Early recognition of diabetes complications
Close-up of a resolving ulcer on the heel of a diabetic patient
The primary goal of diabetes management is to prevent end-organ complications. Most diabetes-related visits with a health-care professional focus at least in part on blood sugar levels and hemoglobin A1c (HbA1c). As a diabetologist, I try to put things into perspective from time to time. I tell patients that a blood sugar level of 200 or 300 mg/dL or an HbA1c of 9% is not bad in and of itself; it's the long-term consequences on the microvascular system that we must work to prevent. I next explain that the damage to the body caused by diabetes occurs on a microscopic level. Long before a patient experiences deficits in visual acuity, burning or stabbing foot pain from neuropathy, or symptoms of end-stage renal disease or uremia, it is my job to detect the earliest manifestations of these conditions. This article will focus on when and how to screen for and treat retinopathy, neuropathy, and nephropathy from the perspective of a health-care professional providing primary diabetic care.
The importance of ophthalmologic care
To prevent retinopathy (Figure 1), a leading cause of blindness in the Western world, the most important thing to do is educate patients about the necessity of regular dilated-eye exams. Examining the fundi under direct ophthalmoscopy in your office will reinforce to patients the importance of this aspect of their preventive diabetes eye care; however, I always stress that the small part of the fundus I can see on a non-dilated eye exam might look all right, but a dilated-eye exam and a full retinal exam by an ophthalmologist should be done on a yearly basis.
The worst thing to do would be to reassure a patient incorrectly of a normal eye exam, when real pathology exists in an area you cannot see with the tools available in your office. I have also been humbled by some of the severe retinal findings reported by an ophthalmologist after I have noted “normal” findings on my own exam. Practicing at a tertiary-care center, I see many patients who have been reassured by previous eye specialists that their “eyes are fine,” only to have our ophthalmologist find severe retinopathy requiring urgent laser photocoagulation therapy.
Last, I emphasize to patients that visual loss in diabetes can be delayed and many times avoided if retinopathy is detected at its earliest stages. Underscoring the relationship between overall glycemic control (based on the HbA1c) and developing or worsening retinopathy also encourages patients to follow up with their eye doctor.