Diabetic eye disease

Points to consider
Pupil dilatation
People with diabetes will need regular photographs to record the progression of any
retinal changes. For these and laser treatments, good wide pupil dilatation is essential,
and drops will be either individually prescribed or instilled by nurses under local
protocols. Generally a combination of different types of eye-drops is used, usually a
cycloplegic and sympathomimetic as the different actions of each eye-drop will enhance
the effects of the other. Make sure that you are aware of potential side effects when using
these eye-drops, as people with diabetes may also have a range of other health problems.
urse prescribers should be aware that research by !eiss et al. "#$$%& on #'( people with
diabetes indicated that phenylephrine '.%) used in combination with a mydriatic showed
no statistically significant difference in the dilatation achieved compared to a #*)
solution used alone in the fellow eye. +hey recommend the use of the '.%) solution for
this patient group who have a higher than average prevalence of vascular disease and
autonomic dysfunction.
People with diabetes often drive to their appointments so that they can get back to work
immediately. , binocular visual acuity of -.$ is re/uired for 01 driving "Driver and
2ehicle 3icensing ,gency, '**-&. 4ude et al. "#$$5& noted a reduction in binocular visual
acuity "62,& post dilatation which, with the addition of glare, caused visual acuity to
drop further, even when using
sunglasses. +hey concluded that patients need to be warned not to drive post dilatation.
Murgatroyd et al. "'**-& advised that retinal screeners need to have clear guidelines with
which to advise patients regarding driving safety.
7etinal problems
+ime management
7emember that people who have had diabetes since childhood have attended many, many
medical appointments, and are an8ious to get on with their lives. 9n some health areas
4oint 7etinal :linics run with physicians and ophthalmologists attending have reduced
the need for some attendances, as has the advent of portable laser machines, which can be
taken to these clinics to laser potentially leaky retinal vessels as soon as possible.
3aser safety
7emember the necessity for wearing the correct goggles whenever you are present during
laser
treatments. , laser safety officer must instruct and update you regularly on safe practice
in your
department. Goggles suitable for one type of laser are unsuitable for another. Make sure
that the
correct goggles are stored with each machine, and do not migrate from one laser room to
another.
!arning lights outside the doors of treatment areas must be switched on for the duration
of
treatments.
Pigmented retinal naevi
Make a web search for more information on this. +he Digital 7eference of
;phthalmology
has some other interesting retinal areas you can e8plore too. <ou could also look at the
=ye
:ancer etwork, where you can find information about choroidal melanoma.
7etinal vein occlusion
, retinal vein occlusion is caused by a tiny blood clot either in the central retinal vein or
one of its
smaller tributaries. Generally they occur in people over the age of %*. ,ccording to the
7oyal :ollege
of ;phthalmologists guidelines "'**$&, hypertension, hyperlipidaemia, diabetes mellitus
and
glaucoma are the main predisposing factors for this condition, which results in oedema at
the optic disc, dilated retinal veins and deep and superficial haemorrhages. +he patient
presents with painless mild to severe loss of vision in the affected eye, which looks
normal. ;n presentation with a sudden loss of vision, the nurse should check blood
pressure and
blood glucose "or urinalysis&. , relative afferent pupillary defect "7,PD& may be present.
7ing the ophthalmologist with these results, and carry out any further instructions. +here
is no effective treatment for this condition. !hen the diagnosis is confirmed, the
ophthalmologist will refer the patient urgently to the physician. ;utpatient follow-up will
be at > months, when photocoagulation will be re/uired if a /uadrant or more of the
retina was involved to prevent neovascularisation "the growth of abnormal new blood
vessels& as this could lead to neovascular glaucoma. +his neovascular glaucoma is caused
by the abnormal blood vessels growing forward on to the iris, through the pupil and into
the drainage angle, gradually blocking the a/ueous outflow. Following laser treatment the
patient is usually reviewed at least at --monthly intervals for ' years. :heck the Good
?ope ?ospital website for more information about retinal vein occlusion and watch the
little movie which shows how this condition can lead to rubeotic glaucoma, and see how
this is treated. 9t is good for you to read about it and you may consider using it for
patients. +here are even patient leaflets you can download if you do not have any.
7etinal artery occlusion
+his presents rather like retinal vein occlusion but the loss of vision when the central
retinal artery is involved is very sudden and severe, generally reduced to counting fingers
or hand movements. +his painless condition presents in a similar way to venous
occlusion inasmuch as the eye looks @normalA in appearance. 6ecause the differentiation
between artery occlusion and vein occlusion can only be definitely made on
ophthalmoscopy, if you do not have recognised competency, then both the venous
occlusion and artery occlusion must be treated as emergency sudden painless loss
+he ophthalmic study guide
of vision. :heck blood pressure and blood glucose "or urinalysis&. :heck for a relative
afferent pupillary defect. 7ing the ophthalmologist with the results, and carry out any
instructions you are given. 9mmediate treatment is normally instituted if the blockage has
occurred within @a few hoursA "1anski, '**(&. 6eyond this time, it is unlikely that vision
will improve, but in fact treatment for this condition is rarely successful. +he main
predisposing factors of this condition are cigarette smoking, cardiovascular disease,
hypertension, carotid artery disease and hyperlipidaemia. +he actual material blocking the
artery
may be derived from deposits on damaged heart valves, or may be thrombotic or from
atheroma of the carotid artery. Graham and =brahim "'**(& list current possible
treatments for retinal artery occlusion asB
C intraocular pressure reduction, possibly using intravenous acetaDolamide "%** mg&
and.or
intraocular pressure-reducing eye-drops
C anterior chamber paracentesis "local anaesthetic drops are applied to the eyeE a >* gauge
needle is attached to an insulin syringe and used to withdraw about *.*#F*.*' m3 of
a/ueous
fluidE antibiotic cover may be given post procedure&
C fibrinolysis with urokinase "has been used, but controversial with maGor side effects&.
!hen you ring the ophthalmologist, you could en/uire whether they would like the
following two
simple treatments commenced while the patient waits for their e8aminationB
MassageB +his is done by applying direct gentle digital pressure to the eye over an eyepad
or some
swabs for #% seconds, then releasing it. +his is repeated several times and may gently
push the
blockage further through the arterial system to improve the circulation to the retina.
6reathing in and out of a paper bag. +his increases carbon dio8ide levels and promotes
vasodilatation
to enable the tiny clot to move to a less damaging area.
9n addition to the above, the ophthalmologist will normally commence aspirin therapy
and make
an urgent medical referral for the management of the patientAs overall condition. Field
and +illotson
"'**5& comment that it is unwise to over-reassure the patient regarding the sight loss, but
they do
need the assurance that everything possible was done to try to save their sight. Given the
predisposing
causes for this condition, you might personally reflect that even if the patientAs sight was
not saved, at least their life e8pectancy may be considerably e8tended.
Further information is available at the ?andbook of ;cular Disease Manag