Eye Care Ebook: Better Eyesight by Exercises

Quantum Vision System

The Quantum Vision System is an overall package to heal and thereby improve vision all together. The step by step guide and the instructional videos contain lots of information regarding the dos and don'ts to protect eyes from further damage. The program is not based on the treatment but also saves us from damaging vision with the use of lenses or glasses. The 3 in one package contains methods to nourish, cleanse, and effectively improve the vision with simple exercise. The eye chart provided is to be used to track the vision improving progress. According to the treatment program, Quantum Vision System can be used to treat various eye problems like Myopia or Near sightedness, Hyperopia or Farsightedness, Prebyopia, Dyslexia, Macular Degeneration, Lazy Eye or Amblyopia, Astigmatism, Cataract, Glaucoma, Tension Headache and Eye strain. The program can treat visual problems within 2 to 3 months.

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What is the relationship between cataract and DM

Cataract is 30 percent more common in diabetic than in non-diabetic persons. Cataract development is a physiologic manifestation of ageing, but this process occurs earlier and more quickly in diabetic people. The mechanisms of cataract development in ageing and in diabetes are similar. The polyol pathway has been incriminated in cataract production in experimental models of diabetic animals, with resultant accumulation of sorbitol and galctitol (a product of galactose) in the lens. This view is strengthened by the beneficial effect that aldose reductase inhibitors have on inhibition of this process and cataract formation, on condition these medicines are used early in diabetic patients. Furthermore, the role of lack of myoinositol or special aminoacids has been discussed, as well as the detrimental effect of free radicals, a view supported by the beneficial effect of antioxidant substances on delay or even prevention of cataract formation. The current prevailing view, however, for the...

Adaptation To Life With Reduced Vision

For the elderly patient, adapting to life with reduced vision is an immense challenge. It is important that, where appropriate the individual be registered either partially sighted or blind according to national guidelines so that local social services can assess the need for involvement of the support agencies. There is a wide spectrum of visual impairment very few patients loose all sight and each case needs to be assessed individually. The patient should be referred to a low visual aid (LVA) clinic (usually run by an optometrist with a special interest in LVA) to try various aids to maximize residual sight. These aids cannot restore normal vision but may help the patient to carry out daily tasks such as reading small amounts of type or signing a cheque. As the diabetic patient approaches old age strenuous efforts must continue to prevent DR by a concerted effort to maintain diabetic, hypertensive and lipid control. This will also benefit general health and reduce the incidence of...

Principles In Eye Care For Patients With Diabetes

Diabetic retinopathy remains the leading cause of new-onset blindness in populations of working age, even in the United States (21) and other industralized countres. Despite clearly defined clinical standards for evaluating and treating diabetic retinopathy cost-effectively, for a variety of reasons (see below), effective treatments such as laser surgery are underused. It has been estimated that 50 of adults with diabetes mellitus in the United States do not receive the recommended annual eye care that would allow diagnosis and treatment of diabetic retinopathy (38-41). Studies have also shown that many persons who require sight-preserving laser surgery do not receive it (42,43). It has been reported that about 26 of patients with type 1 and 36 of those with type 2 diabetes mellitus have never had their eyes examined (44). These patients tend to be older, less educated and to have had a more recent diagnosis than those receiving regular eye care. They are also likely to live in rural...

Evaluation and improvement of eye care for patients with diabetes mellitus

In assessing approaches to improving the care system, it is important to (i) determine the purpose of the proposed system, for example, to screen for a threshold referral level of retinopathy or to provide guidance in management (ii) assess the performance of the system relative to that of the gold standard, in order to identify trade-offs (ii) assess the success and actual performance of different eye care systems in various settings and (iv) understand how patients perceive the benefits of the system. From the perspective of health policy, it should be shown that a traditional or non-traditional proposal for care offers significant benefits over the existing system, sufficient to justify any additional costs. The performance of systems for eye care for patients with diabetes, even in developed countres, leaves much to be desired. Application of a systems approach to the current systems indicates that alternatives should be explored to improve performance in every area of eye care...

Conduct international research into systemic deficiencies in health and eye care that contribute to blindness from

Improvements to increase the cost-effectiveness of eye care for diabetes patients are a global necessity. Blindness due to diabetic retinopathy occurs in part because factors important to both patients and health care providers have not been recognized or incorporated into current diabetes education, screening and treatment programmes. Systems analyses are needed in varous cultures to understand better why patients with diabetic retinopathy go bind, particularly when the technical knowledge and services to prevent the condition exist. Operations research is needed for comprehensive, evidence-based characterzation of the contrbutions of significant factors and their interactions to blindness among patients with diabetic retinopathy. Within a standardized protocol, focus group methods can give detailed insight about bind and non-blind patients with retinopathy, members of their families or social support systems and diabetes and eye care providers, including information on the actual...

Alternatives in eye care for patients with diabetes mellitus

All treatment should be consistent with uniform international standards. The International Council of Ophthalmology guidelines for diabetic retinopathy care (52) (See Annex 4.) give detailed information about the expected performance of ophthalmologists who treat diabetic retinopathy. Education can improve the performance of health care providers, including non-eye care professionals, although long-term data on persistence are lacking. Use of photographic standards might be an alternative that would also enhance the performance of all systems to detect and follow-up cases of diabetic retinopathy.

Provision of Eye Care

Lack of specialist eye care and regular ophthalmology review of residents with diabetes has been demonstrated in UK care homes (Sinclair et al 1997b Ben-bow et al 1997). In a recent large community-based study of older people with diabetes, some of whom were residents of care homes, a large proportion of subjects had evidence of major undetected refractive error. (Sinclair et al 2000b). Screening programs for detecting diabetes-related eye problems are being set up in many districts of the UK. Many are based on examinations being carried out by experienced and specially trained optometrists who are able to check for refractive error, glaucoma and cataract whilst also checking for diabetic retinopathy using the technique of indirect opthalmoscopy through dilated pupils. In other districts, diabetes eye screening is based on taking photographs of the retina using a special camera. The evidence is at present insufficient to make specific recommendation on which is the best method of...

Dealing with Eye Problems

Elderly people with diabetes are at risk for the eye problems brought on by the disease, and these problems can affect all aspects of proper diabetes care. Older patients often get cataracts, macular degeneration, and open angle glaucoma in addition to diabetic retinopathy (see Chapter 5). Fortunately, the risk of developing eye diseases associated with diabetes has been found to decrease as people get older, at every level of hemoglobin A1c. For example, a 70-year-old with a hemoglobin A1c of 11 is at much lower risk than a 60-year-old with the same hemoglobin A1c. The blood glucose of the 70-year-old does not need to be controlled as strictly. An annual eye examination is recommended. One of the biggest failures in diabetes care is that as many as one-third of the elderly never have an eye examination at all. If no examination is done, how can disease be found when it is early enough to treat When problems are detected, they can be treated, and the patient's vision can be saved.

Cataract Surgery Diabetic Retinopathy

Not unlike the blind men who describe an elephant based on which part they are touching, there tends to be a big difference between how a retina specialist views cataract surgery in diabetics and how a cataract jockey views the issue. Retina people tend to be real worrywarts about this, and will be far more cautious about suggesting cataract surgery simply because of all the patients they have seen start with 20 40 glare cataracts and end up 20 200 from progression of their retinopathy after surgery. In the bad old days (a decade or two ago), it was not uncommon to hold off on cataract surgery until the vision was 20 200 or worse because, if things went south, the patient would at least have a fighting chance of ending up about as bad as they were before surgery. On the other hand, most high-volume cataract surgeons will tell you that they simply do not see the type of problems that retina people fuss about. Who is right Everyone, probably. The older literature definitely suggests...

Principles for organizing an eye health system for the care of diabetic retinopathy

Accuracy of examination results I diabetic retinopathy is suspected after screening, a decision must be made about the overall management for a given level of diabetic retinopathy In many developing countries, there are too few persons to provide even basic eye care to the population, let alone specialized eye care for patients with diabetes and related blindness prevention. Involving non-ophthalmic health care providers in various aspects of eye care for patients with diabetes is a viable alternative. Appropriate follow-up intervals Significant problems have been encountered in ensurng regular follow-up of patients with diabetic retinopathy High rates of follow-up have, however, been reported with the use of vans and trained photographic readers using reference standard photographs to provide immediate feedback to patients. By directly addressing patient convenience, access and feedback, this system might serve as a model for a 'marketing' approach for patient-centred detection of...

