Loss of Warnings or Hypoglycaemia Unawareness

Hypoglycaemia itself, or the avoidance of it, is an acute daily problem for people with diabetes but when accompanied by loss or partial loss of warnings, it can have a dramatic effect on the lives of both the person with diabetes and their families. There can be a marked reduction in the quality of life for all concerned.

Total loss of warnings – A condition where the warning symptoms of an impending hypo are not present and so when the blood glucose levels drop there are no warning signs that the person must eat. This makes the likelihood of severe hypos much greater. People with loss of warnings have to rely on the help of others and frequent blood glucose monitoring.

Partial loss of hypo warnings – This means that warning symptoms are present sometimes and not at other times. In some ways this is more difficult than total loss of warnings because the person may not even be aware that they have some loss of warnings and so have unexpected and unheralded moderate or severe hypos. This is particularly dangerous when driving.

Reduced warning symptoms – Is where the early warning signs of hypoglycaemia are reduced or missing [sweating, trembling etc] and the blood glucose drops to the stage where the symptoms are less obvious [confusion, behavioural changes etc]. This means that the person often then requires the help of others to treat the hypo.

The effects of loss of warnings
Information gathered from the experiences of people with diabetes and their carers says that loss of warnings may result in the following:

• A feeling of insecurity and loss of independence
• Embarrassment
• A fear of leaving the home
• Being a danger to oneself and others
• Aggressive or violent behaviour
• Family conflict, breakdown of relationships
• Loss of driving licence – it is illegal to drive with loss of warnings
• Loss of job
• A deliberate raising of blood glucose levels to avoid such situations

Causes of loss of warnings or hypo unawareness

There are several known causes of loss of awareness of hypoglycaemia:

• Duration of diabetes – long term diabetes can result in loss of warnings.
• Hypoglycaemia itself can cause loss of warnings and therefore increase the risk of more hypos. This then becomes a vicious circle of hypos leading to loss of warnings and more hypos!
• Intensive therapy with multi-daily insulin injections and aiming for near normal blood glucose levels, has been shown to cause a threefold increase in the risk of severe hypoglycaemia. This increased hypoglycaemia can therefore increase the risk of loss of warnings.
• Neuropathy – damage to the autonomic nervous system is a complication of diabetes and this can cause loss of warning symptoms.
• Changing insulin species can cause a loss or change in warning symptoms.
• ‘Human’ insulin can cause loss of warnings of hypoglycaemia. This is often not readily admitted by many health professionals but since the early 1990s, Patient Information Leaflets in ‘human’ insulin packs have included a warning of that ‘human’ insulin can cause changed or loss of warnings of an impending hypo.

Is Hypoglycaemia Dangerous?

Hypoglycaemia can affect people’s work, relationships, ability to drive and their quality of life but there are three main aspects to the question of whether it is actually dangerous:

1. Severe untreated hypoglycaemia leads to coma with or without an accompanying seizure and this can lead to death. A study in the UK analysed the records of 23,752 people with Type 1 diabetes between the ages of 1 and 84 who had been diagnosed before the age of thirty to ensure that they really had Type 1 diabetes. They entered the study between 1972 and 1993 and were followed until 1997. By 1997, 949 people had died and hypoglycaemia was responsible for 18% of deaths in men and 6% of deaths in women.
2. There is growing evidence that repeated moderate/severe hypoglycaemia can cause a reduction in cognitive function. This is of special concern in children where the brain is still developing. Some research has suggested that repeated hypoglycaemia in children can reduce the IQ by 5 or 6 points which does not sound very much but one researcher suggested that this could mean the difference between getting a university place and not. [See Useful Research item 8 of contents]
3. Loss of warnings of an impending hypo can be classed as dangerous because it can result in more episodes of hypoglycaemia with all the consequent risks.

It is for all these reasons, and more, that IDDT believes that natural pork and beef insulin must remain available indefinitely. The most common reported adverse reaction to ‘human’ insulin is loss of warnings of hypoglycaemia, which in many people reverses with a change to natural pork or beef insulin. For this sub-group of people it is essential that the choice of animal insulins remains available to ensure that they do not suffer unnecessary and avoidable hypoglycaemia.

Hypoglycaemia and Alcohol

Alcohol can cause delayed hypos in people with Type 1 diabetes – low blood sugars the day after drinking even modest amounts of alcohol the previous evening. Research carried out at the Royal Bournemouth Hospital [Diabetes Care, July 2005] showed that alcohol has been implicated in up to one fifth of hospital visits for hypoglycaemia, low blood sugars. The researchers investigated the effect of evening alcohol in 16 people with Type 1 diabetes who had normal hypo warnings and who drank alcohol on a regular basis. The participants were evaluated with continuous blood glucose monitoring on two occasions – after taking orange juice and vodka or just orange juice followed by the same meal and same dose of insulin. They experienced 1.3 episodes of hypoglycaemia per day during the 24hours after the alcoholic drink compared to 0.6 episodes after a non-alcoholic drink. The researchers suggest that this research may encourage people to be more ‘proactive’ in adjusting their insulin appropriately if they are drinking alcohol.

Just a few words of warning:

• Try to learn how alcohol affects you and learn the best ways to cope with it.
• It is always best to drink with a meal and to tell someone you are with that you have diabetes.
• You should not assume that drinks which contain carbohydrate will counteract the hypo risk because they don’t.
• Low carb alcoholic drinks such as Pils contain more alcohol – so not a good idea!
• The warning signs of hypos can be missed with too many drinks and other people may mistakenly think that you are drunk rather than you are hypo.
• Carry out more blood glucose tests to check for hypos for at least the next 24hours.

