Hasta La Gadget!

Meenakashi Gupta, MD
Vitreoretinal Surgeon
Assistant Professor of Ophthalmology
New York Eye and Ear Infirmary of Mount Sinai

Preventing Diabetes-Related Vision Loss

Diabetes is a growing problem in the United States and worldwide. The number of Americans with this chronic disease is expected to double in the next 20 years to more than 44 million. This means more and more people will face related complications, such as diabetic retinopathy. Affecting about one in three people with diabetes, this eye disease can cause irreversible vision loss and blindness. The good news is that early detection and treatment can prevent or minimize vision loss, and keeping diabetes under control can reduce your risk of developing diabetic retinopathy altogether.

What Causes Diabetic Retinopathy?

Diabetic retinopathy is caused by excess sugar molecules that damage the blood vessels in the retina, the light-sensitive tissue at the back of the eye. In the disease’s early stages, blood vessel walls start to weaken and develop little pouch-like bulges called microaneurysms. These may begin to leak, leading to swelling in the macula, the central portion of the retina that provides our sharpest vision.

As the disease progresses, this swelling, or macular edema, decreases the amount of blood delivered to the retina. In response, the retina may start to grow additional–but very abnormal–blood vessels, creating a condition called proliferative diabetic retinopathy.

These abnormal vessels sometimes cause a vitreous hemorrhage, or bleeding inside the eye, and can also lead to scarring there. Eventually, scar tissue may pull the retina from the back of the eye, resulting in retinal detachment, which can cause significant, permanent vision loss and often requires surgical repair.

Risk Factors and Prevention

People with any type of diabetes are at risk for diabetic retinopathy. The longer you have had diabetes and the more uncontrolled your blood sugar is, the more likely you are to develop it. People with diabetes and uncontrolled high blood pressure or cholesterol are also at increased risk.

That’s why managing your diabetes and staying healthy overall is the foundation for preventing diabetic retinopathy and related vision loss. It is important to work with your primary care doctor or endocrinologist and follow their prescribed regimen for controlling the “ABCs” of diabetes:

• A¬ ¬- A1c. Hemoglobin A1c is a type of blood protein to which sugar molecules are attached. A hemoglobin A1c blood test indicates how well you have been controlling your blood sugar level over the previous three months.
• B – Blood pressure.
• C – Cholesterol.

Symptoms, and When to Seek Care

In the early stages, patients may have no symptoms. Therefore, it is very important for people with diabetes to be seen every year by an ophthalmologist (eye MD) for a complete, dilated eye examination. During the dilated examination, eye drops are used to enlarge the pupils, the opening in the center of the iris (colored portion of the eye). Dilation allows the doctor to evaluate the health of the tissues in the back of your eyes, including the retina and optic nerve.

In later stages of the disease, patients may develop the following symptoms, which call for an immediate visit to an ophthalmologist:

• Floaters (little specks or “strings” floating through your field of vision);
• Wavy or blurred vision;
• Empty spots in your field of vision;
• Decreased vision.

The earlier your doctor detects changes from diabetic retinopathy, the better the visual outcome will be. When the disease is treated very early on, mild damage may be reversible in some instances. Left untreated, diabetic retinopathy can advance to irreversible vision loss, including complete blindness in some cases.

Treatment for Diabetic Retinopathy

Several different treatments are available:

Controlling Your ABCs. Though important in prevention, controlling your ABCs can also play a part in treatment. When diagnosed in its very early stages, patients may be able to manage diabetic retinopathy and reduce the risk of vision loss by controlling their blood sugar, blood pressure, and cholesterol.

Laser Treatment and Eye Injections. In later stages, patients may require different types of laser treatment or periodic (usually monthly) injections of medication directly into the eye to decrease swelling in the retina and/or control the growth of abnormal blood vessels. These treatments are done with anesthesia, so they are usually painless.

Treatment that reduces swelling can improve lost vision in some cases. Treatment for controlling the growth of blood vessels helps stabilize the vision and stop it from getting worse.

Surgery. Two subgroups of patients often end up requiring surgery: those who develop a retinal detachment and those who experience a vitreous hemorrhage that does not go away on its own.

Treatment for both involves vitrectomy surgery, where small instruments are inserted into the eye and the vitreous gel (gel-like fluid in the middle of the eye) is removed.

In the case of vitreous hemorrhage, this allows blood to be removed from the back of the eye. For retinal detachment, this provides better access to the back of the eye, where the surgeon carefully dissects the scarred membranes off the retina to flatten it. Laser treatment is often applied during this procedure, and a gas bubble is put into some patients’ eyes to help press the retina into place.