Checking for Eye Problems

All people with diabetes need to have a dilated eye exam done annually by an ophthalmologist or optometrist. No other physician, including the endocrinologist (yours truly excepted, of course), can do the exam properly. All kinds of treatments can be done if abnormalities are found, but they must be discovered first. (See Chapter 5 for more information on eye problems.) This test is something you must demand. Your doctor must refer you to an ophthalmologist or optometrist every year. Better yet, set up the appointment yourself with the eye doctor's nurse at the end of your first visit so that you are reminded about it each year.

Focusing on Eye Disease

The main eye complications of T1DM are cataracts and retinopathy. I Cataracts are opaque areas of the lens. Cataracts occur in no more than 1 percent of children with T1DM. In both children and adults, if the cataract is blocking vision, the cataract is removed by surgery and a new lens is implanted, restoring vision. I Retinopathy is considerably more common than cataracts, varying from 15 percent to 50 percent occurrence in patients with T1DM in different studies. It's considerably less common today than it was before the era of intensive diabetic treatment. Because diabetic eye disease takes years to develop, the current recommendation is to have your or your child's eyes examined by an ophthalmologist or optometrist when T1DM is first detected, five years after T1DM is diagnosed, and once a year thereafter as long as the examination remains normal. See Chapter 7 for more about eye checks. Figure 5-2B shows the more benign form of diabetic retinopathy. The signs of background...

The Eye Doctor Your Lighting Designer

The eye doctor (ophthalmologist or optometrist) ensures that your diabetes does not damage your vision. This doctor has had advanced training in diseases of the eye. Your primary care physician must see (no pun intended) to it that you have an examination by this specialist at least once a year and more often if necessary. An ophthalmologist or optometrist must dilate the pupils of the eyes in order to do a proper examination. The eye doctor examines you for the conditions I outline in Chapter 5. He or she must send a report to your primary care physician. He or she should also take the opportunity to educate you about diabetic eye disease. Sometimes the good deed of restoring vision leads to unexpected, negative consequences. One ophthalmologist I talked to told me that he restored the vision of a diabetic patient, only to have the patient buy a gun and nearly shoot someone with whom he had a grievance.

Diabetic Eye Disease

Vision loss in diabetes mellitus is usually the result of diabetic retinopathy. A complication of severe diabetic retinopathy is neovascular glaucoma, which can lead to a blind painful eye if not treated expeditiously. Other less common causes of vision loss in diabetes are cataracts and, occasionally, keratopathy (corneal disease). Corneal disease stems from basement membrane thickening that makes the corneal epithelium less adherent, susceptible to injury, and slower to heal than the nondiabetic cornea. Diabetic papillopathy (swelling of the optic nerve) is an uncommon cause of vision loss that is usually transient, but sometimes permanent. Cranial nerve palsies are uncommon causes of diplopia (double vision) that occur more commonly in diabetics than nondiabetics.

Neovascular Glaucoma

Growth of NVI or rubeosis iridis occurs in less than 10 of diabetic eyes, but occurs in 40-60 of eyes with PDR (55). NVI is dangerous, because the new vessels tend to grow over the trabecular meshwork, the outflow channel of the eye, resulting in intractable glaucoma. The presence of NVI, regardless of retinal status, requires prompt scatter laser photocoagulation to induce regression of these abnormal blood vessels (56,57). It is postulated that scatter laser treatment decreases the release of factors from

Eye Disease

Retinopathy is best detected clinically by examining the retina with an ophthalmoscope through dilated pupils. In older individuals, chronic open-angle glaucoma is often a coincidental condition. By itself, glaucoma is not a contraindication to the use of my-driatics to dilate the pupil although this task is less easy when a patient is using pupil-constricting eye-drops. On the other hand, the presence of cataract makes visualization of the fundi much more difficult. Quite often, retinal examination has to be deferred until after cataract extraction. In older diabetic patients, NPDR with macular oedema is the main cause of vision loss. The clinical presentation is less dramatic than that seen with the sudden bleeding of proliferative retinopathy. Instead, vision just becomes less with each successive year. As elderly patients are often much less complaining than their younger counterparts and may have a concurrent cause of visual impairment, such retinopathy is easily missed. Once...

Your Eye Doctor

For anyone with either type 1 or type 2 diabetes, eye care is an important priority. By keeping your blood glucose level close to normal, you can lower your risk for some of the long-term effects of diabetes and preserve your eyesight. An eye specialist monitors changes in your eyes, especially those changes associated with diabetes. He or she then determines what those changes mean and how they should be treated. For example, changes in the tiny blood vessels that supply your retina the part of the eye that detects light and thus visual images could be an early sign of diabetic retinopathy. Left untreated, diabetic retinopathy can lead to blindness. Although your diabetes care provider will look at your eyes during the course of your yearly physical examination, you also need to have them more thoroughly examined by a trained eye specialist. Your eyes need to be dilated for this exam. If you are 10 or older and have type 1 diabetes, you should have a comprehensive examination 3 to 5...

Essential Eye Care

Caring for your eyes starts with a careful examination by an ophthalmologist or optometrist. You need to have an exam at least once a year (or more often if necessary). If you have controlled your diabetes meticulously, the doctor will find two normal eyes. If not, signs of diabetic eye disease may show up (see Chapter 5). At that point, you need to control your diabetes, which means controlling your blood glucose. You also want to control your blood pressure because high blood pressure contributes to worsening eye disease, as does high cholesterol. Although the final word is not in on the effects of excessive alcohol on eye disease in diabetes, is it worth risking your sight for another glass of wine Smoking has definitely been shown to raise the blood glucose in diabetes. Even at a late stage, you can stop the progression of the eye disease or reverse some of the damage if you stop smoking now.

Eye problems

Fortunately, it takes 15 to 20 years of poor diabetic control for your child to develop eye problems. Unfortunately, that means that he may be only 30 years old when his vision begins to deteriorate. This can be prevented by keeping his hemoglobin A1c at 7 percent or below as much as possible (I discuss hemoglobin A1c earlier in this chapter). An eye examination must be done annually to check for diabetic eye disease called retinopathy (see Chapter 5). An ophthalmologist or an optometrist can perform the exam as a side note, it has been shown that no other doctor does as good a job with the exam as these two professionals. Make sure you insist that your doctor arrange for your child to have this examination annually. Fortunately, excellent treatments are available for diabetic eye disease, as you find out in Chapter 5. If it's discovered early by this examination, blindness is usually prevented in patients with T1DM.


Age-related cataracts occur earlier, more frequently, and progress more rapidly in patients with diabetes (54). Fortunately, present microsurgical techniques for cataract removal and prosthetic intraocular lens replacement are very successful and usually result in restoration of vision. However, there is some evidence that cataract surgery may be associated with acceleration of retinopathy. It is imperative that retinopathy be stable before surgery, and vigilance is warranted in the postoperative period to watch for worsening of retinopathy and instituting treatment if needed. In some instances cataracts can make examination of the retina difficult and must be removed to facilitate management of diabetic retinopathy.


When you have had diabetes for a long time, you are more susceptible to cataracts because of a build-up of sugars in the lenses of the eyes. These make the lenses of your eyes opaque, interfering with the transmission oflight to the back ofyour eyes, and can be a particular nuisance in bright sunlight. Fortunately, this problem can be treated quite easily with a simple operation to replace your damaged lenses with plastic ones. It can often be done under a local anaesthetic, and you will normally only have to be in hospital for 24 hours. The results are generally excellent.

How is the diagnosis of diabetic retinopathy made

It is based on a comprehensive ophthalmologic evaluation, which should be performed by an ophthalmologist. As expected, some studies have shown that evaluation by an ophthalmologist has greater effectiveness and sensitivity in detecting retinal damage. However, the initial evaluation by the primary physician (general practitioner, diabetologist, endocrinologist), who should perform a minimal ophthalmologic exam, is also important. In this way, possibly serious damage that could go undetected can be prevented. A comprehensive ophthalmologic exam includes visual acuity evaluation, pupil reaction to light (myosis of the pupil on application of light on it), and fundoscopy. Monoocular examination with the direct ophthalmoscope is not always able to detect all possible retinal lesions, especially when the examiner is not very experienced. Furthermore, diagnosis of maculopathy with simple fundoscopy is difficult to detect in detail, even by very experienced ophthalmologists. For this...

