somebody you know is on a new one of these GLP one
inhibitors, their hemoglobin A1Cwas 11.
(14:11):
And then very quickly it comes down let's say to 8 and they
experience the worsening of their vision changes.
How long can it take before things normalize and the auto
regulation kicks back in? Is there a time frame that
usually give patients like it may get worse and then
eventually it'll stabilize? That's a great question.
I interestingly enough, at the American Academy of
(14:31):
Ophthalmology meeting this past fall in Chicago, this exact
topic was discussed at many of the research meetings, and I
don't think there's enough data to know that yet.
The main thing is that if you have, if you take one of these
medications and if you notice anexchange in your vision, I think
you should be examined immediately.
(14:52):
And my approach as a retina specialist, and this may not
apply to all my colleagues, is that I set a mental threshold.
For example, on a scale of 1 to 10, if they have diabetic
macular edema between zero and three, I may be OK observing
that as long as their vision is quite good, such as 2025 or
2030. But when the amount of macular
edema is higher than that threshold, let's say 4 or
(15:15):
greater out of 10 or the vision reduces to 2040 or worse, I may
initiate treatment even if they're in that temporary phase.
And so that's how I approach that issue.
OK. So earlier intervention can help
to preserve eyesight, that's what you're saying?
Yeah, absolutely. And furthermore, starting
treatment such as injections does not necessarily mean you
need it for the long term. What I tell patients is that the
(15:39):
starting it at the appropriate time allows you to preserve the
most amount of vision and need the least amount of treatment in
the long term. So those are the two things I
tell my patients. I try to optimize #1 is
maximizing your visual outcome, and two is minimizing the total
number of treatments you'll needand that can be achieved by
early intervention. Doctor Mukammal, you are a
(16:01):
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(17:06):
see the world anew. Welcome back.
Today I'm speaking with Doctor Krishna Mukamala, who's a retina
specialist and diabetes expert. Doctor Mukamala, we've talked
about the various ways in which diabetes can affect our eyes.
Now let's turn a little bit to preventative strategies.
We talked about having an IA 1C,hemoglobin A1C that's less than
(17:27):
7. That's an ideal range, but what
are some other things people cando to help to avoid some of
these diabetic eye complications?
So I think from an individual health standpoint, in addition
to diabetes, it's also importantthat blood pressure and
cholesterol is managed. That would be what I would say
for the most part, the triad of minimizing the negative
(17:50):
implications of diabetes. The reason is because, and this
is the example that I give that might make a lot of sense to
your listeners, is that diabetesis essentially elevated blood
sugar in your blood vessels. And with hypertension, the
higher flow through the blood vessels further damages the
blood vessels. And three, when there's
(18:12):
increased lipid, it makes essentially blood more dirty.
Think of it that way. And by reducing the sugar, by
reducing the lipid and by reducing the flow and damaging
the blood vessels, it really reduces the complications
diabetes has. So that's the triad of how to
minimize complications. No, I love that analogy.
Think about a pipe and it just gets thicker and thicker.
(18:33):
It's more viscous. And then the end organ, which is
the retina in this case, just isnot getting enough oxygen.
And that's really why a lot of these changes are happening.
Doctor Mukammala, It's it's an issue with oxygenation.
Absolutely. Now if you think about it, an
example that I give to my patients is a tree.
When you see a tree in a doubt drought stricken area, the the
(18:55):
base of the tree typically is fine.
It's the smallest stems at the very edge or the very top of the
tree. Why is that?
Well, because there's not enoughwater to get to the very top.
And that's the same example thatapplies to the retina and in
fact it applies to the brain, the heart and the kidneys
because these 4 organs, actually, I should say three of
those organs are necessary for life.
(19:16):
The eyes obviously are not, but they have the finest blood
vessels, what we call micro microvasculature.
And it makes sense. The retina is a very small
tissue and therefore would have very small blood vessels.
And the very edge of those bloodvessels are the first to be
damaged in diabetic retinopathy because the blood which delivers
oxygen and nutrients to the veryedges of our body can't reach
(19:38):
there. And those are the tissues that
are impacted first. Another wonderful analogy, Dr.
Mukammala, that really makes a lot of sense.
Now, I wanted to give you a scenario here.
Now, I've had this scenario happen with many of my patients
where, yes, they know that they're diabetic, perhaps their
sugars are not very well controlled and they seem to be
doing fine with their vision. But all of a sudden one day they
(20:00):
wake up and they have really blurry vision in one eye.
They're seeing lots of floaters.They just, they can't even see
properly what? And there's no pain, there's no
other issue. What's happened there?
Can you explain why this happensto patients with diabetes
sometimes when they wake up withloss?
Of vision. Sure.
