PerspectiveSystemic considerations in the management of diabetic retinopathy
Section snippets
Current standard of care
The treatment of DR is an outstanding example of the application of evidence-based medicine in clinical practice. Extensive rigorous trials have provided detailed data regarding the prevalence, progression, visual risks and treatment response in DR and excellent reviews of the current standard of care for the management of DR have been presented elsewhere.9, 10, 11, 12, 13 Laser photocoagulation remains the therapeutic mainstay in eyes that have, or are approaching, high-risk PDR and in eyes
The effect of blood glucose control
Two important clinical trials, the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have conclusively demonstrated the beneficial effects of intensive glycemic control in patients with type 1 and type 2 diabetes.19, 20, 21, 22, 23, 24, 25 Additional studies in Japanese patients with type 2 diabetes have shown similar results.26 The DCCT was a multicenter clinical trial designed to determine if intensive insulin therapy (with the aim of
The role of diabetes mellitus type
DM is generally categorized into two types of disease. Type 1 DM (also known as insulin-dependent diabetes mellitus [IDDM]) is characterized by an absolute deficiency of insulin.28 In some clinical studies, type 1 DM is assumed when diagnosis occurs at or before the age of 30 in patients who require continuous insulin use.29 Type 2 DM (also known as noninsulin-dependent diabetes mellitus [NIDDM]) refers to patients with diabetes mellitus characterized by insulin resistance or a state of
The hazards of concomitant hypertension
Patients with DM commonly suffer from concomitant hypertension. The Wisconsin Epidemiology Study of Diabetes Retinopathy (WESDR) found that patients with type 1 diabetes had a 17% prevalence of hypertension at baseline, and a 25% incidence after 10 years.34 Hypertension was correlated to the duration of diabetes, higher glycosylated hemoglobin, presence of gross proteinuria, and male gender. Among patients with type 2 DM, cross-sectional studies revealed a hypertension prevalence of 38% to 68%.
Renal disease and diabetic retinopathy
A link between renal and retinal angiopathy in diabetes has been long recognized.105 As with hypertension, there are extensive cross-sectional46, 57, 58, 97, 106, 107, 108, 109, 110 and longitudinal studies89, 111, 112, 113 reporting a relationship between proteinuria or microalbuminuria and retinopathy. The interrelationship between DR and proteinuria is complex and the frequent coexistence of retinal and renal microangiopathies may reflect common predisposing factors. Indeed, chronic
Significance of serum lipids
Although dyslipidemia is a clear risk factor in diabetic renal disease,138, 139 the effects of serum lipids on retinopathy and macula edema are less certain. Cross-sectional studies on patients with type I DM show an association between retinopathy and total cholesterol and high density lipids (HDL) but not triglycerides,140, 141 association between DR and triglyceride only,142 or no association with DR at all.143 Cross-sectional analysis from the WESDR showed that cholesterol levels were not
Exercise and diabetic retinopathy
The effects of exercise and physical exertion on DR remain an area of ongoing concern. Exercise may have a positive effect on reducing the risk of diabetic complications by either direct or indirect mechanisms. Aerobic exercises in diabetic patients improve or maintain cardiovascular function, increase levels of HDL, help with weight control, increase insulin sensitivity, and assist in optimizing blood glucose levels. However, there is concern that physical exercise could have potentially
Pregnancy and diabetic retinopathy
In the past, the prognosis for pregnancy in the diabetic patient with microvascular complications was so poor that diabetic women were frequently advised to avoid or terminate pregnancies.166 With recognition of the importance of pregnancy planning and good glycemic control, many diabetic patients in the childbearing age now experience a safe and successful pregnancy and childbirth with minimal risk to both the mother and the baby. There are excellent recent reviews on this subject.167
It is now
Anticoagulation and thrombolysis
The use of aspirin in diabetic patients is not associated with an increased risk of hemorrhage and has no demonstrated impact on the progression of retinopathy or macula edema.181, 182 Although patients with diabetes have a poor outcome after myocardial infarction, they are less likely to receive thrombolytic treatment than nondiabetic patients.183 We are only aware of one case report of vitreous hemorrhage associated with retinopathy after thrombolysis.184 The use of fibrinolytic agents
Smoking and diabetic retinopathy
Smoking is a clear risk factor for cardiovascular disease in both diabetic and nondiabetic persons. It is also a risk factor for progression of albuminuria to proteinuria and nephropathy in both type 1 and type 2 diabetic patients. Smoking can increase blood pressure in diabetic patients with nephropathy but without autonomic neuropathy.190 However, the effects of smoking on DR are unclear. Some studies have suggested an association93, 191 while others have not.41, 69, 73 Muhlhauser has
Influence of anemia
There have been case reports of an association between anemia and DR.193, 194 Shorb reported three patients who had DM for an average of 17 years with mild to moderate NPDR, who rapidly progressed to severe PDR once they developed severe iron deficiency anemia of various etiologies.193 In another study, five diabetic patients with renal failure and anemia received erythropoietin for a year to assess the effect of increasing red cell mass on clinical well-being. An increase in mean hematocrit
Antioxidant ingestion
The effects of antioxidants in DR are as yet unknown. A cross-sectional and longitudinal study of 387 type 2 patients showed no protective effect from Vitamin C, E and β-carotene intake.197 Several animal studies have suggested that vitamin E at high doses may ameliorate many of the early biochemical changes observed in the diabetic retina and other tissues. A study investigating the effectiveness of vitamin E treatment in normalizing retinal blood flow and renal function in type 1 DM patients
Conclusions
Today, blindness from diabetic retinopathy is largely preventable with timely detection and appropriate interventional therapy. These therapeutic advances have appropriately placed great emphasis on the clinical evaluation of the retina and the adherence to rigorous treatment algorithms. However, DM is a systemic disease with numerous complications in organs other than the eye. In addition, concomitant systemic disorders can exert significant influence on the development, progression and
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