Diabetic retinopathy is the most severe of the several ocular complications of diabetes (Frank, 2004). It has few visual or ophthalmic symptoms until visual loss develops (Davis, 1998). Studies such as the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study Group (UKPDS), have concluded that loss of vision and blindness can be prevented by early detection and treatment (Cunha-Vaz, 1998). The National Retinal Screening Programme is aimed to help achieve this goal by prompt identification and effective treatment if necessary of sight threatening diabetic retinopathy, at the appropriate stage during the disease process. Although laser treatments have been available for past 30 years, unfortunately diabetic retinopathy remains a leading cause of blindness amongst the working age population (Kohner, 2007).
This is an opportunity for me to add to my continuing professional development.
I hope to share my newly acquired wealth of knowledge on the subject with my colleagues, which in turn should serve to raise awareness of the serious nature of this complication. I hope to better educate my patients of the importance of adhering to national retinal screening programme and attempt to explore reasons as to why the uptake of this free service is not as much as one would hope.
Background to the Complication
The main pathophysiological defect lies at the level of the retinal capillaries, which undergo progressive degeneration over time. This results in haemorrhages and exudates, along with formation of microaneurysms and closure of small vessels .The affected segments of the ischaemic retina as a consequence of these changes elaborate growth factors encouraging new vessel formation and fibrous ingrowth (Barnett, 2008).
Classification is based on the degree of pathology seen on slit-lamp examination of the eye. It is not correlated to the degree of vision, which may be almost normal until the very late stages of the disease (Patient UK).
The following classification highlights the recognized progressive stages of retinopathy.
(Taken from Barnett, 2008).
Background Retinopathy – This is common even at diagnosis and includes microaneurysms, dot retinal haemorrhages and hard exudates without visual deterioration.
Maculopathy – These are retinal ischaemic changes n the macular region, including ring-shaped exudates. Ischaemic maculopathy due to capillary closure within the macular area or a mixed form of the two may also occur. Maculopathy is the most common cause of blindness.
Preproliferative retinopathy-This may include cotton wool spots, (areas of retinal ischaemia /infarction), venous abnormalities. These changes are highly predictive of the development of the proliferative retinopathy within 2 years.
Proliferative retinopathy-This indicates severe ischaemia of the retina leading to new vessel formation in the optic disc or in the periphery of the retina or iris. Untreated this can cause visual loss or blindness. New vessels formation may b asymptomatic until they rupture leading to pre-retinal subhyaloid or vitreous hemorrhage.
Maculopathy can co-exist with any of the other stages.
The duration and degree of hyperglycaemia is highly indicative of development and progression of retinopathy (Fong, 2004); however it is difficult to comment whether this implies aggressive disease or poor control.
Hypertensive, obese and individuals with dyslipidaemia are also at an increased of developing retinopathy. Pregnant women may occasionally develop rapidly progressing diabetic retinopathy (Patient UK).
Careful management of both hyperglycemia and blood pressure can reduce the incidence and progression of diabetic retinopathy (Mohamed, 2007).
Fong (2004) cites the UK Prospective Diabetes Study (UKPDS 34), which showed a “continuous relationship between the risk of microvasculature complications and glycaemia, such that for every percentage point decrease in HBA1c, there was 35% reduction in the risk of microvasculature complications.”
Adler (2000), cites another UKPDS study which concluded that each 10 mm Hg decrease in updated mean systolic blood pressure was associated with reductions in risk of 12% for any complication related to diabetes, and 13% for microvascular complications.
KA is a 31-year-old Caucasian female diagnosed with Type 1 Diabetes at age 12 when she presented to her GP with polyuria and polydypsia. KA has an older sibling with Type 1 Diabetes.
KA is very angry about having diabetes and cannot see a way out of it. She blames her parents for it. She engaged poorly with the dietitian, and persistently did not attend her appointments at the Adolescent Diabetes Clinic.
She admits that she does not comply with her insulin regimen and chooses not to monitor her blood sugars regularly. KA has multiple emergency admissions with diabetic ketoacidosis.