So that's a case where we call it acute painless loss of
(20:23):
vision. And typically in that scenario
it means that they have what we call proliferative diabetic
retinopathy. We talked about the matrix
earlier about what we look at asretinal specialists and the
first question we asked it is does the patient have non
proliferative or proliferative? And this is the case of
proliferative and proliferation means that the tissues at the
(20:46):
very edge of the retina aren't getting sufficient oxygenation
as we gave in the previous example.
For that reason they beg the tissues nearby, they release a
chemical called VEGF or vascularendothelial growth factor.
And those that chemical is almost like their cry for help.
And that chemical lands on tissues nearby that do have
(21:09):
oxygen. And the goal is to create new
blood vessels from healthy tissues to these non perfused or
tissues that don't have good oxygenation.
The problem is that good bridgesaren't built in one day, but
these vessels are created very quickly to basically satisfy the
oxygen demand of these starving tissues.
And because of that, these bloodvessels are very fragile and
(21:30):
they're very prone to bleeding. And by bleeding, what I mean is
that they may break open and theblood in them may fill the
vitreous cavity. The eyeballs call the ball for a
reason. It's because in the center
there's a space that's quite large, much like a basketball
that's filled with vitreous Jelly.
And when these blood vessels bleed, they feel that vitreous
(21:51):
Jelly, which is very thick and viscous with blood, and it's
becomes very difficult to see through it.
So that would be the reason why this patient has suffered this
issue. Yeah.
And I'm sure you've seen it manycountless times as well in your
patients. We call this a vitreous
hemorrhage. So if this happens, what can the
patient expect? Is this something permanent or
(22:11):
this is reversed with time? So generally speaking, in most
patients this is very easily treatable, right?
By easily there are good treatments that we have.
The first thing that we would look in the eye is to #1
identify the actual underlying cause.
And what I mean is that many of our diabetics who have these
type of complications are in theage range of 40 to 60, depending
(22:34):
on if they're type one or type 2.
So in that same age range, thereare other types of conditions
that can cause the same set of symptoms, including what's
called a PVD or posterior vitreous detachment.
So the first step would be to seek care from eye health
professional and this professional would look in your
eye. They might consider sending you
to a retinal specialist in the retinal specialist job is to
(22:57):
differentiate between the underlying cause between being
diabetic retinopathy or a PVD. Clues they might use include
looking at the other eye. So obviously both eyes are tied
into our body and they may be somewhat asymmetric, but
generally have about the same amount of diabetic retinopathy.
And so if there's there's so much blood in one eye that the
(23:18):
patient can see out and the doctor cannot see in, we would
look at the contralateral eye for clues on the case that
there's not that much blood and we do have good visualization of
the retina, We might consider a dye test.
It's a test where the retinal doctors team might place
fluorescein, which is a safe dyeinto your arm and take photos of
(23:39):
your retina. And by doing that type of test,
it would reveal the blood vessels that are leaking and
would kind of guarantee or certified diabetic retinopathy
is the underlying cause. So that's the diagnostic aspect
or the first aspect to identifying this patient.
The second is the treatment portion.
(23:59):
As far as treatment goes, generally speaking, if the
vitreous hemorrhage is very mild, observation might be
advised. But if it's moderate to severe,
the most common treatment includes injections in the eye.
In the same way that I said the peripheral tissues are lacking
oxygen and releasing VEGF as a chemical signal, anti VEGF
(24:22):
blocks that to reduce further bleeding from those fragile
blood vessels. The example that I give that
patients understand well is likea sinking boat.
A sinking boat may have a hole in it, so on one end you have
water entering the boat through that small hole and then on the
other end you have yourself using a bucket to get rid of
water. And these injections essentially
(24:42):
plug the hole. They don't necessarily get rid
of the blood, but they plug the hole so additional blood doesn't
enter your vitreous cavity and then the body overtime reabsorbs
that blood allowing for clearinga vision.
Now after one or two of these injections over one to two
months, if the blood doesn't clear, we consider it a non
(25:03):
clearing vitreous hemorrhage. At which point a surgery called
a vitrectomy may be required to put small instruments into the
eye under anesthesia to remove that blood and to clear, to
clear the blood and to improve the vision.
Ultimately these injections havebeen game changers for and
they've really helped, number one, prevent complications like
(25:24):
vitreous hemorrhage and improve these complications when they've
occurred. And there is a trend towards
long term treatment with these injections.
For example, in the past, if youthink of gangrene, many diabetic
patients may have heard of the word gangrene where the tip of
your finger gets an infection due to poor blood flow and the
doctor may have to amputate it by cutting it off.