Living With The Daily Risk of Hypos

Here are just a few quotes from people with diabetes:

• “Hypoglycaemia is one of the worst parts of having diabetes”
• “Hypoglycaemia screws up your life.”
• “For some of us it is a constant battle that we go through everyday and every night to try to obtain some sort of normality in our blood glucose levels. The fears and experiences, especially of hypoglycaemia comas and seizures that many of us and our carers suffer, are ever present.”

Practical information from people with diabetes for people with diabetes:

• One hypo can easily lead to another within the next 72 hours. This is because the first hypo used up much of the body’s emergency store of glucose so leaving the body vulnerable to another hypo.
• Strenuous exercise can lead to low the blood sugars the next day.
• Exercise sufficient to lower blood sugars and cause a hypo is not always the strenuous sporty-type exercise. For people with a sedentary job or the elderly, a trip around the busy supermarket is exercise and can be sufficient to cause a hypo.
• Sexual intercourse is exercise and can cause hypos in both men and women.
• Alcohol lowers the blood sugars and can cause hypoglycaemia both at the time and up to 48 hours later. Alcohol also masks the warning signs of a hypo. Hypos can be misinterpreted by others as ‘ you are drunk’.
• Some drugs taken for other conditions may cause hypoglycaemia eg beta-blockers.
• Emotional upset, stress and excitement, which may not always be apparent, can cause hypos.
• With illness and especially vomiting, it is OK to eat or drink anything that will keep the blood sugars high enough to avoid hypoglycaemia.
• All long- and intermediate-acting insulins contain crystals and they settle to the bottom of the vial. They must be re-suspended before drawing up and injecting the insulin. Research has shown that the vial must be rolled or tipped 20 times to achieve a satisfactory mixture. This also applies to insulin in pens. Failure to do this can result in unexpected hypos because there will be less crystals in the insulin and it is the crystals that slow down the action of the insulin.
• A change of insulin type, species and even batch can affect diabetic control and cause hypos.
• Genetically produced synthetic ‘human’ insulin in some people causes more severe hypos, more frequent hypos and reduced or loss of warning symptoms.
• Hypos can occur for no apparent reason and in people who blood test frequently, as well as those who don’t.
• Being able to function and walk around with low blood sugars does not mean that you are not hypo – it probably means that you have missed, or not had, the early warning signs.
• Hypoglycaemia itself can lead to loss of warnings.
• Good diabetic control means avoiding hypoglycaemia just as much as avoiding hyperglycaemia [high blood sugars].

Introduction – The Eyes and Diabetes

There are still many misunderstandings about eyes and the roles of the various healthcare professionals who look after them. These misunderstandings can mean that people sometimes worry unnecessarily. To some extent the blame lies with the professionals involved for using terms and language that people don’t understand and for nor spending enough time explaining conditions of the eyes in a simple and straightforward way.

Many people are quite nervous when they have their eyes examined and this does not just apply to people with diabetes. Our eyes provide sight which is probably the most important of our 5 senses and so it is understandable that we are all a little nervous that when we have our eyes examined – the underlying fear of ‘bad news’.

In this section we hope that we provide some clear explanations of the common conditions that can affect the eye, especially those that apply to people with diabetes. At the same time perhaps we can dispel some of the myths and misunderstandings that occur.

It must be strongly emphasised that it is important that everyone should have regular, full eye examinations but especially people with diabetes. Early detection and diagnosis of many eye conditions means that treatment can start early in order to preserve sight. In the UK everyone with diabetes is entitled to a free eye test.

Anatomy of The Eye

Before considering diabetic eye disease we need to understand a little of how the anatomy of the eye and how the eye works.

• Iris – This regulates the amount of light that enters the eye. It is the coloured part of the eye across the front of the lens. Light enters through a central opening called the pupil.
• Pupil – Is the circular opening in the centre of the iris through which light passes. The iris controls dilation and constriction of the pupil.
• Cornea – Is the clear circular part of the front of the eyeball. It refracts the light entering the eye on to the lens, which then focuses it on to the retina. The cornea is extremely sensitive to pain.
• Lens – Is a transparent crystalline structure behind the pupil of the eye. It helps to refract incoming light and focus it on to the retina. A cataract is when the lens becomes cloudy, and then the lens can be removed and replaced with a plastic intra-ocular lens.
• Vitreous – Is a clear jelly-like material in the middle of the eye.
• Retina – Is a light sensitive layer that lines the interior of the eye. It is made up of light sensitive cells known as rods and cones. The rods are necessary for seeing in dim light. And the cones best in bright light and are essential for receiving a sharp accurate image. Cones can also distinguish colours. The retina works much in the same way as film in a camera.
• Macula – Is the yellow spot on the retina at the back of the eye with the greatest concentration of cone cells. It provides the greatest acuity of vision, such as reading.
• Optic disk – Is the visible portion of the optic nerve on the retina. The optic disk is the start of the optic nerve where messages from cone and rod cells leave the eye and pass along nerve fibres and so transfer all the visual information to the brain. The optic disk is also known as the ‘blind spot’.

How we see
For sight to take place light must be able to pass to the retina at the back of the eye. The light passes through cornea and enters the eye through the pupil. It then passes through the lens and the vitreous to be focused on the retina. The focused light or images of what we have been looking at, are then passed down the optic nerve to the brain.

Retinopathy

Statistics

• Diabetic retinopathy is the leading cause of blindness in people of working age in industrialised countries. It is estimated that 12% of people who are registered blind or partially sighted in the UK have diabetic eye disease.
• 50% of people with Type 1 diabetes and 30% of those with Type 2 diabetes will develop some form of retinopathy in their lifetime and need treatment to reduce the risk of vision loss.