The seriousness of hypoglycemia

Hypoglycemia is a barrier that prevents most patients with diabetes from achieving normal blood glucose levels. They can lower their blood glucose enough to prevent long-term complications such as eye disease, kidney disease, and nerve disease, but preventing heart disease requires a lower glucose level that is difficult to sustain because of the threat of hypo-glycemia, particularly for people with type 1 diabetes. A normal blood glucose is between 80 and 140 mg dl. Hypoglycemia begins below 80 mg dl but you may not feel symptoms until it goes below 60 mg dl.

Principles in assessing methods of care

Secondly, for evaluation, the performance of the system relative to that of the gold standard must be known, so that the trade-offs can be identified. In the case of diabetic retinopathy the practice guidelines of the International Council of Ophthalmology (52) and the Amercan Academy of Ophthalmology (50) prescrbe observation by a trained, experienced observer or a full seven-field photographic interpretation according to the standards of the Wisconsin Reading Center as the gold standard. Thus, any study of the value of a system, such as remote telemedicine care in diabetic retinopathy, must establish its performance and reliability relative to either of these gold standards. Nevertheless, no system is perfect at the outset. I a new approach offers added advantages, such as better access to care, reaching more people with diabetes at a lower unit cost, then a level of technical performance that is at least as good as (or perhaps lower than) current care even i not up to the gold...

Deficiencies Identified in UK Residential Diabetes Care

Lack of specialist health professional input, especially in relation to community dietetic services, diabetes specialist nurses and ophthalmology review. In addition there is a lack of state registered podiatry provision for residents with diabetes of all ages especially for those at highest risk of diabetic vascular and neuropathic damage.

Magnetic Resonance Imaging MRI and spectroscopy

Mri Spectroscopy Show Muscle

From a safety point of view, magnetic resonance techniques represent no radiation risk, but as discussed in Chapter 11, the presence of a strong magnetic field and the switching of magnetic field gradients make metallic objects (splinters, tattoos, coloured contact lenses, piercings, uterus coils), other medical devices (pace makers, cardiac valves, clips, electrodes, neuro-stimulators), implants, prosthetics, shunts and stents contraindication for the MR examination. Another practical consideration is the restricted space in the clear bore of the magnet. The usual clear diameter of 60-70 cm can exclude morbidly obese patients from the examination. Nevertheless, the advantages and the versatility of the method as well as the wider spread of clinical MR systems predetermine broad application in future clinical praxis.

Trials examining glycemic targets

In the ADVANCE trial (Action in Diabetes and Vascular Disease Preterax and Diamicron MR Controlled Evaluation), 11,140 patients who have type 2 diabetes mellitus were recruited in 200 centers in Australia, Asia, Europe, and North America. The eligibility criteria are broad diagnosis of type 2 diabetes mellitus after 30 years of age, age 55 or more years, and high risk for CVD. Patients are randomized in a 2 x 2 factorial design to an open-label, modified-release (MR) sulfonylurea (gliclazide MR)-based intensive treatment with a goal of achieving a HbA1c level of 6.5 or less versus standard care for glycemia as well as a blood pressure intervention (see later discussion). There are two primary endpoints (1) the composite of stroke, MI, and CV death, and (2) the composite of new or worsening nephrop-athy or microvascular eye disease. The scheduled postrandomization follow-up is 4.5 years. The study is designed to provide 90 power to detect

Optical coherence tomography OCT

The limitations of OCT include the inability to obtain high-quality images through media opacities such as dense cataract or vitreous haemorrhage. The use of OCT is also limited to cooperative patients who are able to maintain fixation for the full acquisition time of 2.5 sec per section. with visual acuity. OCT can be used to follow the clinical response to focal laser treatment for clinically significant macular oedema.

Oral diabetes medications or oral hyperglycemic medications

Retinopathy Damage to small blood vessels in the eye that can lead to vision problems. In background retinopathy, the blood vessels bulge and leak fluids into the retina and may cause blurred vision. Proliferative retinopathy is more serious and can cause vision loss. In this condition, new blood vessels form in the retina and branch out to other areas of the eye. This can cause blood to leak into the clear fluid inside the eye and can also cause the retina to detach.

Even More Factors to Consider

There is a paper suggesting that rapid institution of tight control may be especially problematic if it is done around the time of cataract surgery. See Chapter 24. Instead, you should point out that they are dealing with damage that began years ago, and that they cannot make this old damage suddenly disappear with good control. They need to understand that their eye disease is like a moving freight train It takes a while to bring things to a halt. Fortunately, it always pays

Prevention Of Diabetic Retinopathy

Risk was seen in all sub-groups of the study and in all centres participating (DCCT Research Group 1993). The UKPDS has also demonstrated a reduction of risk of retinopathy with tight glycaemic control in Type 2 patients (HbA1c 7 ) giving a 25 risk reduction for retinal photocoagulation (UKPDS 1998a). It was also instrumental in highlighting the vital role that the control of hypertension has to play in reducing complication rates in Type 2 patients. Both clinical and economic data support the rigorous control of blood pressure to study defined levels, often necessitating multiple antihypertensive agents to achieve a target blood pressure of 140mmHg (UKPDS 1998b). Using these targets, the UKPDS demonstrated a 37 reduced rate of progression of retinopathy and a 47 reduced risk of loosing more than three lines of visual acuity as measured by the ETDRS chart (ETDRS 1987). The benefit in terms of visual outcome for patients with tight control of all risk factors would be substantial. The...

When can DM cause reversible haziness of the lens

Multiple reversible haziness of the lens can occur rarely in patients with Type 1 DM (children or young adults) after severe hyperglycaemia and evolve over days or weeks ('snowflake cataracts'). This condition is gradually reversed with control of diabetes. Similar but less intense episodes can be seen in diabetic patients during periods of poor control of their diabetes. This happens more frequently, is manifested with transient refractive visual abnormalities - mostly myopia - which are primarily associated with electrolyte disturbances through the lens, and is reversible. A 68 year old woman, with poorly controlled DM of 25 years duration, comes to the diabetes clinic for follow-up. Her fasting blood glucose is around 256 mg dl (14.2 mmol L) and her HbA1c is 11.2 percent. The patient complains of pricking pains, burning sensation and numbness in her lower extremities, as well as frequent cramps. Furthermore, she reports deterioration of her vision lately with decrease in her visual...

Management Of Patients With Type Diabetes During Surgery

Optimal management of diabetes during surgery requires reliable, frequent blood glucose monitoring as well as timely and appropriate insulin replacement to maintain blood glucose in an acceptable range while avoiding ketoacidosis. The actual regimen adopted depends on the nature of the surgical procedure, expected duration of fasting, as well as the pre-existing insulin regimen. For example, for a patient using an MDI program who is due to undergo cataract extraction, diabetes could be managed by continuing long-acting insulin preparations while omitting the shorter-acting preparations taken with meals. (see Table 1).

Extensive Wet Gangrene Of The Foot

Diabetic Foot Infection Necrosis

A 51-year-old male patient with type 1 diabetes diagnosed at the age of 25 years was admitted to the Vascular Surgery Department because of extremely painful wet gangrene on his right foot. The patient had proliferative diabetic retinopathy which had been treated with laser, significant loss of his visual acuity (3 10 in both eyes), hypertension and diabetic nephropathy. He had lived in a nursing home. His diabetes control was good (HBAic 7 ). The patient had complained of pain in his right foot when he was at rest, 4 weeks prior to

Clinical Features of Diabetic Retinopathy

Dot Hemorrhage Hard Exudate

Neovascularization occurs at the border of the perfused and nonperfused retina. Some outflow of fluid from the eye occurs at the optic nerve, and when retinal ischemia becomes severe enough, vasoproliferative factors may become concentrated at the optic nerve, resulting in neovascularization at the disk (NVD) (see Fig. 5). Neovascularization that occurs elsewhere in the retina is called neovascularization elsewhere or NVE (see Figs. 3 and 4). Because NVD tends to be associated with more severe retinal ischemia than comparable sized areas of NVE, NVD is associated with a greater risk of visual loss. When retinal ischemia is extremely severe, vasoproliferative factors may become concentrated at the anterior outflow channels of the eye, resulting in neovascularization on the trabecular meshwork and the iris that make up the anterior chamber angle. This is referred to as neovascularization of the iris (NVI) or rubeosis. Blockage of outflow through the trabecular meshwork by new vessels...