(25:46):
And in theory, the way it works is by cutting off the tip of
your finger, you're able to saveyour hand and the rest of your
body from infection. So in the same way, many times
we perform laser and this laser coagulates some of the
peripheral retinal tissues, which are generally important
for peripheral vision, but not critical for central or the most
(26:07):
important part of your vision. And those blood vessels are the
fragile ones that are bleeding, are cauterized with laser to
prevent them from bleeding and to preserve the majority of your
vision. So that's another approach that
can be taken based on our view of the retina.
So it seems like you have quite a few tools in your toolkit to
manage diabetic retinopathy. You have the injections, you
(26:29):
have the laser, various different types of laser, and
then there's the surgery as well, correct?
And it's really important that apatient speak with their doctor
about which of these treatments are maybe combination of
treatments may be best for theirparticular case.
I completely agree and the farther you are away from the
Cliff the better. What I have found many times is
(26:49):
that, for example, let's say somebody's at the edge of the
Cliff and you go rush to grab them, just you're rushing
forward may cause them to fall off, right?
So in the same way, when an eye is at the very edge of a Cliff
and about to lose vision, some treatments also have side
effects. And I think that's why it's very
important for early interventionso as to avoid or minimize those
(27:10):
type of side effects. And the earlier you intervene,
the more sight that can be saved, as well as the less
number of treatments that are generally required and hopefully
avoiding surgery. Yeah, those words are gold.
Doctor Mukammala is so important.
I always say an ounce of prevention is worth a pound of
cure, and that could not be moretrue when it comes to vision and
(27:32):
diabetes and vision in particular.
Thank you so much for this enlightening discussion about
diabetes and the eye and variouscomplications that may happen.
Doctor McConnell, if anyone wanted to learn more from you,
maybe you, reach out to you, or perhaps even become a patient,
how could they find you? So first things I would say one
(27:52):
of the blessings of the field ofretinal medicine is I think we
have fantastic retinal specialists throughout the
country. So my first recommendation would
be probably start with your local eye care provider and get
yourself screened for diabetic retinopathy if you are diabetic.
If you do need to see a retinal specialist, your eye care
provider should be able to recommend a local retinal
specialist. The reason I say this and not
(28:14):
take credit for myself is because many retinal treatments
do require ongoing care and maintenance.
So if you're not in the Atlanta area, though, I could certainly
help with diagnostic and treatment protocols, The
execution of that would definitely require a local eye
doctor. And your local eye doctor would
recommend somebody who's very skilled at that.
And you can also reference the asrs.org website, which has very
(28:35):
good retinal specialists in yourarea.
But, but if you're willing to visit Atlanta, you're welcome to
come down. You're very humble, Doctor
McConnell, but thank you for that.
And we will put all of those links with the show notes below.
Again, thank you so much, DoctorMcConnell, for spending some
time with us. We really appreciate your time
and your wisdom, and I will see the rest of you during our next
(28:56):
session together. Thank you.
Thank you. Thank you for tuning in to the
IQ Podcast. I hope you enjoyed today's
episode and learn something new to help you boost your IQ.
Leave us a review and share the podcast with your family and
friends. Stay connected with me for more
eye opening insights on ihealth,nutrition and lifestyle.
(29:19):
Until next time, keep your vision clear and your IQ sharp.
Diabetes is essentially elevatedblood sugar in your blood
vessels. And with hypertension, the
higher flow through the blood vessels further damages the
blood vessels. And three, when there's
increased lipid, it makes essentially blood more dirty.
Think of it that way. And by reducing the sugar, by
reducing the lipid and by reducing the flow and damaging
(00:22):
the blood vessels, it really reduces the complications
diabetes has. So that's the triad of how to
minimize complications. Welcome to the IQ podcast.
I'm Doctor Ronnie Banik, here tohelp you boost your IQ with
powerful insights that connect your eyes, your brain, and your
whole body Wellness. This episode was recorded during
(00:44):
the Eye Health Summit, where theworld's leading experts shared
breakthrough insights in vision and holistic eye care.
Hello and welcome back. I'm Doctor Ronnie Banik, and
today I'm joined by Doctor Krishna Mukamala, who is a
highly experienced retina specialist who has devoted his
practice to helping people with diabetes restore and preserve
(01:07):
their precious eyesight. Thank you so much, Doctor
Mukamala, for joining us today. Thank you.
For having me, Doctor Bannock. Yeah, absolutely.
So let's get right into it. With diabetes, we know that as
an eye doctor, we know that it can cause so many different
issues in the back of the eye. But why did this particular area
of care interest you so much? Feel like an eye is a different
(01:29):
organ than the rest of the body because it's in many ways not a
typical part of much of your routine care at your primary
care doctor. And the truth of the matter is,
in the eye, the retina specifically, is integrally
related to the rest of the body.The reason is because the blood
vessels that feed the eye, and specifically the retina travel
through the rest of the body, and medicines you take as well
(01:52):
as conditions that you have in your body can damage the retina.