She is formally referred for retinal screening in May of 2000. By this time KA was already showing signs of diabetic nephropathy and peripheral neuropathy. Unfortunately, she fails to keep her appointments with the Consultant Diabetologist and with the Retinal Screening Service despite being sent several recalls. All of this indeed leaves KA with a sub-optimal diabetes control and at an increased risk of developing complications.
In April 2006, KA was referred to Ophthalmologist when she saw her GP complaining of blurred vision in her right eye. Fundoscopy reveals proliferative retinopathy in right eye along with preproliferative changes in the left eye. KA consents for undergoing laser treatment but fails to attend her subsequent clinic appointment. The GP was always informed of all DNA’s, which as a matter of routine were all chased up by correspondence and opportunistically when the patient attended the surgery with another complaint.
She next sees the ophthalmologist in July 2008, and on this occasion she is found to have bilateral proliferative retinopathy. A fluorescein angiogram is done and argon laser treatment planned, but KA fails to attend for the treatment, as she is unfortunately taken ill with complicated pyelonephritis requiring a right nephrectomy. Following this, KA started to attend her diabetic reviews and hospital appointments and this was reflected in the improvement of her HBA1c results.
KA is next seen in April 2009 by the ophthalmologist following further fall in her visual acuity. Maculopathy with neovascularistaion are noted on the disc but before she could have the argon laser treatment, KA suffers a right vitreous haemorrhage and in May 2009 she has pan retinal laser photocoagulation and pars plana vitrectomy. KA has been attending her follow up appointments with ophthalmology and at present her vision is stable.
She admits she has never accepted her diabetes and thought she could beat it. It all came to a head for her when she underwent a right nephrectomy, and since then her attitude towards her diabetes and its management has changed .She is appreciative of the fact that the health professionals and retinal screening service never gave up on her. She has now attended DAFNE and DESMOND courses and feels she is better informed about her diabetes now. She has her reasons for not attending her review of diabetes care and other hospital appointments. Mainly it was due to the fact that she was never at one address for long and also there were so many appointments for her to keep, that she often forgot and at other times she could not afford to get time off work. She continues to pursue her career as an orthodontic nurse.
Critical Assessment of Care
KA did not engage herself with the health care professionals, but perhaps more could have been done in involving the community diabetic team who could have reached out to KA in her home setting when KA was first diagnosed with diabetes. The psychological impact of the diagnosis could have been explored by a formal assessment by a psychologist. Formal education about diabetes could have been reviewed at regular intervals, perhaps a short stay admission to a diabetes ward solely for the purpose of education and to raise awareness of the complications could have been considered at the time of diagnosis. KA was formally referred for retinal screening in 2000, eight years after diagnosis. Perhaps the service wasn’t available any earlier in the area.
On the positive aspects of the case, the health professionals left themselves accessible at all times. Ophthalmologist was involved by the GP when KA presented with fall in visual acuity. The doctor patient relationship was maintained throughout and as result although having suffered diabetes related complications. KA always knew and felt supported in her own way by the people who were responsible for her medical care. The health professional never ceased to communicate with each other with all updates as they all felt that KA ought to be seen and not discharged from their services as she repeatedly missed her appointments. Now that KA has become more receptive, she is already benefitting from her newly acquired awareness and managing her diabetes better and in the process reducing the risk of further progression of her diabetes related complications.
Recommendations for change
Emphasis should be on educating the newly diagnosed diabetics. As local services are constantly being developed, PILS and programmes such as DAFNE and DESMOND run by diabetic specialist nurses will prove to be instrumental in achieving enhanced patient awareness and preventing complications.
Ensure children with diabetes are referred to the retinal screening programme by the age of 12 years.
Offer psychological support especially to children with diabetes.
Maintaining up-to-date practice diabetes register with current address and other contact details.
GP should act on information from the Retinal Screening service/Ophthalmologist regarding patients who have missed their screening or ophthalmology appointment.
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