Facts

• If diagnosed early enough diabetic retinopathy is a treatable condition.
• The best way to try to prevent the development of retinopathy is to aim for tight control of blood glucose levels [as near normal HbA1cs as possible] and good control of blood pressure [lower than 130/80mm Hg]. These targets are not always achievable in everyone.
• The only treatment for diabetic retinopathy is laser treatment. It can stop the progression of retinopathy and help to maintain sight.
• Everyone with diabetes is entitled to free eye screening for retinopathy. In 2003, the Government set national targets for eye screening – everyone with diabetes was supposed to be screened by 2008. In 2009 Department of Health figures show that around 700,000 people with diabetes in England are still not being screened.
• There are two vulnerable groups of people susceptible to retinopathy – firstly, pregnant women and secondly, children and adolescents. In the long term children and adolescents are at greater risk of microvascular and macrovascular complications of diabetes.

What is diabetic retinopathy?
Retinopathy is usually classified according to its severity. This may not be the same in both eyes. There are two classifications of diabetic retinopathy:

Background retinopathy
This is the first stage of the development of retinopathy and it is rare before 8 to 10 years of diabetes duration. At this stage the vision is normal and sight is not threatened. If there are diabetic changes present such as small haemorrhages, fatty deposits [exudates] or abnormal blood vessels [microaneurysms] then this is a sign that the retinopathy is worsening and the doctor will be alerted to arrange more frequent follow ups.

Proliferative retinopathy
This is where the blood vessels [capillaries] block and starve the retina of nutrients causing new vessels to grow. These new vessels grow either in front of the retina on to the back of the vitreous or occasionally on to the iris. The new vessels are fragile and may bleed into the vitreous which then affects the sight and may cause floaters, dots or lines and if severe, may cause clouding of the vision or loss of vision.

If the vessels grow on the iris, they can cause a rise in pressure in the eye and severe, painful glaucoma. The new vessels eventually cause scar tissue and this can lead to a retinal detachment where the retina becomes detached from the back of the eye resulting in severe loss of sight.

Points to remember:

• If diagnosed early enough diabetic retinopathy is a treatable condition.
• Regular eye checks do not prevent retinopathy but do enable early diagnosis and early treatment which will benefit your sight.
• Small blood vessels in the retina become blocked, swollen or leaky causing oedema and new, fragile vessels grow haphazardly in the retina. This process can continue for years without causing visual symptoms or visual impairment: during this period, retinopathy can only be detected by eye examination.
• For people with diabetes, eye checks are free in the UK.
• In insulin treated diabetes, annual eye checks should be carried out and in children and young people after the onset of puberty.
• In people with diabetes not using insulin, then eye checks should take place annually from diagnosis onwards.

Who may be at risk of developing diabetic retinopathy?

Retinopathy can affect people with all types of diabetes:

• Anyone with diabetes treated with insulin, both young and old.
• People with Type 2 diabetes treated with diet and tablets or diet only.
• People who have well-controlled diabetes can develop retinopathy.

Can retinopathy be prevented?
No, but early ‘good’ blood glucose control and blood pressure may slow down the rate of progression of the condition. Improving diabetic control rarely has an effect on diabetic retinopathy itself, but it can prevent further deterioration. Therefore you should:

• Always take your diabetic treatment – not doing so is harmful.
• Control your diet.
• Avoid becoming overweight.
• Avoid smoking and alcohol.
• Have regular blood pressure checks.

Retinopathy and genetically produced synthetic ‘human’ insulins
Two of the major insulin manufacturers have admitted that ‘human’ insulin therapy may cause serious adverse reactions. These are very much in line with the evidence from a significant number of patients.

On April 24th 2000, insulin manufacturer, Aventis Pharmaceuticals, issued the following statement in a press release:

“Human insulin therapy may be associated with hypoglycaemia, worsening of diabetic retinopathy, lipodystrophy, skin reactions (such as injection-site reaction, pruritus, and rash), allergic reactions, sodium retention and oedema.”

In the Patient Information Leaflets for some of the insulin analogues, oedema in the eye has also been listed as a possible adverse effect.

The use of synthetic may be putting some people at risk of unnecessary and avoidable complications to which they are already susceptible. Any increased risk of blindness or visual impairment is unacceptable to patients when there are natural insulins available in the UK that have not been said to cause such risks.

Retinopathy and driving
You should tell the DVLA and your motor insurers, if you have retinopathy that requires treatment or has been treated as this can affect your vision or visual fields. It is a condition that should be declared under the item ‘has there been any material change that could affect your driving.’ If you were involved in an accident and you had not declared that you have retinopathy, then you may not be insured and the DVLA could take action because you have not informed them.

Pycnogenol – are we missing something?

What is it and what does it do?
Pycnogenol is the extract of bark of a particular pine tree only known to grow in a specific area in France. Apparently French people with diabetes and retinopathy are often treated with a patented pill called Pycnogenol – not known to be used in the UK or the US.

Pycnogenol apparently is made up of a particular group of bioflanonoids that have been shown to improve the elasticity of the very small blood vessels [capillaries]. It has also been shown to have antioxidant powers that get rid of the free radicals – these are harmful molecules that lead to vascular and other problems.

An article in Diabetes Interview [March 1999] reports a man who was diagnosed with retinopathy requiring laser treatment in 1982. He searched for a possible solution himself and found Pycnogenol in France – his retinopathy regressed and he has had no laser treatment.

We have to be aware that this could happen naturally but…

• A study published in Ophthalmic Research in 1996 proved Pycnogenol’s beneficial effects on the retinas of pigs and cows.
• In the Journal of Cardiovascular Pharmacology, October 1998, it was shown to counteract the blood vessel restricting effects of adrenalin, to decrease the clogging of blood vessels by decreasing platelet clustering and adhesion.
• In the journal Free Radical Biology and Medicine, May 1998, it was shown to significantly decease nitrogen monoxide generation [this is important in many diseases including diabetes].
• In Biotechnology Therapeutics, 1994-95, it was shown to protect the cells lining the lymphatic vessels and the heart from injury due to oxidation.
• In Phytotherapy Research [15;219-233:2001] 30 people with diabetes were treated with 50-mg doses of Pycnogenol 3 times a day for 2 months and 10 people in a control group were treated with a placebo [dummy pill]. The researchers found that in those who took Pycnogenol there was a slowing down of the progression of retinopathy and in some cases the progression actually halted but in the control group using the placebo, retinopathy only got worse. This study should be treated with some caution because it was only small.

