Diabetes is a complex metabolic disease that changes the body’s chemistry and can lead to devastating effects on a number of fronts: heart, bladder, kidneys, feet, skin and – of course – the eyes. Just like any war fought on multiple fronts, a strategic and coordinated plan implemented by allies is the best – perhaps the only way – of confronting this looming health crisis.
Diabetes is considered the fastest growing chronic condition in Australia – indeed, in many affluent nations – most likely the result of increasing rates of obesity, sedentary lifestyles and dietary changes.
In the past year alone, 100,000 Australians were diagnosed with diabetes, bringing the total number of diagnosed diabetics in Australia to about 1.1 million. However, add in those with pre-diabetes and those who are unaware they’re living with the condition, and the estimate soars to 3.2 million.1
With an ageing population, diabetes has been identified as one of the most significant health crises facing Australia. Type 2 diabetes, which is largely preventable, is “projected to become
the leading cause of disease burden for men and the second leading cause for women by 2023”.
A team approach provides flexible, collaborative and comprehensive care to meet individual patient needs
The prevalence of diabetes in Aboriginal and Torres Strait Islander communities is between two- and four-fold higher overall than in non-Aboriginal communities.2
There is no cure for diabetes, but proper management can ensure its impact on the body is limited.
Eye health professionals have a significant role to play in diabetes management as it is estimated that “almost all those with type 1 diabetes and more than 60 per cent of those with type 2 diabetes will develop diabetic eye disease within 20 years of diagnosis”.3
Patient-centred approach
The Royal Australian College of General Practitioners (RACGP) says a multidisciplinary commitment to what it describes as “patient-centred care” is required to help patients prevent and manage diabetes.
The RACGP’s General practice management of type 2 diabetes describe the concept of patient-centred care as incorporating patients as partners in their health care.
“Achieving equitable, safe, effective and high-quality care for patients across the spectrum of type 2 diabetes is no small task.
“It requires a coordinated interaction between patients, healthcare providers and the healthcare system with a focus on improving the patient experience and outcomes throughout the continuum of care.
“Each of these elements requires systems and support. For example, comprehensive care for diabetes starts with prevention: through timely identification of at-risk individuals, education and support, it is possible to prevent or delay the onset of type 2 diabetes. The key is implementing risk assessment strategies and subsequently having the resources and communication strategies to effect change in patients’ lifestyles. These need to operate and be supported at both local and national levels.”
Crucially, the guidelines highlight the benefits of a multidisciplinary team approach to diabetes management, which requires GPs to collaborate and communicate with other health professionals, including optometrists and ophthalmologists.
“Collaborative multidisciplinary teams are best suited to provide diabetes care and facilitate patient self-management… Using multidisciplinary care and engaging the wider team has been shown to improve outcomes for people with diabetes… A team approach provides flexible, collaborative and comprehensive care to meet individual patient needs.”4
Diabetic Retinopathy
Diabetic retinopathy (DR) is one of Australia’s leading causes of vision impairment3 and can lead to blindness if not treated.
Everyone who has diabetes is at risk of developing diabetic retinopathy, which results in damage to the blood vessels at the back of the eye. As the condition advances, black clouds may ‘float’ in the individual’s vision and sight may become patchy or blurred. The consequences and complications of diabetic retinopathy can have a crippling effect on a patient’s quality of life.
DR is typically divided into two stages. The early, usually asymptomatic stage is known as non-proliferative diabetic retinopathy. Key features include haemorrhages within the retina and the leakage of fluid into the retina.
According to the Baker IDI Heart and Diabetes Institute and Centre for Eye Research Australia, “the later stage of diabetic retinopathy involves the growth of new, abnormal blood vessels on the retinal surface that may lead to severe vision threatening eye complications.
“Diabetic macular oedema occurs when the leakage of fluid from small retinal blood vessels affects the macula. Diabetic macular oedema is the leading cause of vision loss in diabetes.”3
Screening
With good screening and care, visual impairment due to diabetes can be avoided for the vast majority of patients.
However, because DR is a disease that often shows little or no symptoms even in the lead up to advanced stages of the disease, screening to allow early detection is key.3
People living with Type 2 diabetes should be screened for diabetic retinopathy at the time of their diabetes diagnosis and then every two years thereafter.2 Once retinopathy has been identified the patient will need to visit an ophthalmologist more regularly – annually or once every few months depending on severity and individual risk factors – for monitoring and/or treatments.2 (see Table above)
Management
Tight control of blood glucose and blood pressure reduces the risk of onset and progression of diabetic eye disease in type 2 diabetes.5
In addition to risk factor control, the TGA has approved the use of fenofibrate for diabetic retinopathy in patients with type 2 diabetes.6
Specific ocular therapies administered by ophthalmologists such as laser photocoagulation therapy, intra-ocular injections, and vitrectomy are considered key for preventing vision loss in the later stages of the disease.5
Other ophthalmological effects
While DR is one of the primary concerns for diabetic patients, there are a number of other ophthalmological concerns. The RACGP guidelines also advise a close watch on refractive errors, which occur as the lens shape alters with changes in blood glucose concentrations and result in blurred vision; and cataracts, which can occur prematurely in people with diabetes.
References
1. www.diabetesaustralia.com.au/Understanding-Diabetes/ [accessed 19 September 2014]
2. National Health and Medical Research Council, NHMRC 2008: Guidelines for the Management of Diabetic Retinopathy, www.nhmrc.gov.au/_files_nhmrc/publications/attachments/di15.pdf [accessed 19 September 2014]
3. Baker IDI Heart and Diabetes Institute and Centre for Eye Research Australia, Out of Sight: A report into diabetic eye disease in Australia, 2013.
4. General practice management of type 2 diabetes – 2014–15. Melbourne: The Royal Australian College of General Practitioners and Diabetes Australia, 2014.
5. ref NHMRC 2008 DR Guidelines
6. ref RACGP 2014 Guidelines
