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Figure 13.9 Ocular Coherence Tomography (OCT) has improved the assessment of diabetic retinopathy, and here demonstrates macular oedema. (Images courtesy of Mr Gary Misson, Warwick Hospital.)

glaucoma that is secondary to rubeosis, people with diabetes are

Cataract more prone to primary chronic (open angle) glaucoma than the Cataract is common in diabetes, and is worsened by poor glycaemic general population.

control. The treatment is the same as for the general population.

Retinal detachment

This is a result of accumulation of fluid between the neural and pigmented retinal layers. As discussed above, fibrosis of the vitreous humour next to the retina promotes this process particularly in those with established proliferative retinopathy. A peripheral detachment may produce a field defect of gradual or sudden onset. This may or may not be noticed by the patient, but is typically heralded by a sensation of bright flashing lights. Traction with or without actual detachment may affect the macula (as discussed above) to produce acute deterioration in acuity.

Retinal vein occlusion

The retinal vein may become occluded, particularly if hypergly-caemia is sufficient to produce hyperviscosity. Occlusion of the central retinal vein causes catastrophic unilateral loss of vision, or more commonly a branch retinal occlusion causes loss of visual field. Associated haemorrhage, oedema and closure of the capillary circulation are typical, and complicate the picture. Fluoroscein angiography may help to determine whether spontaneous resolution is likely or whether focal laser treatment to seal off leaking vessels is required.

Figure 13.10 Scarring resulting from laser therapy in the peripheral retina (photograph courtsey of Dr Sailesh Sankar, consultant Physician, University Hospital, Coventry).

Diabetic optic neuropathy

This is a rare complication of diabetes, causing swelling and loss of function of the optic nerve, with progressive loss of acuity.

Ocular muscle palsies

People with diabetes may develop an ocular muscle palsy as an acute or subacute neuropathic event. This classically affects the third cranial (oculomotor) nerve, producing an outward and downward gaze due to weakness of adduction and unopposed action of the superior oblique. There may be an associated ptosis. In diabetes where the cause is ischaemic the pupillary reflex may be spared.

Living with diabetic retinopathy

Patients whose acuity or visual field is permanently affected require a lot of support. The first issue concerns driving ability and other safety issues. The Driving and Vehicle Licensing Authority (DVLA) issue regularly updated guidance on the medical standards of fitness to drive. For those more seriously affected, low vision clinics are available to help manage everyday self-care and promote independence. Loss of role in the home, work place and in society at large is potentially devastating and requires a proactive approach to individual support to minimise the impact on quality of life.

Summary

Modern ophthalmological techniques including laser therapy represent a major victory in the ongoing battle against diabetes. Combined with effective retinopathy screening programmes they are progressively reducing risk of visual loss. Liaison between primary and secondary care, clearly defined referral pathways, and patient education are vital if the benefits of these techniques are to be maximised. The assessment of visual symptoms in diabetes is complex and patients must have ready access to specialist expertise for the assessment of any unexpected change in acuity. The infrastructure required to provide high-quality care is largely only available in industrialised countries, meanwhile diabetes prevalence is escalating elsewhere. Responding to this escalation and its impact on the visual health of the global community is a major challenge for the coming decades.

Further reading

Diabetic Retinopathy Study Group. Photocoagulation treatment of proliferative diabetic retinopathy: the second report of diabetic retinopathy study findings. Ophthalmology 1978;85:82-106. DVLA. 'At a glance' Guide to medical standards of fitness to drive. Available at:

http://www.dvla.gov.uk/medical/ataglance.aspx Early Treatment of Diabetic Retinopathy Study Group. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study. Arch Ophthalmol 1985;103:1796-806. Retinopathy Vitrectomy Study Report 2. Arch Ophthalmol 1985;103:1644-52. Royal College of Ophthalmologists. Guidelines for Diabetic Retinopa-thy. 2005. Available at: http://www.rcophth.ac.uk/docs/publications/ published-guidelines/DiabeticRetinopathyGuidelines2005.pdf The Diabetic RetinopathyVitrectomyStudyResearch Group. Earlyvitrectomy for severe vitreous hemorrhage in diabetic retinopathy. Two-year results of a randomized trial. Arch Ophthalmol 1985;103(11):1644-52. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. XIV. Ten-year incidence and progression of diabetic retinopathy. Arch Ophthalmol 1994; 112:1217-28.

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