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Diabetic retinopathy (DR) is the major cause of blindness in the working age groups of industrialized countries, and a programme has been launched by the World Health Organization (WHO) and the International Diabetes Federation (IDF) to reduce its morbidity in Europe. Retinopathy progresses slowly, and even when it becomes sight-threatening, may not present visual symptoms. When symptoms do occur, it is often too late to restore full vision or to stop further deterioration by retinal photocoagulation. For photocoagulation to be maximally effective, treatable sight-threatening retinopathy must be identified while still asymptomatic by means of regular fundus examination of all diabetic patients. Given the absence of effective medical treatment, prevention of retinopathy depends on mass screening. The WHO and IDF recommend that internists in charge of diabetic patients perform a fundus examination at least every two years if retinopathy is absent, or as frequently as necessary otherwise. Patients at risk should be referred for assessment and treatment to ophthalmic facilities. Either direct ophthalmoscopy or retinal photography are suitable methods. The setting up of nation-wide screening programmes is essential for coordinated action. Pilot studies have proven that screening is an effective means for decreasing diabetes related blindness and the human and social costs attached to it.
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PMID:Emerging strategies for the prevention and treatment of diabetic eye disease. 177 48

The UK Prospective Diabetes Study (UKPDS) is a multi-centre, prospective, randomised, intervention trial of 5100 newly-diagnosed patients with Type 2 (non-insulin-dependent) diabetes mellitus which aims to determine whether improved blood glucose control will prevent complications and reduce the associated morbidity and mortality. Newly presenting Type 2 diabetic patients aged 25-65 years inclusive, median age 53 years, median body mass index 28 kg/m2 and median fasting plasma glucose 11.3 mmol/l, were recruited and treated initially by diet. Ninety five percent remained hyperglycaemic (fasting plasma glucose greater than 6 mmol/l) and were randomly allocated to different therapies. In the main randomisation, those who were asymptomatic and had fasting plasma glucose under 15 mmol/l were allocated either to diet policy, or to active policy with either insulin or sulphonylurea aiming to reduce the fasting plasma glucose to under 6 mmol/l. Over 3 years, the median fasting plasma glucose in those allocated to diet policy was 8.9 mmol/l compared with 7.0 mmol/l in those allocated to active policy. The Hypertension in Diabetes Study has been included in a factorial design to assess whether improved blood pressure control will be advantageous. Patients with blood pressure greater than or equal to 160/90 mm Hg were randomly allocated to tight control aiming for less than 150/85 mm Hg with either an angiotensin-converting enzyme inhibitor or a Beta-blocker or to less tight control aiming for less than 200/105 mm Hg. The endpoints of the studies are major clinical events which affect the life and well-being of patients, such as heart attacks, angina, strokes, amputations, blindness and renal failure. To date, 728 patients have had at least one clinical endpoint. Surrogate endpoints include indices of macrovascular and microvascular disease detected by ECG with Minnesota Coding, retinal colour photography and microalbuminuria. The studies also aim to evaluate potential risk factors for the development of diabetic complications such as smoking, obesity, central adiposity, plasma LDL- and HDL-cholesterol, triglyceride, insulin, urate and other biochemical variables. The studies are planned to terminate in 1994, with a median follow-up of 9 years (range 3-16 years) for the glucose study and 5 years (range 2-6 years) for the hypertension study.
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PMID:UK Prospective Diabetes Study (UKPDS). VIII. Study design, progress and performance. 177 53

The authors describe a case in which an 88-year-old black male with a long-standing history of diabetes, blindness, and dialysis therapy presented with idiopathic diabetic bullosum of the left foot distal extremities. The lesions usually are intraepidermal and resolve spontaneously over a period of weeks with no resulting scar formation. The lesions are highly recurrent. In this specific case, the long healing time may be attributed to the age of the patient as well as the decrease in immune and systemic response to injury, weakened by dialysis therapy and his poor arterial status.
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PMID:Idiopathic diabetic bullosum. A case report. 178 19