Despite efforts to achieve near normal blood glucose levels, in industrialised countries diabetic retinopathy is still the leading cause of blindness in the working population. This emphasises the need to investigate all possible avenues to prevent people from becoming blind or visually impaired. Therefore IDDT welcomes the findings of this last study and believes that it should not be dismissed simply because Pycnogenol is a herbal remedy. There needs to be further independent studies using Pycnogenol involving greater numbers of participants over a greater duration of time.

To those that either have or are at risk of retinopathy, every avenue of possible prevention or stabilisation should be considered and explored. We now have laser treatment but this does not mean that we should be complacent and not look for other means of prevention and treatment. It surely must be worth some research funding or a review of published studies.

IDDT Warns!
The use of Pycnogenol must not be a seen as a substitute for ‘good’ control and because of its powerful antioxidant effects should only be used in consultation with your medical adviser, as indeed should all supplements and complementary medicines. It is also essential that the use of Pycnogenol does not replace essential regular eye examinations.

More information is available on the manufacturer’s website www.pycnogenol.com

Glaucoma

Statistics

• Glaucoma is a leading cause of blindness.
• Glaucoma rarely affects people under the age of forty.
• In the UK it affects 2% of people over the age of forty.
• There is an estimated 250,000 people in the UK with the condition and it is estimated that only half of the people with glaucoma have been detected.

Facts

• Blindness is preventable if glaucoma is diagnosed and treated early enough.
• Glaucoma is not catching and is not caused by diet, work or any other factors.
• Glaucoma can be controlled with treatment but not cured.
• Glaucoma cannot be prevented but having regular eye checks will enable early diagnosis and treatment and this applies particularly to the above categories. In the UK sight tests are free for people with diabetes and for close relatives of people with glaucoma once they are over 40 years old.

What is glaucoma?
Glaucoma is a condition where there is loss of vision due to damage to the optic nerve that carries the images from the retina to the brain. Usually glaucoma is accompanied by an increased pressure in the eye, but not always. This pressure is called the intra-ocular pressure or IOP. It is this pressure that damages the optic nerve.

There are different types of glaucoma:

Chronic open angle glaucoma – this is the most common form of glaucoma. It produces no symptoms – no pain or redness of the eye and the eyesight seems unchanged. It usually affects both eyes and develops slowly so the loss of sight is gradual.

The whole of the contents of the eyeball are nourished by a fluid, called the aqueous humour. This fluid circulates within the eyeball and leaves the eye by small drainage tubes at the front. If there is an obstruction within this system, then the fluid cannot escape and pressure builds up within the eye. It is this persistent increased pressure that may damage the optic nerve and cause vision loss.

Those most at risk of developing open angle glaucoma are:

• People of Afro-Caribbean origin are between 5 and 8 times more likely to have glaucoma and it may come on earlier and be more severe.
• People with a family history of glaucoma are more at risk. There is a 6 times greater risk if a near relative has it.
• People who are very short sighted [myopic] are more at risk.

Acute angle glaucoma – Is where there is a sudden increase in the pressure [IOP] in one eye. The eye becomes red and painful often accompanied by misty vision and seeing haloes around lights.

Secondary glaucoma – This is a group of conditions where the IOP is raised and this is caused by other diseases of the eye.

Congenital glaucoma -Is where glaucoma is present at birth.

Note: it has been thought that people with diabetes are more susceptible to glaucoma. However, recent research suggests that the higher incidence of glaucoma in people with diabetes is more likely to be due to s greater detection rate because people with diabetes often have more frequent regular eye checks than the general population.

Tests for glaucoma

At a high street optometrist – there are 3 tests that should be done to but not all optometrists do all three tests, so check when you make your appointment.

The 3 tests are:

1. To look at the back of the eye and the optic nerve with a bright light [ophthalmoscope]
2. Measurement of the pressure [often called the puffer test]. A raised pressure at this stage does not necessarily mean you have glaucoma.
3. Field of vision test where you are asked to look at a screen with a series of spots of light and you will be asked which ones you can see.

If there are any abnormalities then the optometrist will refer you to your GP for referral to the hospital.

At the hospital – the following tests will take place at your hospital visit:

Measurement of the intra-ocular pressure – The eye is numbed by a drop of anaesthetic and the eye observed through an instrument called a slit lamp. The cornea [the front of the eye] is lightly touched with an instrument that measures the pressure.

One or more of the following tests will also be carried out:

Gonioscopy – This allows the doctor to observe the angle between the iris and the cornea.

Visual field measurement – You sit at a screen and keep your gaze fixed on a central light. Other lights flash on and off and you press a button when you see them. This test detects any blind areas of your visual field indicating where the nerve damage has occurred.

Optic nerve assessment – Drops are put in the eye to dilate the pupil so that the doctor can examine the back of the eye more fully and to record the health of the optic nerve by the appearance of the optic disk. Retinal photographs may also be taken so that these can be kept in your records to establish any changes in the future.

Note: You should NEVER drive yourself to the hospital because the drops used to dilate your pupils leave the vision blurry for a few hours.

Treatment

Eyedrops – The aim of treatment is to lower the intra-ocular pressure and prevent further vision loss. Most people with glaucoma require life-long treatment, usually with eye drops.

Surgery – In some cases the intra-ocular pressure can be reduced by opening up the draining channels with laser treatment or by surgery to make a small drainage hole at the top of the eyeball. In these cases, the need for ongoing treatment may be removed but not all cases are suitable and the majority of people with glaucoma need eye drops for the rest of their lives.