And so that that integration between the retina and the rest
of the body makes this a very interesting topic.
I understand. So for our listeners who maybe
they have diabetes or they've been diagnosed with pre diabetes
or they have a loved one with diabetes, which is so common,
just give us the overview. What are the five main ways that
(02:16):
diabetes can affect our vision? They're probably a lot more than
that, but let's talk from your from a retina perspective.
What are the five main ways thatdiabetes can affect vision that
you've seen? Sure.
I think the first and most commonly heard word is
cataracts. So many times patients who have
diabetes can develop cataracts at a slightly younger age.
The second is that they're more prone to what's called diabetic
(02:39):
retinopathy, and that's a condition where there could be
bleeding in the retina or in thevitreous cavity.
Furthermore, the damage done by the elevated blood sugar in the
blood vessels can cause some of the retinal tissues to be
swollen up. We call that macular edema.
Furthermore, you can develop various types of glaucoma, so
there are many eye conditions for which being a diabetic puts
(02:59):
you at greater risk, including even a stroke to different parts
of the eye. Let's talk a little bit more
about diabetic retinopathy. So there are different forms of
the condition, right? Different stages of the disease.
Can you share with us what are those different types and how do
we approach each of those types?Sure.
Whenever a patient enters my office for a diabetic
(03:20):
evaluation, I tell my staff thatthere's a matrix.
It's a very simple box that's two by two.
And the first question to answeris do they have diabetic
retinopathy or not? If the answer is no, it's
simple. Continue to manage your A1C, the
goal of which is 7 point or below and move on with your
life. But if you have diabetic
retinopathy, which is evidenced by little spots of blood in the
(03:43):
retina called micro aneurysms, the next question becomes is
this non proliferative or proliferative diabetic
retinopathy? The reason why that question is
so important is because proliferative diabetic
retinopathy or the more serious version can cause significant
vision loss either by forming scar tissue and detaching the
retina or by causing hemorrhage,which causes patients difficulty
(04:05):
seeing through that blood in their eye.
So that's the first question. And the second question is there
or is there not presidents of diabetic macular edema, diabetic
macular edema, to break that down means that in the center
part of your retina called the macula.
And to explain that word, I callit the downtown of the retina,
just as Atlanta, where I reside in the very center has a
(04:26):
downtown and we have a very large suburbs.
The reality is the downtown has a very high density of
population. And in the same way, the macula
has a dense high density of photoreceptor cells.
And in that area, the blood vessels can leak and the water
in the blood vessels can leak into the surrounding tissues,
making it more difficult to see.And if you have proliferative
(04:50):
diabetic retinopathy or if you have macular edema, those
generally require treatment. And that's why identifying those
as critical to making a treatment course.
That's excellent information. I know oftentimes people will go
to the eye doctor for their annual checkups.
Is it any different for diabetics?
For example, the frequency of how soon they should be seen?
(05:11):
Or let's say someone's been justdiagnosed with diabetes, it's a
new diagnosis. When do they need to be seen by
an ophthalmologist? That's a great question.
And what I would say is that anydiabetic should be examined at
the minimum annually, either their optometrist or their
ophthalmologist. I think it's mandatory, and
(05:31):
that's why many times the primary care doctor recommends
that. So that way their eye gets a
good check up. Now, there are many things that
we look at in that kind of exam #1 is that we'll look at the
vision and the glasses and the eye pressure.
Those are standard and basic things, but in addition to that,
it would be very important that your eye care provider looks
specifically at your retina because that's the major area
(05:53):
that can be affected by diabetes.
And that exam might include one of three things.
One would be a dilated eye exam.That's where they place eye
drops in your eyes, so that way they can look deep into your
retina #2 it might include fundus photography, which is a
photo taken of your retina to look for some of the subtle
findings that may not be as easily visible by just looking
(06:13):
in. And the third is an Oct.
Think of it much like a microscope.
Microscope you can see some large items, but looking through
a microscope you can see fine detail.
And an Oct is a noninvasive device that looks specifically
at the macula to look for any macular edema.
So those would be 3 standard tests that might be considered.
(06:34):
And if you don't have diabetic retinopathy, I think it's quite
typical to be examined once a year.
But based on the level of diabetic retinopathy, your eye
care provider may recommend morefrequent visits.
And a few small caveats to that might be if you're pregnant,
because pregnancy can cause changes in your blood sugar with
changes in hormones, and so yourdoctor might recommend more
(06:56):
frequent examinations. Got it.