What about operating on patients who are on Coumadin

It is well accepted that it is OK to do modern cataract surgery on uncomplicated, anticoagulated patients.3 Retinal surgery or even complicated anterior segment surgery is more likely to have problems with bleeding and there is no definitive study that provides a solid answer. Furthermore, you can be screwed no matter what you do If you stop the Coumadin and the patient has a pulmonary embolism or a stroke, there will always be some hired-gun expert to say you should have done something differently. If you don't stop the Coumadin and the patient has a choroidal hemorrhage that destroys the eye, there will always be some hired-gun expert to say you should have done something differently. You can't win unless you put in some thoughtful pre-op face time. a patient with a lot of hemorrhagic potential, this may be something to consider because, again, the potential risk of an intraoperative hemorrhage in the mind of such a patient (e.g., a one-eyed smoker who has high myopia and severe...

Patients without previously diagnosed diabetes and funny things in their retina that look diabetic

This is usually the easiest because even an ophthalmologist can diagnose diabetes. (By the way, remember that we are talking about diagnosing Type 2 diabetes here Type 1 does not show up in your clinic with retinopathy as a presenting sign. Those patients show up in the ER with polydipsia, polyuria and ketoacidosis.)

Local signs of infection not noted by patient

Dangers Infected Diabetic Toe

A 53-year-old lady with type 1 diabetes of 25 years' duration, proliferative retinopathy with reduced vision, peripheral neuropathy and hallux rigidus developed a neuropathic ulcer under callus on the plantar surface of her right hallux. She was warned of the usual danger signs of deterioration (redness, warmth, swelling, pain, purulent discharge) but did not return to clinic until her routine appointment. Callus had grown over the ulcer preventing drainage and the toe had become cellulitic (Fig. 5.1a,b). Callus was debrided and pus drained (Fig. 5.1c). A deep wound swab was taken and oral amoxicillin 500 mg tds and flucloxacillin 500 mg qds were prescribed. She was reviewed the next day. The toe had not improved and she was admitted for bed rest and intravenous antibiotics according to our protocol, namely amoxicillin, 500 mg tds, flucloxacillin 500 mg qds, metronidazole 400 mg tds and ceftazidime 1 g tds. The swab taken at her outpatient clinic visit grew Staphylococcus aureus and...

Anintroduction from the author

Diabetic Retinopathy Patient

Nor does this text offer an in-depth discussion of basic science or an exhaustive review of the available literature. Like the Basic and Clinical Science Course from the American Academy of Ophthalmology, there are some references given at the ends of most chapters for further information. However, if you want an in-depth look at the literature behind treating retinopathy, you are encouraged to review the sections on diabetes in any of the major ophthalmology texts, and in particular, Ryan's retina text. The American Academy of Ophthalmology's Focal Point from March 2003 on diabetic retinopathy by Drs. Fong and Ferris is also an excellent and succinct review. First, some really big numbers An estimated 20.2 million Americans have diabetes mellitus, and the number is expected to grow to over 30 million cases by the year 2025. Thanks to exports like the Great Western Lifestyle, the number of worldwide cases is expected to increase by 72 to 333 million by the year 2025. That is a lot of...

Anterior Segment Complications

Lenticular Sclerosis Red Reflex

Probably the most common problem is scruffing up the corneal epithelium. Diabetics, especially by the time they have retinopathy, tend to have a bad combination of decreased corneal sensation and anterior basement membrane abnormalities. This can predispose them to punctate epithelial erosions or even full-thickness epithelial defects from the use of the contact lens. Fortunately, this is not very common, and if there are symptoms they tend to be mild and self-limited meaning that they are a perfect indication for all those artificial tear samples that keep building up in your cabinets. It also helps to rinse out the methylcellulose after treatment, both to increase the patient's comfort and because sometimes the methylcellulose can thicken and make the eye very irritated once the topical anesthetic has worn off. Don't forget to remind the patient to avoid rubbing their eye while it is numb, as well. If there are a lot of pre-existing anterior basement membrane changes, or if the...

Puttingit All Together

There is no question that one of the landmark studies in all of ophthalmology was the Diabetic Retinopathy Study (DRS), which clearly demonstrated the usefulness of laser treatment in avoiding blindness back in the 1970s.2 (Both the DRS and the ETDRS produced a host of papers the cited reference is an example.) (American Academy of Ophthalmology, Basic and Clinical Science Course, Section 12, Retina and Vitreous 2007-2008 page 109.) Figure 12. Cumulative rates of severe visual loss for the DRS (the protocol was changed in 1976 to allow more treatment of high-risk eyes). This graph, and the heroic work behind its discovery, is truly awesome (in the traditional, non-surfer sense of the word). (The Diabetic Retinopathy Study Research Group, DRS report no. 8, Ophthalmology 1981 88 583-600, Copyright Elsevier 1981.)

Neuropathic Ulcer With Osteomyelitis

Debridement Under Feet

A 57-year-old obese male patient with type 2 diabetes diagnosed at the age of 40 years was referred to the outpatient diabetic foot clinic because of a chronic ulcer under his right foot. He was being treated with insulin and metformin with acceptable diabetes control (HBA 7.8 ). He had a history of background retinopathy and cataract in both eyes. He reported a severe deep tissue infection 5 years earlier after a burn sustained under his right foot. At that time he was hospitalized for about 1 month and treated with intravenous antibiotics and surgical debridement.

Symmetrical Neuropathies

It is important to appreciate that many subjects with distal symmetrical neuropathy may not have any of the above symptoms, and their first presentation may be with a foot ulcer (7). This underpins the need for carefully examining and screening the feet of all people with diabetes, in order to identify those at risk of developing foot ulceration (7). The insensate foot is at risk of developing mechanical and thermal injuries, and patients must therefore be warned about these and given appropriate advice regarding foot care (7,23). A curious feature of the neuropathic foot is that both numbness and pain may occur, the so called painful, painless leg (23). It is indeed a paradox that the patient with a large foot ulcer may also have severe neuropathic pain. In those with advanced neuropathy, there may be sensory ataxia. The unfortunate sufferer is affected by unsteadiness on walking, and even falls particularly if there is associated visual impairment because of retinopathy.

Landmark Clinical Trials Addressing the Management of Diabetic Retinopathy The Diabetic Retinopathy Study

Exudates at or within 500 m of the center of the macula if there is thickening of adjacent retina, or (3) an area of retinal thickening at least one disk area in size, part of which must be within one disk diameter of the center of the macula. When all eyes with diabetic macular edema were considered and irrespective of whether the edema was clinically significant, immediate focal, or grid treatment reduced the incidence of moderate visual loss (loss of 15 or more letters on an ETDRS visual acuity chart) by approx 50 at all time-points (13). On the other hand, PRP was found not to be effective in managing macular edema. In some cases, PRP may accelerate the progression of macular edema. The ETDRS also demonstrated that early panretinal photocoagulation in eyes with severe nonproliferative diabetic retinopathy (NPDR) did not significantly alter the end point of severe visual loss (visual acuity less than 5 200 at two consecutive follow-up visits) and deferral of laser treatment until...

Foot Problems in Diabetes

Patients with retinopathy and nephropathy have been shown to have an increased risk of foot ulceration and amputation. The pathogenic mechanisms by which other complications lead to ulceration and amputation are not entirely clear, but visual impairment makes it more difficult for patients to identify a lesion at an early stage, and tissue repair is slow in nephropathy, because of oedema, the frequent co-existence of macrovascular disease and immunological abnormalities. Thus, such patients must always be regarded as being at high risk.