Tablets – In some cases tablets may be given to reduce the amount of aqueous produced. Initially these tablets increase the amount of urine passed.

Glaucoma and exercise – The Medical Director of the Glaucoma Foundation in the US says that there is research that shows that frequent activity such as swimming or brisk walking can lower the pressure within the eye. But he warns against sports that involve turning upside down – certain yoga positions and scuba diving, may raise the pressure. [Reported in Health Which? December 2000]

Glaucoma and driving – If glaucoma is diagnosed then you should inform the DVLA and your motor insurers. It is a condition that should be declared under the item ‘has there been any material change that could affect your driving.’ If you were involved in an accident and you had not declared that you have glaucoma, then you may not be insured and the DVLA could take action because you have not informed them.

More Information about glaucoma can be obtained from:
International Glaucoma Association
Woodcote House
15 Highpoint Business Village
Henwood
Ashford
Kent
TN24 8DH

Sightline (helpline) number: 01233 648 170
Administration number: 01233 648 164
website: www.glaucoma-association.com

Cataracts

Perhaps there are more misunderstandings about cataracts than any other condition of the eye. Many people are frightened and fear that they are going to lose their sight, but understanding what a cataract is helps to offer reassurance of what can be done.

Facts

• Cataracts usually form slowly with a gradual blurring of vision. They usually develop as part of the normal aging process but they can be formed as a result of injury to the eye. Cataracts can be present from birth.
• Cataracts are more common in people with diabetes and can develop at an earlier age than in the general population.
• Cataract cannot be caused by overuse of the eyes and ‘resting’ the eyes will not stop cataracts from developing or getting worse.
• There is no known prevention for cataracts.

What is cataract?
In a normal eye the lens behind iris and pupil is clear and transparent but when a cataract forms the lens becomes cloudy or opaque. This prevents light that passes through the pupil from reaching the retina and the image or picture on the retina is fuzzy and blurred.

Cataracts usually develop in adult life, caused by the normal aging process in which the lens becomes harder and cloudy. As this happens there may be a need to have new, stronger glasses more frequently but when the cataract worsens stronger glasses will not improve vision.

Treatment
Surgery is usually very successful in most people and is performed when the vision has dropped to the point where it is interfering with daily activities. Even though cataracts usually form in both eyes, the surgery is carried out on each eye at different times with the worst eye being treated first.

What is involved in the surgery?
The surgery is usually carried out without an overnight stay in hospital. Most cataract operations are carried out under local anaesthetic and the ophthalmologist performs the operation with a microscope. The lens is removed through a tiny hole in the cornea and a permanent clear plastic lens is implanted. Occasionally very fine stitches are used to close the wound and these may be painlessly removed later. The implanted plastic lens corrects the vision of the eye but many people still need reading glasses after the operation.

Note: for some people a plastic lens implant is not suitable in which case a contact lens is fitted or special glasses are prescribed some weeks after the operation to remove the lens.

After the surgery

• After the operation the eye will be covered for protection for up to a day but it is advisable to wear the protective eye shield in bed for a month after the operation.
• Eyelids must be cleaned regularly and drops are given to prevent infection and help to reduce any post-operative inflammation. The drops may be necessary for two months after surgery.
• Rubbing or touching the eyes should be avoided.
• There may be sensitivity to light and dark tinted glasses are useful.
• It is advisable to avoid heavy work or lifting but people not in strenuous occupations should be able to return to work couple of weeks after surgery.
• The eye takes a few weeks to settle down and you will be advised when it is time to have an eye test for new glasses.

Macular Degeneration

Macular degeneration affects the macula at the back of the eye and impairs central vision. The macular is a small area on the retina where detailed central vision takes place eg reading. The cells in the macula deteriorate and the central part of vision becomes blurred but what is seen around the blurred area is relatively clear because the peripheral area of the retina is not affected.

Who is affected?
Macular degeneration accounts for about 50% of all visual impairment in the developed countries. It usually affects people over 50years and so is known as Age-related macular degeneration [AMD].

There are other forms of macular disease which can affect younger people:

• Macular dystrophy is damage to the macula – it is rare and tends to run in families.
• Macular disease caused by diabetes ie diabetic retinopathy.

Two types of macular degeneration

Dry – Develops very slowly over a number of years with gradual fading of central vision.

Wet – Develops more rapidly.

Symptoms of macular degeneration

• Central vision is reduced and fine detail is difficult to see.
• Straight lines can appear wavy or misshapen.
• Judging distances and heights can be difficult.
• Colour perception may be affected.

Diagnosis
If your optician, or GP suspects that you have AMD, then you will be referred to the hospital where you will have one or more of the following checks:

• Look at a grid test page to check for blind spots.
• A colour vision test.
• Photographs of the back of the eye [this means the doctor has an accurate record for future comparisons.
• Fluorescein angiogram may be used. Your pupils are dilated and a small amount of fluorescein dye is injected into a vein your arm. It circulates through the body and so the network of blood vessels at the back of the eye can be seen and if there are any leaks of the dye, then it shows the vessels are damaged or new vessels have developed. This occasionally causes nausea and the skin yellows for 3-6 hours and the urine for up to 24hours.

Treatment
So far there is no treatment for the dry type of macular degeneration. Laser treatment may occasionally halt the progress of the wet type if you are seen at the early stages of development. New drugs are now also available for the treatment of wet macular degeneration.

Nutritional Supplements
There have been reports that nutritional supplements may help to treat AMD but they cannot cure or restore vision. The February 2006 edition of the Drugs and Therapeutics Bulletin [DTB], an independent journal providing independent evaluations of treatments, expressed concerns that promotion of certain nutritional supplements claiming to improve or slow down macular degeneration may be medicinal and are aimed at people who are worried about macular degeneration.