Thank you for that information. Now, is there a difference
between having someone having type 1 diabetes in which perhaps
they're not making enough insulin and they have to be on
insulin or some derivative of insulin, and type 2 diabetes
where their body makes insulin, but perhaps their cells are not
able to take in the glucose, so we call that insulin resistance.
(07:19):
So is there a difference betweenwhen these patients should be
seen a type 1 diabetic versus a type 2 diabetic?
That's a great question and I would say the answer generally
speaking is no in in the sense that in both cases, the net
effect is that the elevated level of blood sugar can damage
the blood vessels. And this is an example that I
give that I think many patients understand very clearly.
(07:42):
Let's say you took the PVC pipe that you might have for plumbing
in your home and you poured acidin it.
You would expect that acid wouldcorrode the blood vessels.
I think everybody would have thesame answer.
And I tell patients that's exactly what diabetes does.
In diabetes, what happens is that due to lack of insulin or
(08:02):
due to insensitivity of the tissues to insulin, there's an
elevated amount of blood sugar that's running through the blood
vessels. And that blood sugar in effect
damages the blood vessels, causing those blood vessels to
become weak, much like pouring acid down a pipe.
And a few observations I will make, however, is that
unfortunately, type 1 diabetics,individuals who don't produce
(08:24):
insulin become diabetic at a relatively young age and for
that reason end up with diabeticcomplications also at a younger
age. And I think it's very critical
for them because when you're younger, you have so many other
responsibilities. You have work, you have so many
other types of physicians that you see.
So it becomes increasingly difficult to fit an eye doctor
into your schedule. But it's all the more important
(08:46):
because you have a lifelong vision to preserve in terms of
the retina. And we want to make sure that
these individuals are well caredfor.
And oftentimes as a type 1 diabetic, you might be diagnosed
in anywhere in your first to second decade and you might see
complications as soon as ten years after that if the sugar is
not well controlled. In type 2 diabetics, we
(09:09):
oftentimes see it within roughlyfive to seven years after being
diagnosed, particularly if it's not well controlled.
And that control you mentioned having a hemoglobin of less than
7 is ideal. Do you have any more specific
guidance? Like for example, should type 1
diabetics strive to have becausethey have diabetes for a longer
period of their life, should they have stricter control?
(09:29):
Does it really matter? That's a great question.
Generally speaking among our retina colleagues, I don't know
if there is any other advice beyond keeping the A1C7 or below
because the thought process is that A1C and A1C for your
listeners basically is an average of your blood sugars
over the last three months. And the goal A1C for a diabetic
(09:50):
whether type one or type 2 is roughly 7.
Now there may be individual parameters based on other
conditions the patients has thatthe endocrinologist of the
diabetes provider would give, but an A1C or 7 is thought to
reduce the likelihood of end organ damage.
And many times I have a difficult conversation with my
patients because in spite of controlling their A1C at 7:00 or
(10:12):
below, the eye condition doesn'treverse.
So they wonder, they come to me with an elevated A1CI initiate
treatment. They do their part, but the
retinal condition may not alwaysimprove to their satisfaction.
And I tell them that many times if it's been poorly controlled
or if it's been, if you've been diabetic for a very long time,
you still have to deal with those retinal issues even though
(10:33):
the patient's doing their part. And that's why I think it's
important to start early in terms of eye examinations.
The earlier you start, the milder the complications will be
and the easier they will be to treat and reverse.
And I give them the example of aCliff.
As you walk towards the edge of the Cliff, the moment you fall
off the Cliff, it's hard to bring you back up and our goal
(10:54):
is to find you 100 feet away from the Cliff, so you never
even get close. And that's the benefit of going
through preventative eye examinations early in the
journey. So I wanted to just bring up
there was a large study done years ago called the Diabetes
Control and Complications trial.And in that trial, some patients
had very elevated A1 CS and theygot their A1 CS down very
(11:16):
quickly and actually their diabetic retinopathy worsened.
So what you're saying is people get frustrated because they may
have a high A1C, they get it down, but their eye issues don't
immediately respond. Do you have any thoughts about
why that may happen? That's a great question and I'm
going to add one additional level of complexity to your
discussion that applies in our modern day.
(11:37):
You may be aware that many of our patients in the recent last
five years have been taking whatare called GLP 1 agonists.
And these are medicines branded names such as Ozempic and Mogovy
who have been tremendously effective at reducing blood
sugar levels as well as helping patients lose weight.
And we see the exact same phenomenon in these individuals.
(11:58):
And in fact, if you look at the light labels from any of these
medicines, which are typically in the form of injections they
say may worsen your eyesight or your retinal disease.
And many times I think what happens is that the body has a
tremendous way of auto regulating.