Don’t Be a Stranger

It bears repeating that people with diabetes should see their ophthalmologist annually to be checked for diabetic retinopathy, and immediately whenever they notice any symptoms of this potentially devastating eye disease.

I recently operated on a young woman whose diabetic retinopathy had progressed to the point that she developed a retinal detachment. Following surgery, she was so happy her vision had improved. She told me, “Prior to the operation, my vision was so bad I didn’t know my flip-flops had ladybugs printed on them, and I can see them now!”

Visit us early and often. We may be able to help restore your eyesight

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Dr. Kebede Worku, health minister of Ethiopia, inspects the immunization records at the Feedho Health Post. How can annual reporting of district-level immunization data help portray a more accurate picture of what’s working, and where do challenges remain? Photo by: Getachew / UNICEF Ethiopia / CC BY-NC-ND

This article originally ran at Devex.com on August 1, 2016.

It is time for the world to raise the bar for reporting immunization data.

A few weeks ago the World Health Organization and UNICEF released their annual report on childhood immunization that serves as a “checkup” on how much progress we’re making. This year’s report gave us much to celebrate: We are reaching more children with lifesaving vaccines than ever.

And yet, we’re not satisfied with the report and its outcomes. Why not? The report provides a useful summary of coverage at a national level, but it lacks the resolution that is needed to really understand our progress and the challenges we face in immunizing the world’s children. What we need is data on immunization coverage in each district, not just a national average.

In 2016, it is not too much to ask to for local data to be made available—and it would be many times more valuable in informing the actions required to reach more children with vaccines. If you don’t think it’s possible, just consider this: New York City has used a data base and maps with every single planted tree in Manhattan—showing where it’s located and when it was planted—to modify its schedule for pruning the trees. This data has helped show the “city that never sleeps” how to reduce by 22 percent the number of power outages that occur from branches falling on power lines.

Contrast this with this year’s report from WHO and UNICEF on vaccine coverage. The latest data show that in 2015, a record-breaking 86 percent of the world’s children received the required doses for diphtheria-tetanus-pertussis—the vaccine used to measure basic vaccine reach. What’s more, the number of countries that have achieved and sustained the 90 percent immunization target established for DTP3 has doubled from 63 in 2000 to 126 in 2015—truly remarkable progress. Good news, to be sure. But when summarized at the planetary level, this information is not entirely helpful for understanding where we’re doing better and where we need to improve.

The report does demonstrate that some countries are still missing key targets. Sixty-eight countries are still falling short of the Global Vaccine Action Plan’s 90 percent target—with some fragile states only reaching 15 percent coverage. But what does a coverage rate of, say, 51 percent actually mean? Are the remaining 49 percent spread evenly across the country, or are there pockets of very high and very low coverage? If so, what do those variations teach us about the factors that lead to success in some places and failures in others?

While these findings are encouraging at a macro level, they highlight the critical need to examine coverage data at the district level in order to identify where kids are missed and where they are served well. It is simply impossible to get an accurate picture of immunization coverage in a single national figure, as disparities between states, districts or communities are completely eclipsed in these aggregated data points.

How can immunization program managers identify and correct pockets where coverage is low when only one number is reported for an entire country? They simply can’t—at least not beyond making an educated guess.

It is time to hold ourselves to a higher standard as a global immunization community and aim for annual reporting of district-level immunization data to portray a more accurate picture of what is working and where challenges remain. This will allow policymakers and immunization program managers alike to direct resources at children who are being missed.

For most countries, improvements to immunization data can be made now simply by improving collection and analysis efforts.

To track malaria, for example, scientists generate heat maps from 25 square kilometers of data to show how malaria affects different parts of a single country in very different ways. The travel app Waze uses live data to help us avoid traffic jams, and the Find my Friends app helps us to discover if someone we know is dining at a nearby table. Doesn’t it make sense to expect the same level of resolution from the data we use to deliver lifesaving vaccines?

Better data collection will help but even today every country in the world with only a single, national coverage estimate in the latest WHO and UNICEF report has built that estimate on data collected at a district-level. This data—like the data on the trees of New York City—exists.

The essential next step is to shift the accepted standard for global reporting of immunization coverage from national to subnational, and make this data transparent for all to see. Though some countries may be reluctant, this is exactly what’s needed to address immunization gaps, promote transparency and ensure estimates are accurate. WHO and UNICEF can lead the way by requiring this from 2017 onwards, and actively supporting countries to make the data available.