In particular DTB has reported the claim that ‘Viteyes’ can ‘slow macular degeneration’. DTB says that there is some evidence to support the use of a specific combination of antioxidant vitamins and zinc, the so-called AREDS formula, in specific groups of patients with macular degeneration – those with advanced disease in one eye only but this formula can only be found in a few products – ‘VisiVite Original Formula’, ‘Viteyes AREDS Formula’ and ‘Ocuvite PreserVision’. The use of other nutritional supplements, or use in other groups of people, cannot be recommended.

Warning note: manufacturers based outside the UK can continue to make inappropriate claims for their supplements because they fall outside UK jurisdiction.

DTB’s advice to people with macular degeneration includes stopping smoking and eating a healthy diet rich in green vegetables.

Driving With Eye Conditions

The law requires that you must inform the DVLA in Swansea and your motor insurers if there are any changes in health or sight that could affect your ability to drive safely. Failure to do this could result in prosecution and your motor insurance being invalid.

Meeting the driving standards
To drive a car, you are required to be able to read a number plate at 25 yards or 20.5 metres with both eyes together, in good daylight and with glasses if worn. You must also have an adequate field of vision. The DVLA may require a report from your ophthalmologist about your eye condition. You must NOT drive until your specialist has confirmed that you meet the required standards.

To drive vocational vehicles, the standards are more stringent.

More information can be found in our section on Driving With Diabetes

The Health Professionals Involved in Eye Care

Dispensing opticians – Are qualified to fit and measure for glasses and to examine conditions that affect the outside of the eye. They are not allowed to test the eyes for glasses or to examine the inside of the eye. They are allowed to fit and supply contact lenses to a supplied prescription.

Ophthalmic Opticians or Optometrists – Are different titles for the same qualifications. This group is qualified to fully examine the eyes and to fit ands supply glasses. If there are any abnormalities or suspected abnormalities then they refer the person to their GP or directly to the hospital if it is an emergency situation. They may be ‘high street’ opticians or hospital based.

Note: If you have diabetes and you are having an eye check with an optician/optometrist, it is important that he/she carries out an eye examination with drops to enlarge the pupil so that he/she can observe more of the retina. If necessary, you should ask for this to be done, especially if you are not part of a local retinopathy screening programme.

Consultant Ophthalmologist – This is the hospital consultant to whom the GP refers people with suspected abnormalities and he/she carries out the necessary treatment or surgery.

Remember!
Eye tests are free in the UK for all people with diabetes, for people with glaucoma and their close relatives over the age of 40 and for children and people over 60.

Registering as Partially Sighted or Blind

Diagnosis of retinopathy, or any sight threatening conditionAs we all know, sight is probably one of the most important of the 5 senses that we have and any threat to this is frightening. We all know that retinopathy is one of the complications of diabetes but knowing this is a risk and actually having it diagnosed are totally different things, especially if the diagnosis is of proliferative retinopathy that can threaten sight. Knowing the risk does not prevent the shock of diagnosis, the denial [this can’t be happening to me, the anger, the feelings of guilt perhaps for past indiscretions with food, drink, blood sugar control or the ‘why me?’ feelings. Nor does it prevent the panic at the possibility of changes in lifestyle – just the simple thing of losing your driving licence can mean having to take a whole new look at your life and/or work and that of your family. Perhaps at this stage it is important to remember that early diagnosis and treatment of retinopathy can slow down it’s progression. It is also important to remember that achieving better diabetic control may also slow down the progression. Nevertheless, diagnosis itself can bring about this range of feelings but for the vast majority of people in this situation, there is time to adjust to the diagnosis and to adjust to perhaps looking at the future differently.

Depressing, but maybe we need to take a look…
Understandably some people do not want to read about the complications diabetes because it is upsetting and depressing – perhaps especially those that may affect sight. But the reality is that there are many people already with retinopathy and we cannot ignore their needs – they and their family carers need information and reassurances that there is help available to them. Perhaps by looking at the help and support that is available to people who are partially sighted or blind, it may even help to allay some of the fears we all have.

Registration as partially sighted or blind
Registering is a big step and it may feel like the biggest step you have ever taken. Emotionally it means admitting that you have sight problems that are making your life difficult, but registration could provide you with just the help that you need. If you are in this situation, you may have thought about registering but don’t know what the benefits are or where to start. We hope that this article will give you the confidence to seek the help you need.

What is registration?

• It is entirely voluntary.
• It entitles you to certain benefits and makes it more likely that you will receive the help you need.
• Your local authority keeps a register of blind and partially sighted people in your area. The register is held by the Social Services department or the local voluntary society for the visually impaired acting as an agency for your local authority. Whoever keeps the register it is important to know that it is entirely confidential.
• The purpose of the register is to help local authorities provide people with what they need and are entitled to.

How you register – the first step
If you are under an eye specialist [ophthalmologist] at the hospital then you should speak to him/her to see if your sight makes you eligible for registration. Your eye specialist will certificate you as partially sighted or blind. You should also discuss this with you GP who can refer you for further help.

What are the benefits for you in registering?
Naturally if you are considering registering as partially sighted, you need to know what the advantages are from doing so. You may be entitled to more than you think. There are several main agencies involved that can give you help in all sorts of areas and we are providing some of the details for you.

Benefit agencies
tel: 0845 882 200

Disability Living Allowance
[DLA], claimed before 65th birthday and Attendance Allowance, claimed after the age of 65. These are available to partially sighted and blind people. They help with personal care and mobility.

Additional Income Support
If applicable, is available to partially sighted and blind people

Additional Housing Benefit, Council Tax Benefit or both
Available for both visually impaired and blind people

Incapacity Benefit
Again this applies to visually impaired and blind people and it concerns people who are of working age but are incapable of work.

