What is Diabetes?

Diabetes is a condition in which the body cannot cope normally with sugar and other carbohydrates.  In the general population it affects 1 in 25 people but in Care Homes at least 11% have diabetes and many others are undiagnosed.  Type 1 diabetes tends to affect younger people and is treated with insulin injections and diet.  Type 2 diabetes usually affects older people and is treated by diet, diet and tablets or in some cases insulin injection.  It is a progressive disease and treatments may need changing over time....

 If undiagnosed or untreated, diabetes can cause complications and may damage the large and small blood vessels or the nerve endings. The most serious eye condition associated with diabetes is diabetic retinopathy which causes damage to the network of blood vessels in the retina.  As with so many conditions the key to successful treatment is early detection and in the case of diabetic retinopathy this is best done with a detailed eye examination.  All diabetics should be examined at least annually.

 Diabetic retinopathy is usually graded according to how severe it is. The three main stages are described below.

 Background diabetic retinopathy

 This condition is very common in people who have had diabetes for a long time and vision will be normal with no threat to sight. At this stage the blood vessels in the retina are only very mildly affected, they may bulge slightly (microaneurysm) and may leak blood (haemorrhages) or fluid (exudates). The macular area of the retina remains unaffected.

 Maculopathy

 With time, if the background diabetic retinopathy becomes more severe, the macular area may become involved. This is called maculopathy. If this happens, central vision will gradually get worse. It may be difficult to recognise people's faces or to see detail such as small print. The amount of central vision that is lost varies from person to person. However, the vision that allows us to get around at home and outside (peripheral vision) will be preserved. Maculopathy is the main cause of loss of vision and may occur gradually and progressively. It is rare for someone with maculopathy to lose all their sight.

 Proliferative diabetic retinopathy

 As the eye condition progresses, it can sometimes cause the blood vessels in the retina to become blocked. If this happens then new blood vessels form in the eye. This is called proliferative diabetic retinopathy, and is nature's way of trying to repair the damage so that the retina has a new blood supply. Unfortunately, these new blood vessels are weak. They are also in the wrong place - growing on the surface of the retina and into the vitreous gel. As a result, these blood vessels can bleed very easily and cause scar tissue to form in the eye. The scarring pulls and distorts the retina. When the retina is pulled out of position this is called a retinal detachment.  Early detection and treatment are key to successful management.

 Reducing the Risk 

 It has been shown that excellent control of diabetes significantly reduces sight threatening complications.  Alongside this it is also important to monitor and treat high blood pressure. These are the two main things which can help prevent sight loss from diabetes.  Two other factors to consider are smoking and cholesterol.  Stopping smoking and reducing cholesterol are both beneficial in reducing the risk of diabetic related sight loss.

 Laser treatment

 It has been shown that excellent control of diabetes significantly reduces sight threatening complications.  Alongside this it is also important to monitor and treat high blood pressure. These are the two main things which can help prevent sight loss from diabetes.  Two other factors to consider are smoking and cholesterol.  Stopping smoking and reducing cholesterol are both beneficial in reducing the risk of diabetic related sight loss.

Most sight-threatening problems caused by diabetic retinopathy can be managed by laser treatment if it is given early enough. It is important to realise, however, that laser treatment can only preserve the sight that is left and cannot restore lost vision. The laser is focused with extreme precision so that blood vessels that are leaking fluid into the retina can be sealed. If new blood vessels are growing, more extensive laser treatment has to be carried out. No treatment is possible without some side effects.  The treatment for sealing blood vessels has few side effects, although the laser is very bright and causes a temporary reduction of sight which may last an hour or two after the treatment. It is also quite common to lose some vision to the sides (peripheral vision) and this may affect the ability to walk and move around safely. Occasionally central vision may not be as good as before so that, for example, print is not as easy to see, this is usually temporary, but sometimes does not improve. After lengthy treatment, most people develop a headache.  Certainly within a Care Home these side effects will need to be taken into account and the person closely monitored to prevent accidents or falls.

 Other related problems

A cataract is a common eye condition that develops as people get older but someone with diabetes is nearly twice as likely to develop cataracts. The cataracts may also develop at an earlier age and more rapidly. 

Temporary blurring may occur as one of the first symptoms of diabetes although it may also reoccur at any time when the diabetes is not well controlled.  This is an important factor because, if a resident’s diabetes fluctuates then so may their vision, which will put them at a higher risk of a fall.

People with diabetes are twice as likely to develop glaucoma as are non-diabetics.  Glaucoma in turn is a condition which has few obvious symptoms but if untreated can cause blindness.

 GAIN diabetic eye care standards

Under GAIN you will be required to annually record a residents visual acuities and the outcome of their retinal screening.  The GP can record the visual acuities however it is important that the resident is wearing their latest prescription in their glasses when this is done.  This sounds obvious and easy but sometimes a resident will wear an old pair of glasses, their ‘wrong’ ones or even somebody else’s.  This will make it very difficult or even impossible for the GP to be certain of the validity of the visual acuities being recorded.  The retinal screening service in Northern Ireland is provided by the Royal Victoria Hospital via the GP.  This is a fantastic service for diabetics, all of whom should attend annually, however not all residents are well enough to travel out to this clinic and so we can provide retinal examination. The results of this screening or our retinal examination will need to be recorded for GAIN.

 To help you deliver the GAIN standard on diabetic eye care we do two things.

Record the current visual acuities of every resident we see.

Provide a written report for the GP and the Home for every diabetic seen.

As always if you have a question on this or any other issue relating to eye care please feel free to contact us anytime.

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