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John Thompson, a 22-year-old black man in New Orleans, was convicted in 1985 – in two separate trials – of carjacking and murder and sentenced to 49 years on the carjacking charge and to death for the murder. He spent the next 18 years at the Louisiana State Penitentiary, 14 of them on death row. He was 30 days away from execution when his attorneys finally found the evidence that cleared him. The New Orleans DA’s office, then headed by Harry Connick, Sr., had known all along that a blood stain found on one of the carjacking victims, did not match Thompson and concealed that fact from Thompson’s attorney in the carjacking case. In the murder case, they made a plea deal with a second man – who was the likely killer – to testify against Thompson. The informant got five years; Thompson was sentenced to death.

Most importantly, by winning a false victory on the carjacking charge, Connick and his henchmen effectively deprived Thompson of the right to testify in his own defense in the murder trial – a flagrant bit of Constitutional misconduct. The carjacking charge was dropped in 1999 and Thompson – now free to tell his side of the story – was retried in the murder case in 2002. He was acquitted in 35 minutes.
None of the DAs involved in Thompson’s case were ever disciplined or held accountable in any way. They almost never are.

As Brandon Buskey, a staff attorney for the ACLU’s Criminal Law Reform Project, wrote in NY Times op ed: “In privileging the discretion of prosecutors and judges to enforce the law, we have come perilously close to placing these officials above the law.”

Added Buskey: “…advocates across the country continue to expose judges who unlawfully deprive defendants of lawyers or throw people in jail simply because they are too poor to pay small amounts of money. We are constantly confronted with wrongful convictions rooted in a prosecutor’s belief that winning a case is more important than seeking justice. These experiences compel us to recognize that sometimes the criminals our justice system most needs to confront are actually running it.”

Under American law, prosecuting attorneys are among the most powerful of public officials. They can choose whether or not to bring criminal charges, what charges to bring, what evidence justifies charges, and they hold the power to plea bargain. Their power is nearly absolute and unreviewable, with absolute immunity from civil liability. At its best, this means prosecutors have significant opportunity to show leniency and mercy in a system that is frequently marked by broad and harsh criminal laws. At its worst, it leads to many wrongful convictions.

There are a number of ways for a prosecutor to commit misconduct. He could make inappropriate comments to jurors, or coax witnesses into giving false or misleading testimony. But one of the most pervasive misdeeds is the failure to turn over favorable evidence to the defendant, as required by the landmark Brady v. Maryland case of 1963, in the which the Supreme Court ruled that withholding exculpatory evidence violates due process “where the evidence is material either to guilt or to punishment.” It’s the most common form of misconduct cited by courts in overturning convictions.
In 2015 alone, a record 149 people in 29 states, the District of Columbia, federal courts and Guam – were exonerated of crimes they didn’t commit. These 149 innocent defendants had spent on average about 14-and-a-half years of their lives in prison. Official misconduct was a factor in 65 exonerations in 2015, a record number. Three-quarters (44/58) or 75% of the homicide exonerations in 2015 included known official misconduct.

There was a time when the American public believed that innocent people didn’t go to prison. If you were arrested and convicted by a jury of peers, you were guilty. Most people had faith that prosecutors and police and judges conducted investigations and trials with total integrity with goal of fairness and equal justice for all.

That faith is clearly misguided. Since the first DNA exoneration in 1989, 336 people have been exonerated and released on the basis of DNA testing alone. At least 20 of those spent time on death row. In fact, the total number of exonerations since 1989 – based on all factors, not just DNA – is 1,740, according to the National Registry of Exonerations at the University of Michigan Law School.

There is no aspect of the criminal justice system in greater need of reform. Of the many ways innocent people wind up in jail for crimes they didn’t commit – eyewitness misidentification, false confessions, tainted forensic science, incompetent legal representation, false testimony by dubious informants – none is more grave and destructive to the American criminal justice system than official misconduct. Public faith in the integrity and fairness of the investigatory and prosecutorial process is the fundamental tenet of the justice system.

Prosecutors have been literally getting away with murder for years and it is past time for the free ride to end.

The Supreme Court missed a chance to swing the pendulum back in the right direction in 2011 when, in a 5-4 opinion written by Clarence Thomas, they threw out John Thompson’s $14 million jury award for wrongful conviction on the grounds that he had shown a violation only in his own case, and not a pattern of misconduct.