The latest studies on diabetic retinopathy reveal important clinical and therapeutic advances. From a clinical point of view, diverse methods of examination have enabled to study the primary damages of the pigmentary epithelium in cases of diabetic retinopathy in the young at the age of puberty and post-puberty. Moreover, neuro-functional exploration discloses the visual alterations which could not be objectified with classical methods of examination. The study of the circulation in different ocular tissues gives evidence of important facts concerning the evolution of the disease. The comparison of fluorescein angiography with other techniques of in-vivo injection has demonstrated the existence of a retino-choroidopathy with a particular pattern. Indications for pan-retinal coagulation and photo-coagulations can be better defined. Insulin pumps or combined pancreatic and kidney transplantation may contribute to achieve the glycemic balance but they do not solve the problem of diabetic retinopathy at an advanced stage. Other general therapies which are intended to improve the circulation of the hematological or immunological data have not yet proved to be effective in serious cases of retinopathy. Providing the latest research findings to ophthalmologists, primary care physicians and allied health professionals is the first priority in order to significantly reduce blindness due to diabetes by the year 2000.
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PMID:[Evolution of the conceptualization of diabetic retinopathy]. 180 76

Diabetes eye complications, and particularly diabetic retinopathy, are the major cause of blindness in the working age groups of industrialised countries. Laser photocoagulation has been proven to reduce blindness due to retinopathy by at least 60% but even more patients would benefit if treatment were delivered at an early enough stage. High risk retinopathy, though, does not cause visual symptoms and when the latter occur it is often too late to reverse them. Hence, a screening programme for diabetic retinopathy should aim at detecting patients at risk when they can still be effectively treated. This can be obtained by regularly checking the patients' eyes. Its target, as defined by the joint World Health Organisation/International Diabetes Federation Saint Vincent Declaration Working Group, is to reduce diabetes-related blindness by one third or more in the next 5 years. The number of persons to be screened is high, 30,000/million total population/year, but available data indicate that this is feasible and that the initial investments in professional and material resources are more than justified by the reduction of preventable blindness and of the financial burdens that go with it. Indeed, prevention of the major cause of blindness in the working age should rate the same priority as other widely deployed programmes, such as those to screen for cancer, neonatal hypothyroidism and phenylketonuria. The concerted action of government health departments, patients' and professional associations will be vital for the successful implementation of this programme. The texts of this document (a protocol for the screening of diabetic retinopathy and cataract), Appendix 1 (data collection card) and Appendix 2 (informative leaflet for the patients) were approved by 57 specialists, representing 30 diabetic and ophthalmic societies from 21 European countries, and endorsed for translation into all European languages and distribution at the appropriate levels.
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PMID:Protocols for screening and treatment of diabetic retinopathy in Europe. 182 Nov 98

There is a need for greater educational emphasis, both at undergraduate and postgraduate level, on the detection of diabetic eye disease, in particular diabetic retinopathy. The early diagnosis of the sight-threatening lesions of proliferative retinopathy and maculopathy is a prerequisite for the prevention or reduction of the visual loss and blindness associated with this diabetic complication. It is also essential that patients are aware that diabetes can result in visual loss due to diabetic retinopathy. Patients should understand that diabetic retinopathy may be present without ophthalmic or diabetic symptoms and that its incidence increases with duration of diabetes, poor diabetes control, and hypertension. They must also be aware that, if detected early, retinopathy can be treated successfully and vision preserved. Early detection depends on regular eye examination involving both visual acuity assessment and ophthalmoscopy through dilated pupils by experienced personnel. A comprehensive programme of screening followed by prompt and adequate treatment would made a significant contribution to eradicating diabetic retinopathy as a cause of blindness.
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PMID:Screening for diabetic retinopathy. 182 56

A personal series of 6780 patients with diabetes mellitus is reported. Of these 1410 were thought to have insulin-dependent (Type 1) diabetes and 4926 non-insulin-dependent (Type 2) diabetes. Among the former, 128 patients were only diagnosed when in severe ketoacidosis or coma. In 116 patients the diabetes was diagnosed in pregnancy. Chronic alcoholism was an aetiological factor in 75 patients; in 52 it led to the diagnosis being made, and it complicated treatment in 129 additional patients. In the patients with Type 2 diabetes whose treatment was stabilized 23.5% were having insulin injections, 44.5% tablets, and 32.0% diet only. Sight-threatening retinopathy developed in 21.3% of patients with Type 1 and 7.9% of those with Type 2 diabetes. The rate of developing sight-threatening retinopathy was 1.1% of patients per year. Blindness occurred in 0.28% of patients with Type 1 diabetes per year and 0.097% per year in Type 2 diabetes. If the mean survival of patients with retinopathy going blind is 7.5 years, this would mean 7500 people in the UK blind from diabetic retinopathy. There was a striking drop in the annual incidence of blindness after 1970 coinciding with the introduction of specific treatment for diabetic retinopathy. Juvenile cataract developed in 1.7% of patients who developed Type 1 diabetes before 30 years of age. Clinically important diabetic neuropathy developed in 17.4% of patients with Type 1 and 11.6% of those with Type 2 diabetes. The main features were paraesthesiae and numbness (49%), neuropathic ulceration (37%), pain (5%), autonomic symptoms (5%), and amyotrophy (4%). Oculomotor palsies and mononeuropathies were noted. Foot ulceration occurred in 81 patients with Type 1 and 279 of those with Type 2 diabetes. Charcot changes in the feet were noted in 21 patients. Major amputations were needed in 18 patients with Type 1 and 60 with Type 2 diabetes. Proteinuria believed to be due to diabetic nephropathy developed in 12.8% of patients with Type 1 and 4.7% of those with Type 2 diabetes. The prevalence of early renal failure was 4.6% and 1.4%, respectively. Coronary artery disease was noted in 9% of patients with Type 1 diabetes, and was more common in those who developed diabetes after 20 years of age. Myocardial infarction was as common in women as in men. In Type 2 diabetes coronary artery disease gave rise to symptoms in 19.1%, and myocardial infarction was more common in men.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Diabetes in the United Kingdom: a personal series. 182 47

