How would you advise the patient now based on these findings

As already mentioned, diabetic retinopathy is divided into non-proliferative DR (NPDR or background DR) and proliferative DR (PDR) depending on the presence or not of neovascularization of the retina (in the area of the optic disk or the periphery), and it can, at any stage, be accompanied by diabetic maculopathy.

Studies in Type 1 diabetic patients (DCCT, 1995) showed that good glycaemic control based on intensive insulin therapy decreased the risk of DR by 76 percent, after the first 36 months of therapy. Also, in the group of secondary prevention, intensive insulin therapy decreased the risk of retinopathy progression by 54 percent, despite initial deterioration during the first year of therapy. Furthermore, in patients with Type 2 DM (UKPDS study), intensive therapy either with insulin or with oral antidiabetic medicines decreased microvascular complications risk by 25 percent compared to the group that was treated with conventional therapy.

It is also obvious that the patient has secondary failure to the oral antidiabetic medicines. Fasting blood glucose measurements in the morning, as well as two hours postprandially, were mostly higher than 200 mg/dl (11.1 mmol/L). Furthermore, C-peptide levels were especially low (see Chapter 1). Based on these findings, it was decided to start an intensive insulin regimen with slow-acting insulin combined with rapid-acting insulin before the three main meals. At the same time the patient was treated with laser photocoagulation (grid pattern). In this case photocoagulation is the treatment of choice with proven value in maintaining and possibly improving vision. The patient did not accept the recommended intravitreal injection of triamcinolone (0.4 mg/ 0.1 mm3 normal saline). Fluorescein angiography of the fundus after the laser treatments is shown in Figure 13.3.

Figure 13.3. Late phase fluorescein angiography of the patient's fundus, showing the micro-aneurysms that fluoresce and the sites of previous Laser photocoagulation. On the optic disk there are hyperfluorescent foci due to probable early neovascularization.

During the next seven months the patient improved her blood glucose control dramatically (HbA1c = 6.7 percent). There are other treatments, however, that can still be recommended to the patient.

Apart from a good glycaemic control, attention needs to be paid to control of hypertension and serum lipids, and management of other coexistent complications, like diabetic nephropathy and albuminuria, heart failure and anaemia.

Strict control of blood pressure is therefore equally essential. The UKPDS study showed that good control of blood pressure in Type 2 diabetic patients decreased the risk of DR progression by 34 percent, irrespective of the kind of antihypertensive therapy (ACE inhibitor or beta-blocker). Also, the EUCLID study (EURODIAB Controlled Trial of Lisinopril in Insulin Dependent Diabetes) showed that therapy with lisinopril decreased the risk of DR progression, but this could be due to the lisinopril-induced decrease in blood pressure in patients with latent hypertension. According to the American Diabetes Association guidelines, the higher cut-off level for blood pressure control is 130/ 80 mmHg. Therefore, the use of an antihypertensive factor - preferably an ACE inhibitor - is absolutely indicated in this case.

Furthermore, the Early Treatment Diabetic Retinopathy Study (ETDRS, 1991) showed that aspirin (650 mg/day) had no effect - negative or positive - in the progression of DR.

Note: The case of this patient, although rare, is interesting, because it shows an example of oedematous maculopathy without coexisting DR in the rest of the retina.

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