Auto regulating essentially means that the bodies, blood
vessels and the different tissues become accustomed to a
(12:20):
certain level of life. Think of it where for example,
let's say you're used to making $1,000,000 a year, whatever that
number is, and then all of a sudden your income drops by 50
or 100%. You have a very difficult time
adjusting to that. And in the same way, even though
the blood sugar levels elevated,the body has auto regulated in a
way that adjusts to that. And when there's a significant
(12:41):
reduction, even though that's generally a good thing for the
overall body, it has a difficulttime coping and then resetting
its level. Now what I tell patients in this
situation is that even though yes, we see increased diabetic
retinopathy in the transient phase or the intermittent time
period after which your sugar has dropped, it's still an
important thing to do. And the reason is because we
(13:05):
have very good treatments for diabetic retinopathy and macular
edema, and these typically include injections into the
white part of your eye called intravitreal injections.
You may see many advertisements for different brands on TV.
And we have lasers that can be performed in surgery.
Now, the goal is to control the majority of disease in the
office with either injections orlaser and to avoid surgery, but
(13:27):
that option also exists. Having said that, I personally,
as a retina specialist, don't have any treatments to save your
brain from a stroke, your heart from a heart attack, or your
kidneys from dialysis. And I think that's one of the
key things about reducing the A1C is that there's many organs
to control besides the eye. And that's why I'm OK with
patients taking this class of medications, as long as they
(13:49):
follow up with me to monitor their eyes.
Thank you for sharing that because I know so many people
out there may be on these drugs or even compounded drugs or
various other forms of the drugs.
It's very common in our population these days.
So let's say somebody you know is on a new one of these GLP one
inhibitors, their hemoglobin A1Cwas 11.
(14:11):
And then very quickly it comes down let's say to 8 and they
experience the worsening of their vision changes.
How long can it take before things normalize and the auto
regulation kicks back in? Is there a time frame that
usually give patients like it may get worse and then
eventually it'll stabilize? That's a great question.
I interestingly enough, at the American Academy of
(14:31):
Ophthalmology meeting this past fall in Chicago, this exact
topic was discussed at many of the research meetings, and I
don't think there's enough data to know that yet.
The main thing is that if you have, if you take one of these
medications and if you notice anexchange in your vision, I think
you should be examined immediately.
(14:52):
And my approach as a retina specialist, and this may not
apply to all my colleagues, is that I set a mental threshold.
For example, on a scale of 1 to 10, if they have diabetic
macular edema between zero and three, I may be OK observing
that as long as their vision is quite good, such as 2025 or
2030. But when the amount of macular
edema is higher than that threshold, let's say 4 or
(15:15):
greater out of 10 or the vision reduces to 2040 or worse, I may
initiate treatment even if they're in that temporary phase.
And so that's how I approach that issue.
OK. So earlier intervention can help
to preserve eyesight, that's what you're saying?
Yeah, absolutely. And furthermore, starting
treatment such as injections does not necessarily mean you
need it for the long term. What I tell patients is that the
(15:39):
starting it at the appropriate time allows you to preserve the
most amount of vision and need the least amount of treatment in
the long term. So those are the two things I
tell my patients. I try to optimize #1 is
maximizing your visual outcome, and two is minimizing the total
number of treatments you'll needand that can be achieved by
early intervention. Doctor Mukammal, you are a
(16:01):
wealth of information about diabetes and vision health.
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(17:06):
see the world anew. Welcome back.
Today I'm speaking with Doctor Krishna Mukamala, who's a retina
specialist and diabetes expert. Doctor Mukamala, we've talked
about the various ways in which diabetes can affect our eyes.
Now let's turn a little bit to preventative strategies.
We talked about having an IA 1C,hemoglobin A1C that's less than
(17:27):
7. That's an ideal range, but what
are some other things people cando to help to avoid some of
these diabetic eye complications?
So I think from an individual health standpoint, in addition
to diabetes, it's also importantthat blood pressure and
cholesterol is managed. That would be what I would say
for the most part, the triad of minimizing the negative
(17:50):
implications of diabetes. The reason is because, and this
is the example that I give that might make a lot of sense to
your listeners, is that diabetesis essentially elevated blood
sugar in your blood vessels. And with hypertension, the
higher flow through the blood vessels further damages the
blood vessels. And three, when there's
(18:12):
increased lipid, it makes essentially blood more dirty.
Think of it that way. And by reducing the sugar, by
reducing the lipid and by reducing the flow and damaging
the blood vessels, it really reduces the complications
diabetes has. So that's the triad of how to
minimize complications. No, I love that analogy.
Think about a pipe and it just gets thicker and thicker.
(18:33):
It's more viscous. And then the end organ, which is
the retina in this case, just isnot getting enough oxygen.
And that's really why a lot of these changes are happening.
