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HOW DIABETES AFFECTS YOUR EYES
Eye checks
Everyone with diabetes should have regular, preferably annual, visual acuity and retina checks. Your retina can be examined either with an ophthalmoscope after dilating drops have been put into your eye (the effects of these can be reversed after the examination) or with a special infra-red camera. The retinal camera produces a Polaroid picture within a few minutes, and because it uses infra-red light no dilating drops are needed.
If minor changes are found, all that is needed is a reassessment of your glucose balance and more frequent checks. If you have more severe changes, laser treatment is used with the aim of encouraging regression of proliferative vessels and preventing further new vessels forming. Laser treatment is usually carried out by an ophthalmologist and may have to be repeated. Anyone on treatment with normal blood glucose levels is less likely to develop retinopathy than people with high glucose levels. Lesions (microaneurysms, hemorrhages or exudates) may also regress if control is improved after retinopathy has developed, though it is obviously better to try to prevent them from appearing in the first place.
Cataracts These are more common among people with diabetes than in the general population. They are caused by deposits in the lens of the eye which block vision. They can be treated by removal of the eye’s lens, which has become opaque. This is replaced either with an implanted lens, or are given contact lenses or glasses. The operation has an excellent success rate. If you have diabetic retinopathy as well as cataracts, your ophthalmologist may have to treat the cataract before the extent of the retinopathy can be seen. Nowadays it can sometimes be removed as a day-case procedure.
See your doctor
If you notice any change in your vision, see your doctor at once. Although cataracts and diabetic retinopathy may be the reason for a change in your vision, the most common cause is a high blood glucose level or a changing blood glucose level. This alters the focusing properties of the lens temporarily, causing blurring. The blurring disappears once your blood glucose level is controlled, so do not waste money on new glasses until you are sure that any change in your vision is not caused by glucose problems. Always bear these points in mind:
1. Tell your doctor immediately if your vision deteriorates.
2. The commonest cause of visual change in diabetes is high or changing glucose levels. Do not buy new spectacles when your glucose control is poor.
3. Regular eye checks can detect diabetic retinopathy at an early stage.
4. Diabetic retinopathy is treatable.
5. Diabetic retinopathy may be prevented by good glucose control.
6. People with diabetes may develop cataracts: they too can be treated.
*31/102/5*

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THE DAWN PHENOMENON IN PEOPLE WITH DIABETES
Many people with diabetes have a sharp rise in their blood glucose just before they wake up in the morning. There is still some argument about precisely why this is, but many researchers believe that it is simply because blood insulin levels are getting lower. However, earlier in the night, your blood glucose may have been low, even hypoglycemic. If you are waking with high blood glucose levels, check what is happening to your blood glucose during the night. Use an alarm clock to wake yourself up at, say, two and five in the morning to check your blood glucose level. Managing high pre-breakfast glucose levels depends on the type of insulin you are taking and whether you also have nocturnal hypoglycemia.
High all the night If you are running high throughout the night, the solution should be straightforward. Increase your long-acting or medium-acting evening insulin or, if you are overweight, eat a little less before you go to bed. If you are on very long-acting insulin, taken only in the mornings, you may have to increase it, and then you may have to readjust your diet so that you do not go low in the afternoon or evening. If you have a late main evening meal, after about eight o’clock, you may need to increase your evening short-acting insulin, rather than the long-acting one.
Low then high It is a little more difficult to sort things out if you are hypoglycemic during the night and you then awaken with a high blood glucose level. Obviously, if you increase your long-acting insulin, you may become seriously hypoglycemic at two or three in the morning, before the insulin runs out. One way of coping is to have a rapidly absorbed snack just before you go to bed, rather than a very high fibre one from which the glucose is absorbed more slowly. This can be combined with a slight increase in your evening medium-acting or long-acting insulin and a slight decrease in your fast-acting insulin. Altering the quantity and timing of your main evening meal may help, if this is practical, and altering the time at which you give your insulin injection can also help sometimes. Discuss this with your doctor. If you cannot get it right on twice-daily insulin injections, consider splitting the evening injection so that you have the short-acting insulin before the main evening meal and the long-acting or medium-acting insulin before going to bed. Another approach is to try a CSII pump, which will give a constant insulin infusion throughout the night. Some models also allow you to program for delayed insulin boosts to cope with an early morning rise (for example, the CPI 9100 model).