Disorders of automatic autonomic nerves

Abnormalities of the pupil of the eye. Neuropathy may prevent the pupil from opening to let more light in when necessary. Reduced vision in low light means that the patient has to be much more careful about driving at night. There's no treatment other than better glucose control.

Oxidative stress in premature infants

Hypoxia Premature Infants

Retinopathy of prematurity (ROP) is a vasoproliferative retinal disorder of premature infants. Its basic pathogenesis is not fully understood but exposure to the extrauterine environment including necessarily high inspired oxygen concentrations produces cellular damage mediated by ROS. Hyperoxygenation favors peroxidation of vasoactive isoprostanes, resulting in vasoconstriction and vascular cytotoxicity leading to ischemia, which predisposes to the development of vaso-proliferative retinopathy.118 Severe ROP can lead to lifelong visual impairment or blindness.119

Measuring Cognition In Diabetes

The present chapter does not summarize the cognitive findings typical for diabetes type 1 and type 2. Nevertheless, we wish to address issues that need to be considered in order to design an optimal test battery for the assessment of diabetes-associated cognitive decline. Firstly, when patients with diabetes are compared with non-diabetic controls, effect sizes for the differences in performance between the groups are generally small (Chapters 10-12). This indicates that an optimal test battery should be very sensitive to be able to detect small changes in cognitive function and should not suffer from ceiling effects. Cognitive domains that are generally sensitive to brain dysfunction are speed of information processing and executive function, both requiring either fast or effortful processing. Furthermore, the impact of confounding factors should be kept to a minimum. In diabetes, potentially confounding factors are peripheral complications, such as neuropathy which may result in...

Preventing type diabetes

Doctors can predict type 2 diabetes years in advance of its actual diagnosis by studying the close relatives of people who have the condition. This early warning period offers plenty of time to try techniques of primary prevention (which I explain in the Preventing type 1 diabetes section, earlier in this chapter). After a doctor discovers that someone's blood glucose levels are high and diagnoses type 2 diabetes, complications such as eye disease and kidney disease (see Chapter 5) usually take ten or more years to develop in that person. During this time, doctors can apply secondary prevention techniques (the various treatments I discuss in Part III).

The Patient With Diabetic Retinopathy

Diabetic retinopathy is a significant cause of visual impairment in elderly people. In the Framingham Study, 3 of all people aged 65-74 y had diabetic retinopathy, with 7 of 75-85 y olds being affected (Kini et al 1978). The duration of diabetes is the critical risk factor in the development of retinopathy those with Type 2 diabetes have a similar risk as those with Type 1 diabetes mellitus (Nathan et al 1986). Strategies to prevent or retard the development of diabetic retinopathy are described in Chapter 9. Even if visual impairment does result, much can be done to minimize resulting disability and handicap. Ophthalmology departments usually have affiliated units specializing in the provision of low vision aids and other appliances. An array of products are also available to help the visually impaired with blood sugar monitoring and insulin administration (Petzinger 1992). In many countries, those registered as visually impaired or legally blind are eligible for special services and...

Agenda purpose and expected outcome

Issues in eye care in diabetics Eye care deficiencies contributing to blindness from diabetic retinopathy Improving integration of eye care within diabetes management Training of general practitioners in diabetic retinopathy detection Detection and referral within diabetes care clinics Detection within eye care clinics (prmary, secondary, tertiary) Community-based screening modes Identify core diabetic retinopathy related eye health education messages for integration with diabetes patient education materials.

Multiple Sclerosis Amyotropic Lateral Sclerosis

Kendra Welch, 56, was diagnosed with MS a year ago, by MRI. She went to a chelating doctor and this cleared up her temporary ischemic attacks (T.I.A's) which were occurring daily. But she had lost her balance, eyesight was getting worse, her feet and hands stung. Her sister also had MS but nobody else in the family did which baffled her doctor. Her brain tissue was full of barium, europium, gadolinium, and platinum. These are dental alloys, although barium could come from bus exhaust (she wore no lipstick). She was advised to have all metal removed from her mouth immediately. Two days afterward she came into the office without any neurological symptoms. She stated she was afraid to stop her new health program, though, and this was good policy.

Supporting evidence is of class R

Studies have shown that retinal examinations by physicians who are not eye care specialists are not reliable in detecting retinopathy (American College of Physicians, American Diabetes Association, and American Academy of Ophthalmology, 1992 American Diabetes Association, 2003b Diabetic Retinopathy Study Research Group, The, 1981 ETDRS Research Group, 1985 ETDRS Research Group, 1991 Klein, 1984 Klein, 1987).

Counseling and Preconception Care Recommendations to Reduce Maternal and Fetal Risks of Preexisting Diabetes What Are

Counsel on management of significant hyperglycemia. (For patients with DM1, review DKA prevention with special consideration for pregnancy's impact on risk for DKA and DKA's potential impact on pregnancy). Counsel on hypoglycemia safety, including driving safety and the use of glucagon Genetic counseling for diabetes Counsel on the risk of retinopathy Initiate preconception ophthalmologic evaluation Obtain lipid profile, if not previously performed Medical nutrition therapy (MNT) Retinopathy Why Do I Have to Have an Eye Exam

Detecting Prediabetes

A person with prediabetes does not usually develop eye disease, kidney disease, or nerve damage (all potential complications of diabetes, which I discuss in Chapter 5). However, a person with prediabetes has a much greater risk of developing heart disease and brain attacks than someone with entirely normal blood glucose levels. Prediabetes has a lot in common with insulin resistance syndrome, also known as the metabolic syndrome, which I discuss

Dialysis In Esrd Diabetic Patients

In diabetic patients, several complications such as retinopathy, glaucoma, cataracts, CAD, cardiomyopathy, cerebrovascular disease (CVD), peripheral vascular disease (PVD) limb amputation, motor neuropathy, sensory neuropathy, autonomic dysfunction (diarrhea, vomiting, postural hypotension), myopathy, and depression persist or progress during ESRD, and are already present at the initiation of RRT. Macrovascular disease, particularly CAD is accelerated in patients with diabetic ESRD and it is the most common cause of death in these patients. Early cardiac evaluation in all diabetic patients as well as vigorous treatment of hypertension is the key component in the management of DN.

Ocular Ischemic Syndrome Thermonuclear Retinopathy

Global ocular ischemia may be very difficult to diagnose, particularly if the patient already has lots of diabetic eye disease. You won't see it very often unless you have a practice full of patients with awful disease, but you do not want to miss it if it does show up because it can be treatable if caught early and disastrous if caught late. In the past this syndrome has had a number of confusing names, including retinopathy of carotid insufficiency and venous stasis retin-opathy (the latter being most problematic because some people have used the same term to describe a non-ischemic central retinal vein occlusion). Lately, everyone seems to agree that the most useful name is ocular ischemic syndrome (OIS), mostly because that is what the people at Wills Eye Hospital call it, and who's gonna argue with them

T Dry Steamed billed Carrots

Here's a tasty twist on a veggie favorite. Heather Dismore uses fresh herbs here to give these carrots a new and interesting flavor. Carrots are one of the best sources of vitamin A, antioxidants, lutein, and beta carotene. These are the nutrients best known for eye health. The orange fruits and vegetables are all good sources of these antioxidants, so get them in whenever you can

Screening For Diabetic Complications

All elderly people with diabetes should be reviewed at least 6-monthly for refraction, and at least yearly for ophthalmoscopic examination with pupil dilatation. Detection of any retinopathy, cataract or other ocular abnormality warrants referral to an ophthalmologist. Early retinopathy can be reversed by improved metabolic control or halted by laser therapy. Eye disease Visual acuity

Species of Plants Reported to Be Used Traditionally to Treat Diabetes

(Marles and Farnsworth, 1995) Gymnemic acids III, IV, V, VII, and gymnemoside B tested for antidiabetic activity (Yoshikawa et al., 1997a, b) A polyol conduritol A suppresses cataracts (Miyatake et al., 1994) Extracts from fruits have antidiabetic activity (Handa et al., 1989)

The Diabetes Educator

The DSME entity will designate a coordinator with academic and or experiential preparation in program management and the care of individuals with chronic disease. The coordinator will oversee the planning, implementation, and evaluation of the DSME entity. Standard 5. DSME will involve the interaction of the individual with diabetes with a multifac-eted education instructional team, which may include a behaviorist, exercise physiologist, ophthalmologist, optometrist, pharmacist, physician, podiatrist, registered dietitian, registered nurse, other health care professionals, and paraprofessionals. DSME instructors are collectively qualified to teach the content areas. The instructional team must consist of at least a registered dietitian and a registered nurse. Instructional staff must be Certified Diabetes Educators (CDEs) or have recent didactic and experiential preparation in education and diabetes management. Standard 6. The DSME instructors will obtain regular...