Doctor Mukammala, It's it's an issue with oxygenation.
Absolutely. Now if you think about it, an
example that I give to my patients is a tree.
When you see a tree in a doubt drought stricken area, the the
(18:55):
base of the tree typically is fine.
It's the smallest stems at the very edge or the very top of the
tree. Why is that?
Well, because there's not enoughwater to get to the very top.
And that's the same example thatapplies to the retina and in
fact it applies to the brain, the heart and the kidneys
because these 4 organs, actually, I should say three of
those organs are necessary for life.
(19:16):
The eyes obviously are not, but they have the finest blood
vessels, what we call micro microvasculature.
And it makes sense. The retina is a very small
tissue and therefore would have very small blood vessels.
And the very edge of those bloodvessels are the first to be
damaged in diabetic retinopathy because the blood which delivers
oxygen and nutrients to the veryedges of our body can't reach
(19:38):
there. And those are the tissues that
are impacted first. Another wonderful analogy, Dr.
Mukammala, that really makes a lot of sense.
Now, I wanted to give you a scenario here.
Now, I've had this scenario happen with many of my patients
where, yes, they know that they're diabetic, perhaps their
sugars are not very well controlled and they seem to be
doing fine with their vision. But all of a sudden one day they
(20:00):
wake up and they have really blurry vision in one eye.
They're seeing lots of floaters.They just, they can't even see
properly what? And there's no pain, there's no
other issue. What's happened there?
Can you explain why this happensto patients with diabetes
sometimes when they wake up withloss?
Of vision. Sure.
So that's a case where we call it acute painless loss of
(20:23):
vision. And typically in that scenario
it means that they have what we call proliferative diabetic
retinopathy. We talked about the matrix
earlier about what we look at asretinal specialists and the
first question we asked it is does the patient have non
proliferative or proliferative? And this is the case of
proliferative and proliferation means that the tissues at the
(20:46):
very edge of the retina aren't getting sufficient oxygenation
as we gave in the previous example.
For that reason they beg the tissues nearby, they release a
chemical called VEGF or vascularendothelial growth factor.
And those that chemical is almost like their cry for help.
And that chemical lands on tissues nearby that do have
(21:09):
oxygen. And the goal is to create new
blood vessels from healthy tissues to these non perfused or
tissues that don't have good oxygenation.
The problem is that good bridgesaren't built in one day, but
these vessels are created very quickly to basically satisfy the
oxygen demand of these starving tissues.
And because of that, these bloodvessels are very fragile and
(21:30):
they're very prone to bleeding. And by bleeding, what I mean is
that they may break open and theblood in them may fill the
vitreous cavity. The eyeballs call the ball for a
reason. It's because in the center
there's a space that's quite large, much like a basketball
that's filled with vitreous Jelly.
And when these blood vessels bleed, they feel that vitreous
(21:51):
Jelly, which is very thick and viscous with blood, and it's
becomes very difficult to see through it.
So that would be the reason why this patient has suffered this
issue. Yeah.
And I'm sure you've seen it manycountless times as well in your
patients. We call this a vitreous
hemorrhage. So if this happens, what can the
patient expect? Is this something permanent or
(22:11):
this is reversed with time? So generally speaking, in most
patients this is very easily treatable, right?
By easily there are good treatments that we have.
The first thing that we would look in the eye is to #1
identify the actual underlying cause.
And what I mean is that many of our diabetics who have these
type of complications are in theage range of 40 to 60, depending
(22:34):
on if they're type one or type 2.
So in that same age range, thereare other types of conditions
that can cause the same set of symptoms, including what's
called a PVD or posterior vitreous detachment.
So the first step would be to seek care from eye health
professional and this professional would look in your
eye. They might consider sending you
to a retinal specialist in the retinal specialist job is to
(22:57):
differentiate between the underlying cause between being
diabetic retinopathy or a PVD. Clues they might use include
looking at the other eye. So obviously both eyes are tied
into our body and they may be somewhat asymmetric, but
generally have about the same amount of diabetic retinopathy.
And so if there's there's so much blood in one eye that the
(23:18):
patient can see out and the doctor cannot see in, we would
look at the contralateral eye for clues on the case that
there's not that much blood and we do have good visualization of
the retina, We might consider a dye test.
It's a test where the retinal doctors team might place
fluorescein, which is a safe dyeinto your arm and take photos of
(23:39):
your retina. And by doing that type of test,
it would reveal the blood vessels that are leaking and
would kind of guarantee or certified diabetic retinopathy
is the underlying cause. So that's the diagnostic aspect
or the first aspect to identifying this patient.
The second is the treatment portion.
(23:59):
As far as treatment goes, generally speaking, if the
vitreous hemorrhage is very mild, observation might be
advised. But if it's moderate to severe,
the most common treatment includes injections in the eye.
