Case 2: Type 2 Diabetes & Maculopathy
A typical patient, photographs courtesy of City Hospital & Good Hope Hospital (Birmingham) Medical Illustration, and Miss Hope-Ross (Good Hope)
- age 59
- Early maculopathy, & severe pre-proliferative
- 16 years of non-insulin dependant type 2 diabetes
- Well, reasonable diabetic
Enlarge New blood vessels growing on the retinal surface and slightly in front of the surface.
severe maculopathy, & severe pre-proliferative
Single arrow points to a blot haemorrhage,
- Repeated laser, intensive diabetic control
- Angry patient ... why did this happen?
- ... 'Why didn't we check the blood pressure the previous year?' More laser.
- Proliferative retinopathy had developed in the interim requiring laser.
- Less ischaemia . Considerable improvement after extensive laser.
- wears hearing aid (deafness is related to diabetes)
severe diffuse maculopathy
Sight reduced to 6/12.
Pictures side by side for comparison: 1996 above, 1998 below
Fluorescein Angiography below: arrows point to leakage: same visit as above (1998)
- burn size has increased a little and sight reduced a little, maintains reasonable health
- severe neuropathy, very frail
What was going on?
- We know good diabetic control is important. This patients achieved good control, but only after the retinopathy had developed
- the laser was successful at reserving some sight, but did not retain/restore good sight
- we should have lowered this patient's blood pressure more
- we like to achieve good control (HbA1c level below 7%), BP below 130/80
- early maculopathy in one year is often followed by diffuse maculopathy the next year, with visual loss
- BP control to 130/80 slows the progression rate of retinopathy by 40% HbA1c: for each 1% there is a 32% difference in progression rate. This affects all aspects of retinopathy.
- Many patients become angry with professionals or very unhappy about their condition: effective counselling and effective support early on and continuing reduces such problems.
- To maintain good health long term, diabetes must be detected before complications develop, and treated aggressively to reach the target. We know that if someone presents to the eye clinic for the first time with retinopathy, they have had diabetes about 14 years (or fewer years if very badly controlled) even if they did not know. Screening for diabetes is critically important, but it still not being carried out systematically across the whole of the UK.
- 2014...much less leser would be used with anti-VEGF injections.