Struggle against Diabetes 
(Lucha contra la diabetes)
Amputee in a wheelchair.
Renal involvement in diabetes.
Eye and cardiac involvement in diabetes.
Section 12 Counselling for diabetic retinopathy
The management of the diabetic patient depends on teamwork and close liaison 
between physicians, ophthalmologists, general practitioners and paramedical 
staff including chiropodists, dieticians, screeners and many other personnel. 
Only in this way will the risk factors discussed below be drawn to the attention 
of the most appropriate health care worker. 
12.1 Risk factors
Due to the chronic nature and insidious development of diabetic 
complications many patients fail to appreciate the seriousness of the condition 
and the life-shortening effects of the disease. in particular, previous confusion 
within the medical profession on the role of tight diabetic control has been 
swept aside by the clear evidence of the importance of establishing good 
hyperglycaemic control to delay significantly the complications. This especially 
true for retinopathy18
It is equally the remit of all medical personnel caring for one or more aspects 
of the diabetic state that they explain not only the value of good control of 
diabetes but that diet, exercise, avoidance of cigarette smoking and attention 
to weight will all have beneficial effects on the prevention of complications. 
Even in cases of advanced DR with maculopathy, it is not too late to institute 
a change of life-style which will benefit the end-organ disease.
12.2 The young diabetic 
A small sub-group of young, insulin-dependent diabetics appears to be 
susceptible to a particularly rapidly advancing form of PDR. In some cases, 
even extensive laser therapy fails to control the proliferative disease and 
extensive vitreo-retinal surgery is performed with limited functional success. 
It is unclear whether poor compliance and/or poor attention to their 
diabetes is the main factor in the progression ot the disease or whether 
other factors such as hormone dysfunctional particularly insulin-like grown 
factor-1 (IgF-1), have a part in this serious condition. These patients require 
special attention and monitoring the value of frequent, positive counselling 
cannot be overstated.
12.3 Driving and visual fields
It is now recognized that panretinal photocoagulation may have damaging effects 
on visual field function, in addition to the effects of retinopathy itself. In the UK, 
the Driving and Vehicle Licensing Authority (DVLA) has set minimal standards of 
visual field function which are required for permission to hold a Driver's License.
All patients who require retinal photocoagulation should be asked to provide 
informed written consent to therapy as for any surgical procedure. It is the 
ophthalmologist's duty to explain clearly the reasons for laser therapy, the type 
of therapy to be undertaken and the likely effects on the patient's vision.
In the UK it is the patient's responsibility to inform the DVLA that he/she has had 
laser therapy for diabetic retinopathy. If this is not possible, then the patient's 
next of kin or GP should inform the DVLA of the patient's visual status. As a last 
resort the ophthalmologist is duty bound to inform the Medical Adviser of the 
12.4 Pregnancy
Patients with diabetes who are considering pregnancy should preferably attend 
a pre-pregnancy clinic, with their husbands if possible where the risks of 
pregnancy for the eyes can be carefully explained within the context of each 
patient's particular state of health. In particular, the effects of tightening 
control on retinopathy can be explained and the need for frequent monitoring 
of the retinopathy throughout the pregnancy. In addition, the safety of 
fluorescein angiography and/ or laser therapy if required during the pregnancy, 
can be emphasized. The minimum recommendations suggested by the WHO are 
that fundus examination should be performed at pre-pregnancy, at the diagnosis 
of pregnancy, at the end of the first trimesters and in weeks 20-24 and 30-34. 
More frequent examinations are recommended if active disease is detected.
12.5 Surgery
Much of the surgery for PDR, and even routine eye surgery eg for cataract in 
non-PDR patients has special risks and variable outcome fro patients which 
compares less well than similar surgical procedures on non-diabetic patients. 
Patients may need considerable pre-operative counselling regarding the precise 
surgical risks that they face and information on the likely visual result. In addition, 
the impact of the final visual result on the patient's ability to continue monitoring 
their disease as well as their ability to function independently in their home 
environment, should be taken into account in any surgical decision which are 
This applies particularly to the elderly and infirm, may of whom live alone or in 
sheltered accommodation. In these circumstances, discussion with the patients 
carers may assist in reaching decision.
12.6 Social services for the visually handicapped.
In spite of appropriate treatment a small group of patients will fail to respond and 
progress inexorably to severe visual impairment and blindness. It is important that 
such patients are advised fully concerning the support services which are available 
to them through the Social Services and in particular what benefits are available 
to them to enable them to lead as normal a life as possible. In particular with 
appropriate visual aids they should be encouraged to maximize the residual vision 
which they possess. The ophthalmologists role is to ensure that such patients are 
referred to the appropriate professionals and services for their individual needs.
Early registration with the Social Services will minimize the handicapping effects 
of visual impairment through the use of appropriate low visual aids for use at home 
and at work, including CCTV's (closed circuit television). Young people in particular 
benefit from mobility and rehabilitation support services of this nature.
Epidemiology Clinical features Risk factors Screening
Lasers and lenses. NVD,, NVE.. Maculopathy
Vitrectomy. Cataract Special problems Counselling
References.. AAO guidelines Atlas of Retinopathy Contact lenses
Main index Main page.