Maternal Complications

Retinopathy, the growth and deterioration of blood vessels in the retina, leads to impaired vision and blindness. This disease is caused by poor blood circulation in the eye and the interplay of hypoxia with endothelial growth factors as a consequence of continually high blood glucose levels. Although pregnancy is not known to cause retinopathy, it can exacerbate pre-existing disease in the mother (19). The study conducted by Merimee et al. (20) in ateliotic dwarfs who lack growth hormone (GH) indicated that the lack of GH may prevent diabetic retinopathy. The investigators did not observe any retinopathy in their study group of patients completely lacking GH. Human chorionic somatomammotropin (HCS), present in high concentrations during pregnancy, is known to have GH-like qualities and may also contribute to the acceleration of neovascularization noted in pregnant women (21). Therefore, careful ophthalmic evaluation and monitoring is necessary before and during pregnancy to screen...

Handling the Physical and Emotional Consequences of Type Diabetes

The long-term complications consist of eye disease known as retinopathy, kidney disease known as nephropathy, and nerve disease known as neuropathy. Diabetes is the leading cause of new cases of blindness new cases of kidney failure requiring dialysis, which cleanses the blood of toxins when the kidneys can no longer do their job and loss of sensation in the feet as well as other consequences of nerve damage.

Examining diabetes caused by destructive diseases of the pancreas

The life expectancy of patients with CF used to be very short, and there was little concern about the development of diabetes. With modern methods of CF management, however, many more patients are living to develop diabetes. They're subject to complications similar to those associated with autoimmune T1DM and must be screened for eye disease (see Chapter 5), high blood pressure, and kidney disease in the same way. For example, a study of 38 CF patients in Diabetes Care in December 2006 pointed out that the prevalence of eye disease in CF-associated diabetes is similar to autoimmune T1DM of the same duration, about 27 percent of patients. One great difference between autoimmune T1DM and diabetes caused by CF, however, is the absence of coronary artery disease in the latter form because the intestine has trouble absorbing fats.

Are the Cognitive Changes During Acute Hypoglycaemia Important and Valid

Just as more studies that examine the practical cognitive aspects of hypoglycaemia would be useful, so would more studies of the brain's processing efficiency. Cognitive tests typically involve a melange of inseparable mental processes, and yet very specific aspects of the human brain's activities can be measured in the clinical laboratory (Massaro, 1993). Studies of the cognitive effects of hypoglycaemia have thus begun to address the impairments to various cognitive domains in more detail. Basic, specific aspects of visual and auditory processing have been examined during acute hypoglycaemia in non-diabetic humans. Standard tests of visual acuity - those that are measured by an optometrist - are not affected by hypoglycaemia, but other aspects of vision are affected (McCrimmon et al., 1996). These include This means that the ability to see the environment changes in important ways during hypoglycaemia. Visual acuity is preserved, as tested by the ability to read black letters on a...

Use of photographic systems by nonphysician nonprofessional providers

The use of non-physician health care professional examiners for detecting diabetic retinopathy has been coupled with use of photographic systems in the United Kingdom (84,85). The performance of trained photographic readers using a Polaroid camera system has matched or exceeded that of physicians and optometrcs. An accuracy of more than 90 in staging retinopathy has been reported with a modified Early Treatment Diabetic Retinopathy Study system that is similar to the International Clinical Diabetic Retinopathy system used by the American Academy of Ophthalmology and the International Council of Ophthalmology Use by ancillary health care workers (and physicians) of a reference card or set of photographs in grading the severity of disease has been validated in the care of trachoma and other eye diseases, such as with the WHO trachoma grading card and primary eye care chart. The principle has also been used in numerous randomized controlled trals to achieve consistency in grading the...

Technical issues in the use of standard photographic images

In 2004, the American Academy of Ophthalmology concluded that, in the United States, single-field photography is adequate for screening for the purpose of detecting diabetic retinopathy but not for management (73) What is 'acceptable' necessarily varies from society to society in relation to the acceptable 'error' or 'miss' rates and the associated costs of achieving specific performance levels. Most studies indicate that performance levels with photographic systems are at least as good as or better than those of examinations by physicians and health care providers other than experienced retina specialists (75). Sufficient evidence therefore exsts that different societies and countres can adopt different technical performance standards and thus use different techniques. Some will want to do everything possible to avoid misclassification and thus use dilated seven-field photography, while others will adopt the seemingly opposite approach of using a single-field photograph through an...

A uniform classification system should be adopted

It is recommended that the International Clinical Classification of Diabetic Retinopathy (See Annex 3.), which provides a sound scientific bass for a uniiorm grading system, be used as an acceptable minimum standard for assessing diabetic retinopathy in programmes for prevention of blindness. This system provides a simplified but sound scientific basis for uniorm grading by general ophthalmologists who have a basic understanding of diabetic retinopathy and skis in evaluating the retina. It has been adopted by the International Council of Ophthalmology and by many member societies.

The Natural History Of Type Diabetes

Aldose reductase is an enzyme that causes accumulation of sorbitol at the cellular level in various diabetic conditions. Sorbitol accumulation directly leads to tissue damage and promotes the macro- and microvascular complications of diabetes because excess intracellular sorbitol levels decrease the concentration of various protective organic osmolytes. This is seen in the animal model of cataracts that contain decreased levels of taurine, a potent antioxidant and free-radical scavenger. Interestingly, inhibitors of aldose reductase have restored levels of protective osmolites and prevented diabetic complications by diminishing sorbitol reduction (13).

What would you recommend to the patient at this stage

A portable glucose meter for monitoring blood glucose levels at home and for determining the kind of diabetes therapy is necessary. Regular measurements of blood pressure at home could also be helpful. Despite the obvious diagnosis of DM and the negative urine culture, an exclusion of other causes of proteinuria (see theoretic section above) would be appropriate as well. For this reason, potentially useful tests would be determination of erythrocyte sedimentation rate (ESR), CRP and immunologic tests. Fundoscopic evaluation by an ophthalmologist is also absolutely necessary.

Screening for Complications at Diagnosis

Diarrhoea or constipation, and impotence should alert you to the possibility autonomic neuropathy (see Chapter 7). Symptoms of claudication should be inquired about. Physical examination requires measurement of lying and standing blood pressure and assessment of peripheral blood vessels. Visual acuity (VA) can be checked using a 3 m Snellen chart. Patients whose VA is worse than 6 6 in either eye should be examined using the pinhole test which will partially correct a refractive error. Alternatively, they may use their distance glasses if worn. In patients with poor VA which remains unaltered or worsens in the pinhole test, the retina should be closely inspected for lesions, particularly those of maculopathy. Direct ophthalmoscopy should start with the lens at zero and a red reflex obtained. When present, this indicates that there is no significant evidence of a cataract, vitreous haemorrhage, or retinal detachment. By setting the lens at +10 initially, and using a succession of less...

Rationale For Goodquality Care

Symptom control and reduced fatigue Reduced risk of metabolic decompensation Reduced hospitalization Reduced need for caregiver support Maintain optimal visual acuity Maintain optimal cognitive function Reduce vascular risk Better glycaemic control may reduce incidence of complications Better screening for maculopathy and cataracts will reduce number population of all ages (Rohan et al 1989). Delay in diagnosis of this condition results from lack of awareness of its importance, lack of testing for visual acuity, and failure to use mydriasis. This combined with inexperience at fundal examination, even by medically qualified health professionals, creates an unfortunate situation since more than 70 of patients are likely to benefit from laser photocoagulation Rohan et al 1989).

