Diabetes and visual problems
Diabetes mellitus is the leading cause of preventable sight loss in adults of working age (16–64 years) in the UK. The nurse’s role involves identifying people at risk of developing type 2 diabetes and encouraging them to attend a diabetes prevention or remission programme.
Article by Linda Nazarko
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Overview
Diabetes mellitus is the leading cause of preventable sight loss in adults of working age (16–64 years) in the UK (Liew et al, 2014). Diabetes increases the risk of developing cataracts, glaucoma, diabetic retinopathy and maculopathy (Newman-Casey et al, 2011; Royal National Institute for the Blind (RNIB), 2022). In the UK, over 4 million people are known to have diabetes, the most common being type 2 diabetes (Diabetes UK, 2021). The nurse’s role involves identifying people at risk of developing type 2 diabetes and encouraging them to attend a diabetes prevention or remission programme (NHS England, 2022). The nurse can enable and empower patients to manage their diabetes and attend screenings, reducing the risks of visual problems.
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Definition
Diabetes is defined as a chronic, metabolic disease characterised by elevated levels of blood glucose – known as hyperglycaemia – which, over time, leads to serious damage to the heart, blood vessels, eyes, kidneys and nerves (National Institute for Health and Care Excellence (NICE), 2022). The most common is type 2 diabetes, usually found in adults and occurring when the body either becomes resistant to insulin or does not produce enough insulin. In the past three decades, the prevalence of type 2 diabetes has risen drastically in countries of all income levels. Type 1 diabetes, also known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin (World Health Organisation, 2021).
Normal vision
Light enters the eye through the cornea and passes through the pupil. The pupil regulates the amount of light that enters the eye – dilating when light levels
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Conditions
Cataracts
A cataract is the ‘opacification of the crystalline lens’ (Kothadia et al, 2011).
The lens of the eye is normally clear, but becomes opaque or cloudy when a cataract occurs. Ageing increases the risk of cataracts. People with diabetes can develop cataracts earlier and are five times more likely to develop them than the general population (Kiziltoprak et al, 2019).
Glycation increases the risk of cataracts because it leads to a breakdown of proteins in the lens (Sadowska-Bartosz and Bartosz, 2016), causing the lens to become cloudy. Patients experience blurred vision, difficulty seeing in bright sunlight or darkness and difficulty differentiating colours. The level of impairment is related to the position of the cataract in relation to the macula (the part of the eye responsible for central vision) and the size of the cataract. People with diabetes can reduce their risk of developing cataracts by optimising
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Treatment
Laser photocoagulation
Laser photocoagulation is the standard treatment of retinopathy. Laser light is applied to a large part of the peripheral retina and destroys the new blood vessels. Most patients require several sessions to effectively treat retinopathy. A Cochrane review showed that this treatment reduced the risk of severe visual loss by over 50% at 12 months (Evans et al, 2014).
Less extensive laser treatment is required to treat maculopathy (Ghanchi, 2013). The laser treatment seals the leaking capillaries that are causing exudate and oedema in the macula. Patients require close follow up, as further treatment may be needed. Laser surgery has been shown to reduce the risk of blindness by 50%.
Steroids and anti-VEGF drugs
Anti-vascular endothelial growth factor (anti-VEGF) drugs and steroids are administered intra-vitreally. They can be used as alternatives or adjuncts to laser photocoagulation. Steroids, such as Ozurdex (the brand name for long-acting dexamethasone), act by
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Prevention
There are four approaches to preventing diabetic eye disease:
People with diabetes are also encouraged to regularly attend diabetic workshops at GP practices or in clinics, in order to gain more awareness around effective management of diabetes and prevention of diabetic eye diseases.
Detection and screening
In the UK, people with diabetes are offered
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Resources
Bixler JE. Cataracts and Their Treatment in People with Diabetes. In: Prevention and Management of Diabetes-Related Eye Disease. Arlington (VA): American Diabetes Association; 2019.6-10. https://doi.org/10.2337/db20191-6
Bukke SN, Badugu RL, Gurapa R, et al. Clinical study on correlation of HbA1c with different grades of diabetic retinopathy at S.V.R.R.G.G.H, Tirupati – a hospital based descriptive correlative study. J Evid Based Med Healthc 2021;8(23):1949-1953. https://doi.org/10.18410/jebmh/2021/366
Diabetes UK. 2021. Diabetes Statistics. https://www.diabetes.org.uk/professionals/position-statements-reports/statistics (accessed 6 April 2023)
Electronic Medicines Compendium (EMC). 2022a. Ozurdex. https://www.medicines.org.uk/emc/product/5654/smpc (accessed 6 April 2023)
Electronic Medicines Compendium (EMC). 2022b. Lucentis. https://www.medicines.org.uk/emc/product/307/smpc (accessed 6 April 2023)
Evans JR, Michelessi M, Virgili G. Laser photocoagulation for proliferative diabetic retinopathy. Cochrane Database Syst Rev. 2014;2014(11):CD011234. https://doi.org/10.1002/14651858.CD011234.pub2
Fung TH, Patel B, Wilmot EG, Amoaku WM. Diabetic retinopathy for the non-ophthalmologist. Clin Med (Lond). 2022;22(2):112-116. https://doi.org/10.7861/clinmed.2021-0792
Ghanchi F; Diabetic Retinopathy Guidelines Working Group. The Royal College of Ophthalmologists' clinical guidelines for diabetic retinopathy: a summary.
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