Diabetic Eye Disease. Identification and co-management By Alicja R Rudnicka and Jennifer Birch

Diabetic Eye Disease. Identification and co-management By Alicja R Rudnicka and Jennifer Birch book free download.

This book is directed towards optometrists, general practitioners, specialist registrars in general internal medicine/diabetes and doctors who may be training for their ophthalmology examinations as well as other health care professionals with an interest in identification and co-management of diabetic eye disease. Medical students requiring in-depth knowledge of the clinical and histopathological interplay between diabetes and diabetic eye disease would find this text useful. It begins with an introductory chapter into the natural history, clinical presentation, treatment and complications associated with diabetes mellitus. This is followed by a chapter emphasizing the importance of pre-conceptual advice and the clinical risk factors in the progression of diabetic retinopathy in pregnancy. Histopathology, pathogenesis and biochemical mechanisms of diabetes mellitus are described in Chapter 3 with attention to the retinal microvasculature. Findings from some of the most important epidemiology studies into the natural history of diabetic eye disease (Chapter 4) and its clinical presentation are described in detail (Chapter 5). Colour plates supported by schematic diagrams cover the spectrum of retinal features observed in diabetic retinopathy. Chapter 6 discusses the management of diabetic retinopathy and the urgency of referral for different grades of retinopathy. Recommendations laid out in Chapter 6 may need to be modified to suit locally agreed criteria for referral of diabetic retinopathy to a specialist. For the interested reader a chapter is included on the treatment for diabetic retinopathy including retinal laser photocoagulation and vitrectomy surgery (Chapter 7). Changes in visual function due to abnormalities in the retina and anterior eye in diabetes are discussed in Chapter 8. 

                     Around 2 per cent of the UK population are believed to have diabetes, of whom approximately 200,000 have Type 1 diabetes, and more than a million have Type 2 diabetes (Calman, 1998). This has considerable implications for the management and allocation of public health funds. Diabetic retinopathy is the leading cause of blindness in people of working age in industrialized countries (Evans, 1995). It has been estimated that systematic screening for diabetic retinopathy could prevent about 260 new cases of blindness per year among people under seventy years of age in England and Wales (Rohan, Frost and Wald, 1989). Consensus is yet to be established about the most effective way to screen for sight-threatening diabetic retinopathy. Consequently there is wide variability in the screening services provided, both in coverage and methods used. Approximately 50 per cent of people with diabetes rarely or never attend hospital diabetic clinics (Gibbins and Saunders, 1989), hence, the role of general practitioners, optometrists and technicians as primary screeners has been examined. In addition, a review of patients registered blind due to diabetes in the UK revealed that 50 per cent had had no prior eye examination despite being known to have diabetes (Clark et al., 1994). Chapter 9 explains the principles and terminology used in screening epidemiology. It reviews various screening methods that have been used to detect diabetic retinopathy. It is possible that appropriately trained and experienced optometrists, using a combined modality screening in a primary care setting, could identify with high sensitivity and specificity those patients requiring referral for treatment. It is likely that primary care-based screening will utilize one of the following, or a combination of, fundus photography with 35 mm or digital image recording and/or suitably trained optometrists performing slit-lamp biomicroscopic fundus examination (see Chapters 10, 11 and 12). 

                    The use of a recording medium has been shown in many studies to improve the sensitivity and specificity of screening for diabetic retinopathy. A recent study using a combination of measurement of visual acuity, fundus photography and direct ophthalmoscopy through dilated pupils performed by an optometrist with specialist back-up resulted in what was described as a ‘fail-safe’ method for detection of sight threatening retinopathy (Ryder et al., 1998). The British Diabetic Association has published guidelines relating to the establishment of screening services based upon fundus photography and using optometric services. An essential element in any diabetic retinopathy screening programme must be an efficient patient identification and re-call system. Provisions should also be made for continuing accreditation, quality assurance and audit. Funding for screening has not yet been specifically identified on a national basis. However, classification of national screening targets and protocols is likely to form part of the National Service Framework for diabetes and is due to be published in 2001. Advice on how to approach the Health Service for support is presented in Chapter 13. An example of one scheme in operation in East London is given (Chapter 14) and it highlights the complexities encountered with the administration and documentation at each stage of the screening process. 

             The final chapter deals with a mixture of retinal pathologies in diabetic patients and serves as a reminder that diabetic patients can suffer ocular complications other than diabetic retinopathy. We are very grateful to all the contributors who have worked very hard over a long time to finally make this book a reality. In particular, we would like to thank Mr Rolf Blach and Mr Peter Hamilton for initiating the co-operation between Moorfields Eye Hospital and the Department of Optometry and Visual Science at City University, which led to the formation of a diabetic co-management course for optometrists. This course was in part responsible for the genesis of this book.

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