Metabolic Control In The Disabled Diabetic Person

While this chapter has focused on disability and handicap resulting from diabetic complications, it should be appreciated that the onset of disability and handicap can have implications for diabetic control. Thus the person with hemiplegia or visual impairment may have difficulty with self-monitoring of glycaemia and with self-administration of insulin. Reduced mobility may lead to weight gain and or loss of good metabolic control. As part of the rehabilitation program, the ability of the person to manage their diabetes should be assessed and, when necessary, remedial action taken.

Non Dr Causes Of Decreased Vision In Older Diabetics

Cataract Cataract is the most common cause of deteriorating vision in the elderly population. The lens thickens and opacifies with age and the lens opacities seen in the diabetic population are usually consistent with these changes, although the increased metabolic insult to the lens in diabetic patients causes these changes to accelerate and occur prematurely (Figure 9.10). A rarer form of cataract seen only in the diabetic population and as a direct result of poor diabetic control in Type 1 patients may occur. This is termed the 'snow-flake' cataract which resembles white flakes occurring in the lens just under the lens capsule. Usually they do not affect vision but tend to make fundal examination difficult. Type 2 diabetics may present with blurring of vision due to increased myopia resulting from overhydration and swelling of the lens secondary to prolonged high blood glucose. These refractive effects reverse as the Figure 9.10 Cataract. This finding is the most common occular...

Laser Treatment Of Diabetic Retinopathy

Laser treatment is carried out through a dilated pupil using a contact lens applied to the cornea anaesthetized by topical anaesthetic drops (Figure 9.7). There are a number of lasers that may be used, such as Argon or diode lasers. The wavelength chosen ranges from 488 to 577 nm. Operators avoid the shorter blue end of the spectrum as this can lead to effects not only on the blue A further possible complication is loss of peripheral vision. This is a direct effect of the treatment itself, which is effectively ablation of healthy retinal tissue by placing spaced burns in the periphery of the retina (Figure 9.8). This results in loss of visual field (peripheral vision). After a full treatment the field is reduced by 40-50 . If the treatment involves both eyes this may affect the fitness to drive.

Other sources of bias and error

Many patients with diabetes have complications leading to reduced visual acuity, and this requires that the print size of self-administered questionnaires is larger than that used in other populations, to ensure that misreading biases are not introduced. Likewise, other sources of bias should be considered and eliminated, such as with tools designed to assess quality of life, where a relative or friend of the patient may fill in the form for them.

First Trimester Weeks

The first prenatal visit may be the first time a patient with diabetes is seen. Ideally baseline evaluation and education take place before preconception as outlined in Chap. 15, but in many cases, pregnancies are unplanned. In the case of the unplanned pregnancy, this evaluation and education should take place as soon as the pregnancy is diagnosed. For patients who have had the benefit of preconception care, the first prenatal visit is usually scheduled between 6 and 8 weeks of gestation. This first visit should include a comprehensive medical assessment, including an assessment of the patient's diabetes control, renal, cardiac, thyroid, and ophthalmologic status, and counseling about diabetes management during pregnancy. A second visit in a short time frame may help prevent the patient from being overwhelmed as well as accomplish all these goals. A visit for the gravid patient who has not had preconception counseling or who may not be under excellent glycemic control is scheduled as...

Final Postpartum Visit

The final postpartum visit, which is usually done 6 weeks after delivery, is comprehensive and covers a wide range of systems from general well-being, coping with changes since delivery, and breastfeeding support. The visit focuses on questions pertaining to diabetes care, insulin requirements, blood pressure control (especially if preeclampsia occurred), eye health, maternal weight loss, a thorough physical exam, and contraception. Please see Chap. 9 for a more comprehensive review of fertility control.

Diabetic Retinopathy in Pregnancy

Evaluation of the retina is essential during preconception care of women with preexisting diabetes mellitus. An adequate examination requires the appropriate equipment by an experienced ophthalmologist who understands the risk for progression of retinopathy during pregnancy. A dilated eye exam and baseline retinal photographs are necessary since direct ophthalmoscopic examination alone may not identify DR (86). The frequency of eye examinations during pregnancy should be determined by the initial baseline evaluation of retinopathy and the risk factors associated with pregnancy. Currently, it is recommended that ophthalmologic follow-up continues throughout pregnancy and the postpartum period with photocoagulation initiated for significant neovascularization (67, 87).

Driving and Hypoglycemia

Some of the medicines used to treat diabetes (insulin, sulfonylureas, repaglinide, and nateglinide) can cause hypoglycemia, which can affect reflexes and judgment. In addition, long-term diabetes complications, especially vision problems and neuropathy, may interfere with driving ability. Be extra vigilant if you have complications, especially vision problems and diabetic neuropathy.

It takes time and effort but intensive diabetes management can increase your freedom and flexibility and help you avoid

When Katherine was diagnosed with diabetes, she was heartbroken. She had witnessed the devastation of the disease through her mother, who had lived with diabetes for 30 years. She stood by as her mother first lost her eyesight, then suffered a leg amputation, and finally succumbed to kidney failure. Katherine did not want to face the same ordeal. She learned from her diabetes educator that these complications were not always inevitable. There were steps she could take to greatly reduce her risk for these complications. The results of these two studies are very clear. The researchers in the DCCT found that after 10 years, intensive management reduced the risk of developing diabetic eye disease (retinopathy) by 76 percent. Among individuals who already had early signs of eye disease before entering the trial, intensive management slowed the progression of retinopathy by 54 percent. Tight blood glucose control also reduced the risk of kidney disease by 50 percent and that of nerve...

Diabetes Complications and Prevention

Fred went to the doctor because he was having problems with his vision. He didn't expect a diagnosis of diabetes. And to make it worse, he found out he would also need laser treatments for his eyes. He read that complications arise after living with diabetes for years. It hardly seemed fair that he had diabetic eye disease even before he knew he had diabetes. He wondered what else might be wrong with him. vision problems, such as blurry or spotty

The diabetes care team

Whether an individual with diabetes is cared for principally by a general practice team or by a hospital diabetes specialist team, it is now widely recognised that care is best provided by groups of health-care professionals with their own particular skills, working closely together. The teams include a consultant physician, diabetes specialist nurse, dietitian, chiropodist, general practitioner and practice nurse. They can also call upon the skills of a psychologist, ophthalmologist, nephrologist, neurologist, vascular and orthopaedic surgeons, obstetricians, midwifes and other specialists as necessary.

Longterm complications

The possibility ofdeveloping long-term complications is one ofthe most frightening aspects of diabetes. Prolonged periods of high blood sugar increase the risk of complications in people with diabetes. Common ailments include cardiovascular disease (such as high blood pressure and atherosclerosis), eye disorders, kidney disease, nerve disorders, and foot and leg problems. Most of these conditions result from years of chronic high blood sugar levels. The good news is that many ofthe possible problems can be treated, and often the treatment is most effective when the complications are noticed at an early stage. This is why you will be asked to go for regular medical check-ups.

How is retinopathy treated

Laser treatment developed in recent years can do a great deal to repair the damage caused by diabetic retinopathy. It is normally directed at the peripheral part of the retina, well away from the macula, and can remove hard exudates and prevent new blood vessels from growing. The earlier the treatment is given, the more successful it is, which is why it is essential that you should have your eyes checked at least once a year. An optician, a specialist ophthalmologist or a doctor who is skilled at this type of examination can do eye checks.

Testing Testing Tests You Need to Stay Healthy

Eye Exam i Have a dilated eye examination by an ophthalmologist or optometrist once a year. (See the section Checking for Eye Problems, later in this chapter.) i In 1994, 57 percent of people with diabetes had an annual eye examination. By 2005 it had grown to only 60.6 percent.

Sites for the Visually Impaired

Diabetes has a major impact on vision when the disease is not controlled (see Chapter 5). You can find huge quantities of information on every issue relating to visual impairment at the sites listed in this section. The American Foundation for the Blind has resources, information, reports, talking books, and limitless other facts and wisdom about dealing with visual impairment. This site points you in the right direction for information on every aspect of blindness. It is a guide to other sites about visual impairment.

Correcting the Cause of Complications

When the Diabetes Control and Complications Trial (DCCT) was published in the New England Journal of Medicine in September 1993, the study showed that people with type 1 diabetes could be controlled intensively with multiple daily shots of insulin. The better control resulted in a very significant reduction in complications of diabetes like eye disease, kidney disease, and nerve disease (see Chapter 5).