“I don’t care about the money, says Thompson, who founded and runs an organization called Resurrection After Exoneration to promote and sustain a network of support among formerly wrongfully incarcerated individuals in the South and to reconnect exonerees to their communities. “I just want to know why the prosecutors who hid evidence, sent me to prison for something I didn’t do and nearly had me killed are not in jail themselves. There were no ethics charges against them, no criminal charges, no one was fired and now, according to the Supreme Court, no one can be sued… Because of that, prosecutors are free to do the same thing to someone else today.”

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Luxury French shoe designer Christian Louboutin is ditching the red carpet for Rio de Janeiro — at least for the next few weeks. The Cuban team will be wearing clothes designed by Christian Louboutin to the Rio Olympics.

Louboutin has three stores in Brazil — one in Brasilia and two in Sao Paolo, in the heart of Iguatemi shopping center, which is sort of like a Brazilian Bloomingdale’s for the country’s luxury aficionados.

Luxury giants have been popping up in Brazil’s upscale shopping centers in recent years, to the delight of the country’s elite.

Ready…set…Rio! We’re gearing up for the 2016 Olympic Games with @sportyhenri. Christian Louboutin and former French handball player Henri Tai have created chic head-to-toe looks, including non-performance footwear for the delegation of over 100 Cuban elite athletes to wear at the Closing Ceremony and other formal occasions. #CLxSportyHenri

A photo posted by Christian Louboutin (@louboutinworld) on Jul 21, 2016 at 9:11am PDT

The French shoe designer is one of about 50 major fashion houses in the country. Others include Louis Vuitton, Cartier and the French leather goods company Longchamp. They’re unstoppable.

But this year, Louboutin is coming to Rio as the official garment designer for the Cuban team.

The designer is abandoning his usual studded loafers, vertiginous sandals, and red soles, and taking on ready-to-wear with a mission to dress the Cuban athletes in style this summer.

If Brazil seems to be fertile ground for the shoe designer and other European brands, the choice of Cuba remains far afield. You don’t need to go to Louboutin’s website to know that he doesn’t sell his famous stilettos in Havana.

Those who have visited Cuba — the land of Fidel and Raul Castro — know that the country is mostly populated with small-scale souvenir shops, and hardly any of them sell imported products.

Taking visual cues not only from Cuban heritage but from the athletes themselves, Christian Louboutin and Henri Tai incorporated inspiration and guidance from these extraordinary men and women to create unique non-performance looks. #CLxSportyHenri

A photo posted by Christian Louboutin (@louboutinworld) on Jul 23, 2016 at 10:04am PDT

Christian Louboutin’s website will show you — via a very sophisticated map — that the nearest shop is 537 kilometers from Cuba. Translation: If you want shoes, you have to go to Miami.

But anyway, the reason why the prolific, legendary shoemaker is taking on this project with the Cuban Olympic team is simply because he’s enthusiastic about it. It’s not because he’s concerned with drumming up more business. The ultimate proof: His Olympic items will not be offered for sale, either online or in retail stores.

To complete the athletes’ tailor-made ensembles, Christian Louboutin high-top trainer and loafer style Naza Star for men were exclusively fabricated for the athletes in calf leather on slim fitting silhouettes, enabling a light tread for gymnast Manrique Larduet Bicet and adding elegance to the remarkable size 51.5 foot of wrestler Mijaín López Núñez! Read more about the exclusive Olympic Celebratory Outfits via the link in our bio. #CLxSportyHenri

A photo posted by Christian Louboutin (@louboutinworld) on Jul 22, 2016 at 11:52am PDT

In preparation for this collection, Louboutin worked closely with his friend Henry Tai, former international handball player and founder of e-concept store SportyHenri.com. The pair came up with the idea for the project during a photoshoot on the Cuban coast. Louboutin brings his expertise in fashion and Henri brings his knowledge of the professional world of sports. The results: A custom-made wardrobe for an entire delegation of over 100 athletes, imagined for formal events.

The collection features scarlet jackets for men and sandy tones for women, calfskin sneakers for men and low-heeled sandals for women. These items are complemented by an array of shorts, skirts and capris, carried out in a chic and sober way.

Far from the standard ultra slim sizes, the gala outfits were envisioned for the dream-like bodies of athletes — bodies freed from stereotypes.

It’s a project at the crossroads, where Cuba joins Rio in the most elegant and authentic way.

The collection is evidence that latin charm continues to dream, and that, in full Olympic swing, it would be wrong to deny it.

This post first appeared on HuffPost France. It has been translated into English and edited for clarity.

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