In the same way that I said the peripheral tissues are lacking
oxygen and releasing VEGF as a chemical signal, anti VEGF
(24:22):
blocks that to reduce further bleeding from those fragile
blood vessels. The example that I give that
patients understand well is likea sinking boat.
A sinking boat may have a hole in it, so on one end you have
water entering the boat through that small hole and then on the
other end you have yourself using a bucket to get rid of
water. And these injections essentially
(24:42):
plug the hole. They don't necessarily get rid
of the blood, but they plug the hole so additional blood doesn't
enter your vitreous cavity and then the body overtime reabsorbs
that blood allowing for clearinga vision.
Now after one or two of these injections over one to two
months, if the blood doesn't clear, we consider it a non
(25:03):
clearing vitreous hemorrhage. At which point a surgery called
a vitrectomy may be required to put small instruments into the
eye under anesthesia to remove that blood and to clear, to
clear the blood and to improve the vision.
Ultimately these injections havebeen game changers for and
they've really helped, number one, prevent complications like
(25:24):
vitreous hemorrhage and improve these complications when they've
occurred. And there is a trend towards
long term treatment with these injections.
For example, in the past, if youthink of gangrene, many diabetic
patients may have heard of the word gangrene where the tip of
your finger gets an infection due to poor blood flow and the
doctor may have to amputate it by cutting it off.
(25:46):
And in theory, the way it works is by cutting off the tip of
your finger, you're able to saveyour hand and the rest of your
body from infection. So in the same way, many times
we perform laser and this laser coagulates some of the
peripheral retinal tissues, which are generally important
for peripheral vision, but not critical for central or the most
(26:07):
important part of your vision. And those blood vessels are the
fragile ones that are bleeding, are cauterized with laser to
prevent them from bleeding and to preserve the majority of your
vision. So that's another approach that
can be taken based on our view of the retina.
So it seems like you have quite a few tools in your toolkit to
manage diabetic retinopathy. You have the injections, you
(26:29):
have the laser, various different types of laser, and
then there's the surgery as well, correct?
And it's really important that apatient speak with their doctor
about which of these treatments are maybe combination of
treatments may be best for theirparticular case.
I completely agree and the farther you are away from the
Cliff the better. What I have found many times is
(26:49):
that, for example, let's say somebody's at the edge of the
Cliff and you go rush to grab them, just you're rushing
forward may cause them to fall off, right?
So in the same way, when an eye is at the very edge of a Cliff
and about to lose vision, some treatments also have side
effects. And I think that's why it's very
important for early interventionso as to avoid or minimize those
(27:10):
type of side effects. And the earlier you intervene,
the more sight that can be saved, as well as the less
number of treatments that are generally required and hopefully
avoiding surgery. Yeah, those words are gold.
Doctor Mukammala is so important.
I always say an ounce of prevention is worth a pound of
cure, and that could not be moretrue when it comes to vision and
(27:32):
diabetes and vision in particular.
Thank you so much for this enlightening discussion about
diabetes and the eye and variouscomplications that may happen.
Doctor McConnell, if anyone wanted to learn more from you,
maybe you, reach out to you, or perhaps even become a patient,
how could they find you? So first things I would say one
(27:52):
of the blessings of the field ofretinal medicine is I think we
have fantastic retinal specialists throughout the
country. So my first recommendation would
be probably start with your local eye care provider and get
yourself screened for diabetic retinopathy if you are diabetic.
If you do need to see a retinal specialist, your eye care
provider should be able to recommend a local retinal
specialist. The reason I say this and not
(28:14):
take credit for myself is because many retinal treatments
do require ongoing care and maintenance.
So if you're not in the Atlanta area, though, I could certainly
help with diagnostic and treatment protocols, The
execution of that would definitely require a local eye
doctor. And your local eye doctor would
recommend somebody who's very skilled at that.
And you can also reference the asrs.org website, which has very
(28:35):
good retinal specialists in yourarea.
But, but if you're willing to visit Atlanta, you're welcome to
come down. You're very humble, Doctor
McConnell, but thank you for that.
And we will put all of those links with the show notes below.
Again, thank you so much, DoctorMcConnell, for spending some
time with us. We really appreciate your time
and your wisdom, and I will see the rest of you during our next
(28:56):
session together. Thank you.
Thank you. Thank you for tuning in to the
IQ Podcast. I hope you enjoyed today's
episode and learn something new to help you boost your IQ.
Leave us a review and share the podcast with your family and
friends. Stay connected with me for more
eye opening insights on ihealth,nutrition and lifestyle.
(29:19):
Until next time, keep your vision clear and your IQ sharp.
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