Social services
Contact your local office

Community Care Services assistance from your local Council
Available for both blind and partially sighted people and includes home help, mobility training, home adaptation or counselling etc.

Help towards residential or nursing home fees
Available for blind and visually impaired people and can provide financial help towards care.

Car Parking Concessions
Available to the blind only – the car does not have to be yours.

Additional Range of concessions that may be available to you:

• Special equipment, a reader or assistance at work
• Railcard and other travel concessions
• Help with telephone installation charges and line rental
• Exemptions from BT Directory Enquiry charges
• Free postage on items marked ‘articles fore the blind’
• Free permanent loans of radios, cassette players and TV sound receivers

The RNIB [Royal National Institute of Blind People] 105 Judd Street
London
WC1H 9NE

helpline: 0303 123 9999
website: www.rnib.org.uk

The RNIB can offer general and information about practical help that may be available to you. IDDT has made contact with the RNIB [Royal National Institute for the Blind] and arranged for any of their information leaflets to be available to you through IDDT. They have large print leaflets to suit the needs of people with visual impairment covering issues such as available financial benefits and products that can improve your quality of life. The RNIB provides a range of leaflets about benefits, services, practical information as well as help with coming to terms with sight loss.

Tips For People With Visual Impairment

Visual difficulties can affect people with or without diabetes but the one thing that insulin-treated people have to do is be able to inject the accurate amount of insulin. While visual difficulties may not prevent many activities, not being able to do your own injections [and blood glucose tests] results in a loss of independence, especially for people who live alone. There are also many everyday things that fully sighted people take for granted but these become difficult or impossible for people with visual impairment.

Alison Blackburn has had diabetes for many years and is visually impaired. She shares with us some of the tips she has picked up over the years that her sight was deteriorating. These have enabled her to maintain her independence and ability to do many of the everyday things in life.

Tips for injecting your insulin

Using an pen injection device

• There are a variety of pens available and they have clicking devices so that you can count the clicks to know how many units you are injecting.
• There are pre-filled disposable pens available for some brands of insulin and this means that you do not have to re-load the pen when a cartridge runs out. This can be easier for people with visual impairment [and for people with hand movement problems].
• Magnifiers are available that fit on to the pen.

Using a syringe to inject
While a pen injector may seem ideal, not everyone likes to use them and some people still prefer to use syringes for their injections. Here are a few of Alison’s tips:

• Syringe magnifiers that slot over a disposable syringe are available.
• If you take the same dose of insulin regularly, score the outside of the syringe at your dose and then draw up to this mark. If you take two different doses, morning and evening, score two syringes but make sure you keep them in different places.
• If seeing the clear insulin is difficult then hold a coloured card behind the syringe for a better contrast making sure that the colour is one that you can see well. If you ‘haven’t enough hands’ pin the card to the wall or a door.
• Syringes are available in different sizes, 100ml, 50ml and 30ml. If your dose is small enough choose the smallest size syringe because the markings are further apart and easier to see – 30ml are easier to see than 50ml and 50ml easier than 100ml.
• A nurse or relative can draw up a week’s supply of insulin in syringes and leave them in the fridge. Again if the dose or type of insulin is different at different times of the day, make sure that the morning syringes are stored on the top shelf and the evening ones on the bottom shelf. If using longer-acting cloudy insulin, then make sure that you roll the syringe about 20 times to ensure that the insulin is mixed properly before injecting.

Tips for the kitchen

• If you make tea or coffee from leaves or powder then use the old-style sugar dispensers that were used in transport cafes. This way you get a limited amount of powder each time you tip up the dispenser. This is also a useful way of measuring custard powder, gravy etc.
• For people with poor eyesight, powders can be stored in large clear coffee jars. If these are held up to the light, it is possible to see the colour of the powder.
• If this doesn’t work then powders and foodstuffs can be stored in jars or canisters that are labeled with tactile buttons which you can feel. Self-adhesive, jelly like buttons can be purchased and you can stick different numbers of jars with different contents or place the buttons on a different part of the jar. Rubber bands work just as well and are cheaper! It is important that other members of the family don’t move the buttons or bands otherwise you may be making coffee with gravy powder!
• When storing foods stack in a regular, particular way so that you know the order.
• Always store cleaning materials well away from food stuffs.
• If you keep cleaning fluids in the house, then smell ALL liquids before you use them for eating or drinking.
• Liquid level indicators are available free to people who are registered blind or partially sighted. They are battery-operated gadgets that clip on the side of a cup or mug and they beep when the liquid is nearly to the top so preventing spilling.
• If you have difficulty with mixing in a cooking bowl [because the contents fly on to the ceiling!] then put the contents into a plastic box with a lid. Fasten the lid well and shake vigorously.

Gas and electricity companies – If visual impairment is developing then gas and electric companies will fit tactile buttons to cookers and other household equipment, such as fires and microwaves. The larger companies are often happy to do this free of charge but if you are registered with Social Services, they should organise this for you.

Quarterly Newsletter and Type 2 & You for blind and visually impaired people

Until December 2013 we recorded our Newsletter and ‘Type 2 & You’ on tape to send to members through the post. However, tapes are soon no longer going to be available, so we have put the publications on our website so that they can be listened to from your computer or from a computer in your local library.

We hope that this change does not cause inconvenience but if you do need help with this, please don’t hesitate to get in touch with IDDT by calling 01604 622837 or email enquiries@iddtinternational.org

Healthy Kidneys

The healthy balance of our body’s chemistry is largely due to the work of our two kidneys that are about the size of a fist and are shaped like beans. They are situated just above the waist in your back and are partly protected by the ribs. You can live a healthy life with only one kidney.

What do normal kidneys do?

• The kidneys get rid of the body’s waste products and excess water as urine. The waste products form from the breakdown of the protein we eat and from normal muscle activity.
• The kidneys also produce hormones that help in the production of red blood cells, build strong bones and help to keep blood pressure under control.