Where to stage the treatment

Suggested two- and three-stage PRP patterns. (Reproduced, with permission, from Folk JC, Pulido JS, Ophthalmology Monographs 11 Laser Photocoagulation of the Retina and Choroid, American Academy of Ophthalmology, 1997.) By the way, this is a great book for laser treatment in general lots of timeless info about lasering many different diseases. 2. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology 1991 98 766-85. 6. Shimura M, Yasuda K, Nakazawa T, Kano T, Ohta S, Tamai M. Quantifying alterations of macular thickness before and after panretinal photocoagulation in patients with severe diabetic retinopathy and good vision. Ophthalmology 2003 110 2386-94. 7. Blankenship GW. A clinical comparison of central and peripheral argon laser panretinal photocoagulation for proliferative diabetic retinopathy. Ophthalmology 1988 95 170-7. Folk JC, Pulido JS. Laser photocoagulation of the retina...

Where should you treat

For the standard treatment, the posterior border usually starts a disc width from the nerve and just outside the major arcades around the macula. The temporal treatment line is usually two to four disc diameters temporal to the fovea (Figure 8). Treatment is then carried out to the point where your contact lens can't easily see through the patient's lens usually to an area anterior to the equator. Figure 9. Patterns used in a study comparing central versus peripheral PRP. Over six months, the results were similar and the peripheral group had less macular edema. (Blan-kenship GW, A clinical comparison of central and peripheral argon laser panretinal photocoagulation for proliferative diabetic retinopathy. Ophthalmology 95 170-7, 1988. Copyright Elsevier) Figure 9. Patterns used in a study comparing central versus peripheral PRP. Over six months, the results were similar and the peripheral group had less macular edema. (Blan-kenship GW, A clinical comparison of central and peripheral...

What about doing a YAG

There is no clear consensus on whether performing YAG laser capsulotomy can stir up retinopathy. It probably does not have much of an effect but, as usual, there are never any guarantees. If you have to do a lot of hacking and slashing with the YAG you may cause enough inflammation to affect the retina, especially if the patient has already had complicated cataract surgery. It probably makes sense to put diabetics on some sort of anti-inflammatory drop around the time of the laser more laser or more preexisting damage may mean more topical therapy.

One More Thing Diplomacy in Action Is it the doctor or the patient

As you delve into a patient's medical care you need to get some idea about how aggressive their medical doctor is when it comes to controlling all of their risk factors. Sometimes the patient will tell you that their doctor doesn't do very much for them. If this happens, try to avoid riding any excessively high horses until you have learned all the facts. Although righteous indignation is a fun emotion in Hollywood epics about the struggle between good and evil, it should not be your default response to a patient who complains that their doctor does not seem to care about their diabetes. It is far more likely that the patient is poorly motivated, and their otherwise-busy healthcare providers have recognized this and therefore do not pour a lot of effort into the patient's management. A high-handed letter from the ophthalmologist demanding to know why no one

Getting Things Lined Up

First of all, the patient should be as comfortable as possible under the circumstances. One of the best ways to facilitate this is to allow someone else to stuff a diagnostic contact lens onto your eye at some point during your training. As you experience this, try to study their every move and your response to each move. Based on how it feels you will develop nuances that will allow you to be much gentler with your patients. The same is true for the inevitable battle with the contact lens. If you tell them to hold still and try not to blink you might as well inject them with pure meth-amphetamine and see whether they can shake your slit lamp right off the table. Instead, you may want to consider telling them to blink as much as they want, but to also concentrate on keeping their forehead pressed against the bar. This way, they can focus on just this rather simple task, which is far more useful to you than yearning for some fairyland where patients actually open their eyes and stop...

The definitive prosthesis

Putting the definitive prosthesis on and off may be difficult if hands are neuropathic and eyesight is poor, and visual inspection of the stump may be difficult. Velcro straps are useful in the patient with neuropathy and poor hand function to aid donning and doffing of the prosthesis. If skin is atrophic and circulation is reduced, stasis dermatitis may be a problem, and the skin is easily injured.

Be A Health Detective

Cure yourself of retinitis pigmentosa, Muscular dystrophy (the inherited kind), and break down your family's faith in the gene-concept for these diseases. Bring hope to your family by proving diseases' true etiology. Bring respect back for your loyal genes that bring you hair color, and texture, not hair loss. That bring you eye color, not eye disease. Your genes brought you the good things about your ancestors, not the bad things. Parasites and pollution brought you the bad things.

Controlling Your Blood Pressure

Keeping your blood pressure in check is particularly important in preventing the macrovascular complications of diabetes. But elevated blood pressure also plays a role in bringing on eye disease, kidney disease, and neuropathy. You should have your blood pressure tested every time you see your doctor. The goal is to keep your blood pressure under 130 80. (See Dr. Rubin's book High Blood Pressure For Dummies, 2nd edition, published by Wiley, for a complete explanation of the meaning of these numbers.) You may want to get your own blood pressure monitor so that you can check it at home yourself.

Patients treated with oral hypoglycaemic drugs

Patients may find that there are differences in employment for those on metformin only, as compared with those taking sulphonylureas. There is little risk of hypogly-caemia for people taking metformin alone, and if this controls the diabetes, changing to metformin may help a patient's employment prospects. Patients with tablet-treated diabetes are not usually permitted to join the police, armed services, or fire brigade, or to pilot aircraft. People already working in the police and fire service are usually permitted to continue, although their role may be changed. Merchant seamen who develop diabetes requiring tablet treatment are usually allowed to remain at sea, subject to a regular medical check. Patients may be allowed to drive large goods vehicles, passenger-carrying vehicles, or main-line trains, if they can prove that their diabetes is well controlled and that they have no tissue damage impairing relevant functions (e.g. poor vision, numb feet).

Laser photocoagulation

The aim is to induce regression of new vessels and sometimes to seal leaking new vessels. It is also used to treat maculopathy. Laser treatment prevents severe visual impairment in the majority of patients although the results for maculopathy are less predictable because treatment is close to the macula. Patients should understand that laser treatment may not improve vision but it should stop major deterioration. The treatment is usually given in one or more 30-60 minute sessions as an out-patient. Local anaesthetic and dilating eye drops are used and the patient just has to remain still and concentrate while the treatment is given. Afterwards there is blurring of vision, photophobia, and sometimes eye discomfort or headache. Patients who complain of severe pain should be referred to the eye casualty service.

Diabetic tissue damage

This may be present when a person applies for a job, or may develop during employment. People with diabetes may fail to appreciate the existence or significance of complications. Visual loss from diabetic eye disease, retinopathy, or cataracts, can obviously affect someone's job. Cataracts should be extracted promptly. Retinopathy or its treatment can cause visual loss new vessels may cause vitreous haemorrhage, maculopathy can cause severe visual loss, laser photocoagulation can reduce peripheral vision. Peripheral vascular disease may limit walking distance, cardiac disease may limit exertion. Nephropathy may require time-consuming treatment. Autonomic neuropathy may be embarrassing (for example gustatory sweating or diabetic diarrhoea) or dangerous (for example postural hypotension which may limit where the person may work with safety). Neuropathy in the hands may limit jobs requiring fine finger work, and in the feet may cause problems for those relying on foot work. Diabetic foot...

Treatment Of Established Disease

Based on the ETDRS, early photocoagulation is not recommended because severe visual loss is uncommon in treated and untreated eyes moreover, PRP is associated with significant loss of visual acuity and peripheral vision, especially in the first few months after treatment (25). The DRS did identify high-risk characteristics for which PRP is clearly beneficial (i) eyes with neovascularization and preretinal or vitreous hemorrhage and (ii) eyes with neovascularization on or within one disc diameter of the optic disc equaling or exceeding 1 4 to 1 3 disc area in extent even in the absence of preretinal or vitreous hemorrhage (30). Anecdotal reports suggest intraocular injection of triamcinolone acetate into the vitreous is helpful in eyes with macular edema however, there are no randomized clinical trials proving its efficacy in diabetic patients (25,31,32). In addition, it has been associated with elevations in intraocular pressure leading to glaucoma, cataract...