Eye complications
Diabetic retinopathy is a leading cause of visual disability. Significant retinopathy is rarely encountered in the first five years of type 1 diabetes mellitus, nor before puberty. However, over the subsequent two decades, the vast majority of people with diabetes develop retinal changes.
DAN (Diabetes Association of Nigeria) recommends that the initial eye examination should be done:
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⦁ Shortly after the diagnosis of type 2 diabetes.
The eye examination should be repeated annually for both type 1 & 2 diabetes. Less frequent examination (every 2-3 years) may be considered one or more normal eye exams.
Good control of diabetes results in the occurrence of retinopathy. Timely laser photocoagulation has been demonstrated to prevent a major proportion of severe visual loss associated with proliferative retinopathy. It has also been shown to be of considerable benefit to patients with macular oedema.
To prevent retinopathy and visual loss, the following are recommended:
⦁ Promoting good glycaemic control in all diabetic individuals
⦁ Controlling blood pressure
⦁ Detecting and treating glaucoma at an early stage
⦁ Detecting and treating cataracts.
⦁ Detecting and providing timely treatment of potentially serious retinal changes
The DAN guideline also states that aspirin does not increase the risk of retinal haemorrhage, and its use for cardioprotection is not contraindicated in retinopathy.
Nephropathy
Diabetic nephropathy is a major cause of death among people with diabetes and an important cause of morbidity and increased health care costs due to diabetes. It leads to end-stage renal disease requiring dialysis or renal transplantation.
This complication may be prevented, and progression can be slowed by:
⦁ Strict glycaemic control
⦁ Vigorous treatment of hypertension
⦁ Avoidance of nephrotoxic drugs and early and effective treatment of infection.
The onset of clinical nephropathy is manifested by proteinuria. However, an earlier marker of the onset of nephropathy is the presence of microalbuminuria (defined as an overnight excretion of 20-200 µg/min or excretion of >30 mg/24 hr) on more than one occasion.
The following action should be taken:
⦁ People with diabetes should have their urine tested at initial assessment and periodically at annual reviews.
⦁ In the absence of proteinuria, a test for microalbuminuria is recommended where local resources permit.
⦁ In the presence of microalbuminuria or gross proteinuria:
⦁ A full assessment of renal function should be performed periodically
⦁ Treatment of hypertension should be instituted as early as possible, and good control should be achieved. Emphasis should be given to:
⦁ Avoidance of nephrotoxic drugs and early and effective treatment of infection
⦁ Optimal diabetes control
⦁ Dietary modifications in the form of reduced protein intake and salt restriction, if the need arises
The DAN guideline recommends the use of ACE inhibitors and ARBs in treating non-pregnant patients with micro- or macroalbuminuria. It further recommends a reduction in protein intake and monitoring of serum creatinine and potassium levels in patients on ACE inhibitors, ARBs or diuretics.
Neuropathy
Neuropathy is a common complication of diabetes. It causes clinical manifestations and disabilities of a diverse spectrum and considerable severity. Both peripheral nerves (sensory and motor) and the autonomic nervous system can be affected. Patients present with distal symmetrical polyneuropathy (DPN), focal neuropathy or manifestations of autonomic involvement such as gastroparesis, constipation, diabetic diarrhoea, bladder dysfunction, impotence and orthostatic hypotension.
Peripheral nerve affection together with peripheral vascular disease predisposes to foot ulcers and infection. If not detected early, these lesions may progress to gangrene and result in amputation.
Neuropathic involvement can be prevented or delayed by good glycaemic control. Foot complications can be avoided by good foot care and the detection of early lesions.
Foot Care
Severe foot lesions requiring amputation are one of the major complications of diabetes.
The two main approaches to prevention are (1) identification of high-risk individuals and (2) early detection of foot lesions: for example, trauma, infection or ulcers.
Intensified foot care should be ensured for patients at high risk, such as those with:
⦁ Symptoms and/or signs of neuropathic involvement
⦁ Nephropathy or significant retinopathy
⦁ Foot deformities and chronic orthopaedic or rheumatic disorders, and
⦁ Poor hygiene
Instructions on foot care should be an integral part of any educational activity on diabetes.
They should focus on:
⦁ Self-examination
⦁ Avoidance of trauma
⦁ Cessation of smoking, and
⦁ Wearing properly fitted shoes.
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