Diabetic eye complications, and particularly diabetic retinopathy, are the major cause of blindness in the working age groups of industrialized countries. Laser photocoagulation has been proven to reduce blindness due to retinopathy by at least 60% but even more patients would benefit if treatment were delivered at an early enough stage. High-risk retinopathy, though, may not cause visual symptoms, and when the latter occur it is often too late to reverse them. Hence, a screening programme for diabetic retinopathy should aim at detecting patients at risk when they can still be effectively treated. This can be achieved by regularly checking the patients' eyes. The screening programme's target, as defined by the joint World Health Organization/International Diabetes Federation Saint Vincent Declaration Working Group, is to reduce diabetes-related blindness by one-third or more in the next 5 years. The number of individuals to be screened is high, 30,000 per million total population per year, but available data indicate that this is feasible and that the initial investments in professional and material resources are more than justified by the reduction of preventable blindness and of the financial burdens that go with it. Indeed, prevention of the major cause of blindness in the working age group should rate the same priority as other widely deployed programmes, such as those to screen for cancer, neonatal hypothyroidism, and phenylketonuria. The concerted action of government health departments, patients' and professional associations will be vital for the successful implementation of this programme.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:A protocol for screening for diabetic retinopathy in Europe. Retinopathy Working Party. 182 43

The authors report on one case of Wolfram syndrome, a rare condition, which is characterized by juvenile onset diabetes mellitus, diabetes insipidus, optic atrophy and sensorineural deafness. The findings of this 13-year follow-up show that this patient developed typical neurological complications of long-standing diabetes mellitus as in the common type 1 variant. Moreover, some peculiar signs occurred such as anosmia, ophthalmoplegia interna, and central nystagmus. Since Wolfram syndrome is probably part of a more generalized neurodegenerative disorder, long-term prognosis will depend both upon the severity of chronic diabetic complications and upon the rapidity, by which degeneration of cerebellar, pontine and brain stem structures appear. Prognosis of the cardinal clinical signs is such that optic atrophy, though usually quite rapid in the beginning, generally does not lead to complete blindness. Sensorineural hearing loss progresses very slowly so that deafness might be expected exceptionally only. The hearing deficit in classical diabetics, however, is of retrocochlear origin. Therefore, in Wolfram syndrome, a combined inner-ear and retrocochlear hearing loss may occur.
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PMID:Juvenile onset diabetes mellitus, central diabetes insipidus and optic atrophy (Wolfram syndrome)--neurological findings and prognostic implications. 185 94

Eighteen patients with diabetes mellitus, some of whom had variously retinopathy, pregnancy, and the carpal tunnel syndrome, and were variously treated with steroids and vitamin B6, have been overviewed for periods of 8 months to 28 years. We have established an association of a deficiency of vitamin B6 with diabetes by monitoring the specific activity of the erythrocyte glutamic oxaloacetic transaminase and again by the association with the carpal tunnel syndrome (C.T.S.). It has been known for a decade that C.T.S. is caused by a B6 deficiency. The absence of retinopathy in vitamin B6-treated diabetic patients over periods of 8 months - 28 years appears monumental. These observations are like discovery and constitute a basis for a new protocol to establish the apparent relationship of a deficiency of vitamin B6 as a molecular cause of diabetic neuropathy. Blindness and vision are so important that the strength or weakness of the observations are not important; the conduct of a new protocol is important.
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PMID:A deficiency of vitamin B6 is a plausible molecular basis of the retinopathy of patients with diabetes mellitus. 188 84


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