Diabetic retinopathy An interactive afternoon: July 2005 David Kinshuck 1.Ice breaker Medical aspects of prevention of retinopathy…a reminder/update…DK Laser tricks/update…DK Case…Sam Mirza Groups..cases…use cases for discussion Break Feedback from groups…..discussion DK…to tie up lose ends…?use a common database, 4.40 check everyone’s topics discussed..discuss them 9.summary home ?4.55

Groups... 6 or less/group Facilitator…present the cases Facilitator..ensure everyone speaks/contriubutes ~equally More expert/less expert all contribute This facilitates deep learning and putting into practice

Prevention of type 2 diabetes & retinopathy/blindness from type 1 & type 2 Prevent diabetes.. Exercise, Obesity, smoking, healthy diet detect diabetes.. Screen Patients’ relatives.. Family history 50% type 2.. biggest advance Treat diabetes & prevent retinopathy Exercise, Obesity, smoking, HbA1c, BP, cholesterol, ACE/ATII healthy diet Treat retinopathy.. Focal laser Grid, PRP Indirect ?pre-prolif ?investigate ?triamcinolone Improve control …retinopathy worse in short term LIGHT burns ENOUGH PRP detect retinopathy.. Screen Background … tight control Rehabilitate & support Low Vision service depression Other agencies

Medication & lifestyle Exercise, Obesity, smoking, HbA1c, BP, cholesterol, ACE/ATII healthy diet Exercise minutes a day ~weight ~50% Cholesterol Statin 25% whatever level Low saturated fats (red meat, dairy products) Low trans fats (cakes etc) Fibrates ~TG ~25% Olive oil, sunflower oil, Fish x2 week ~20% HbA1c 1=38% Type 2 Diet metformin 2 nd drug insulin once insulin multiple Type 1 insulin long acting & rapid acting Platelet adhesion Aspirin Healthy diet 7-9 portions vegetables, fruit/day ~30% Blood pressure 1mmHg =1.1% 130 (eyes) 115 (kidneys) ACE/ATII 50% > amlodipine > Bendrofluazide > B blocker >other Green…% reduction in retinopathy

HbA1c 1=38% Type 2 Diet > metformin > 2 nd drug > insulin once > insulin multiple Type 1 insulin long acting & rapid acting > pump As run out of insulin need more Do not assume other professionals are in control …practice nurses treat… YOU can advise the target Very hard to achieve good control…needs a lot of effort (may be too late if complications present)

Insulin needs 1/2= basic demand 1/2= with food less with exercise >30minutes; stress..complex effects Normal glucose level

Type 1 insulin long acting =lantus/levemir & rapid acting Eg novorapid But many patients are using twice daily insulin mixtures… one paper…3x retinopathy as multiple injections

Hypo! Impossible to achieve perfect control…1000s tricks to improve, takes expert advice and a lifetime to learn

Diabetes..total quality………………………….. 1.Try and join the diabetic team meetings 2.Patient does 90% of the work, professional 10% 3.Learn from patients…listening will teach you and helps patients…they realise you understand their problems, and so on. 4.Share information with patients …show them the haemorrhages on the photographs, discuss what the HbA1c means, and so on. 5.Unfortunately the disease can be vicious..the patient may be making tremendous effort, but even this is not quite enough.