People with insulin-treated diabetes should always eat a snack before going to bed.
*28/102/5*

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DIABETES: TAKING ORAL HYPOGLYCEMIC DRUGS
If you are taking oral hypoglycemic pills and your blood or urine glucose levels become very high, consider increasing your dose. Naturally, whether you can do this, depends on whether you are already on the maximum dose or not. If you are not on the maximum dose, try taking another half pill a day or another whole pill if this does not take you over the maximum.
One of the problems of being on pills is that they may not be absorbed if you have diarrhea or vomiting. Even if they are, they may not be sufficient to overcome the increased insulin resistance that can result from infection and other illnesses. If you have diarrhea and vomiting or if you cannot bring your blood glucose level down yourself, or if you feel very ill, contact your doctor immediately. Sometimes it may be necessary to have insulin injections to control your blood glucose level during a time of illness. This does not necessarily mean that the insulin will need to be continued when you have recovered.
Loss of glucose control on oral hypoglycemics
Many people with the form of diabetes that starts during middle age and the later years (maturity onset type) can control their blood glucose on diet and oral hypoglycemic treatment. Most people whose diabetes begins under the age of thirty years need insulin treatment but a few with maturity onset diabetes of youth (MODY) can be treated successfully with oral agents.
Control of your weight through diet is especially important in maturity onset diabetes because obesity increases the body’s resistance to the action of insulin. However, if insulin production fails, whether in maturity onset diabetes or MODY, insulin injections will be needed for glucose control. This is not a disaster.
Geoffrey, who is now fifty-eight years old and a production manager, had been taking chlorpropamide since his diabetes was diagnosed five years previously, gradually, increasing the dose to the maximum of 500 mg daily.
Despite sticking carefully to his diet and remaining at the ideal weight for his age and height, his glucose levels began to rise. His doctor added metformin treatment and the dose of this was increased to its maximum, but to no avail. Geoffrey’s blood glucose levels continued to rise and he began to feel thirsty and had to get up to urinate several times each night. He felt tired and listless. I told him that he now needed insulin treatment but Geoffrey had a horror of injections and was convinced that he would never be able either to give his own insulin or allow anyone else to give it to him.
‘I would sooner die than go on to insulin,’ he said.
Nothing I said could persuade him to change his mind. Over the succeeding weeks he became increasingly ill, was drinking large quantities of fluids daily, started to lose weight and was irritable with his wife and family. He developed an embarrassing soreness around his penis, a fungal condition called thrush, which men and women with diabetes can develop with poor glucose control. This was treated but it recurred. At each clinic visit I tried to persuade Geoffrey to change his mind about insulin treatment but he remained adamant. Then finally one day he came into the clinic in tears. He could no longer do his job properly, he felt awful and was badly depressed. His wife, who came with him, was very worried about him. I got out an insulin syringe and needle and demonstrated on myself how simple it is to insert the needle under the skin. After thirty minutes’ persuasion by me and his wife, Geoffrey stuck the needle into his arm.
‘It doesn’t hurt,’ he said, astonished.
He is now on twice daily insulin injections with good glucose control, is back at work and says he feels marvelous. He wishes he had tried insulin sooner.
Call for help
Even the best informed and most efficient people have occasional Problems. It is not an admission of defeat to call for help -just common sense. Doctors greatly prefer being called when they can help prevent a problem from getting worse than when a disaster has occurred. Contact your doctor sooner rather than later.
Problems with glucose control
? Hypoglycemia is preventable. Learn your warning signs – and learn from your mistakes.
? Measure blood glucose levels frequently when you are ill.
? Plan what to do if you become ill before it happens.
? Take more insulin if your blood glucose level rises.
? Check for ketones if your blood glucose level rises or you cannot eat.
? Never stop taking your insulin.
? Do not be afraid to call for help.
*29/102/5*