What causes kidneys to stop working?

• Diabetes
• High blood pressure
• Chronic kidney infections
• Severe injury or birth defects
• Certain drugs and other kidney disease

Inside each kidney there are about one million tiny units called nephrons that filter and remove excess fluid and waste products from the blood. The entire body’s blood supply circulates through the kidneys every two minutes. The waste products and the fluid that are filtered out are excreted as urine. The urine travels through tubes, the ureters, into the bladder where it is stored and eventually passes out of the body through another tube called the urethra. If the kidneys fail then the harmful waste products build up in the blood, called uremia, and you feel ill.

Some of the signs and symptoms of kidney failure are:

• Extreme tiredness
• Nausea and vomiting
• Shortness of breath
• Difficulty sleeping
• Swelling of hands, feet and face
• High blood pressure
• Itchiness
• Loss of appetite

The kidneys and blood pressure
One of the most important functions of the kidneys is the control of blood pressure. High blood pressure, hypertension, is very common in people with kidney failure and can occur from the early stages of kidney damage. But it is a ‘chicken and egg’ situation – high blood pressure can cause kidney failure but kidney failure can cause high blood pressure. As people with kidney disease have a significantly increased risk of heart disease compared to the general population, it is important that high blood pressure is treated.

Kidney Disease and Diabetes

One of the long-term complications of diabetes can be kidney disease and most of us are aware that prevention of the development of kidney disease is one of the reasons we need to keep good blood glucose control. Aggressive treatment of blood pressure and stopping smoking, are also methods by which kidney disease can be either prevented or treated.

Facts

• Diabetes is the single most common cause of end-stage renal disease [ESRD] in Europe and the US.
• Between 30 and 50 % of people with diabetes are at risk of kidney disease.
• People with Type 2 diabetes often have microalbuminuria and overt nephropathy shortly after the diagnosis of their diabetes, because diabetes is often present many years before diagnosis.
• The key to preventing kidney damage is early detection of the excretion of protein in the urine and early intervention with treatment.
• People with kidney disease are at higher risk of heart disease. Therefore attention should be given to lowering blood pressure and cholesterol, taking exercise and not smoking.

Definition of kidney disease or nephropathy [its medical name]

Diabetes at Your Fingertips, a very useful book, defines it as:
“In the first instance nephropathy makes the kidney more leaky so that protein [albumin] appears in the urine. At a later stage it may affect the function of the kidney and in severe cases leads to kidney failure.”

What are the ways in which diabetes can affect the kidneys?

• If there is a lot of sugar in the urine, because you are running high for whatever reason, then this can lead to infection that can spread from the bladder to the kidneys. Chronic kidney infections do not always produce symptoms and may only show up on routine clinic tests.
• In both longstanding and poorly controlled diabetes the kidneys have to work hard to get rid of the excess sugar and the small blood vessels in the kidneys can be damaged, in a similar way as the small vessels in the eyes which causes retinopathy. It is logical therefore that if both diabetes and high blood pressure are present the risk to the kidneys is greater.

Does kidney damage produce symptoms?

• In the early stages there are no symptoms and any kidney damage should be picked up in the urine tests carried out at your normal clinic visit when albumin levels are measured.
• If large amounts of urine are lost then this leads to frothing of the urine and a build up of fluid in the body with swelling of the ankles [oedema] but this should be spotted in the routine clinic urine tests.

What is microalbuminuria?
This is the name for the condition described above where abnormal amounts of protein [albumin] leak from the kidneys into the urine. It is the first sign kidney disease may be developing. If kidney damage progresses then there are increased amounts of protein excreted in the urine and this is called macroalbuminuria.

The presence of microalbuminuria is detected by testing all the urine collected during a 24hour period. The test carried out in the laboratory checks the ratio of albumin to creatinine, another substance which, if higher than normal, is a good predictor of kidney damage. Creatinine is a waste product produced as a result of muscle activity. The albumin/creatinine ratio is measured in micrograms per milligram, g/mg. People without diabetes normally excrete less than 25 g/mg per day although this ‘normal’ figure is less in men [18 g/mg] than in women [25 g/mg].

Understanding the results
From personal experience, when my daughter was given the results of her first 24 hour urine collection, we knew they were high but did not know how high. The actual figures were meaningless to us because we didn’t know the normal range and how high they can go. For example a figure of 29 sounds dreadful but not if you look at the worst possible figures! So that other people are able to understand their results and maybe not worry quite so much, with the permission of Diabetes Interview we are printing their table of ranges of albumin/creatinine ratios:

Male

Normal albuminuria	17g/mg or less
Low microalbuminuria	18-65 g/mg
High microalbuminuria	66-250 g/mg
Proteinuria	More than 250 g/mg

Female

Normal albuminuria	25 g/mg or less
Low microalbuminuria	26-29 g/mg
High microalbuminuria	93-355 g/mg
Proteinuria	More than 355 g/mg

Note: Don’t panic at one high result! Results of urine tests for protein can be high for various reasons – for example it could be due to an infection of the kidney, bladder and urethra or if you had been exercising vigorously around the time of the test. If subsequent tests are consistently higher than expected, then your doctor should carry out further tests and, if necessary, treatment.

Your doctor will decide when, and if, you should receive treatment for microalbuminuria. The key to preventing kidney damage is early detection of the excretion of protein in the urine and early treatment to slow down the progression of microalbuminuria to prevent further kidney damage. Microalbuminuria can progress to renal failure if left untreated.

The Use of ACE Inhibitors

ACE inhibitors, are drugs normally used for the treatment of high blood pressure. This is a category of drugs called Angio-Converting Enzyme inhibitors – ACE for short. ACE is an enzyme found in our bodies which activates a hormone called angiotensin causing the blood vessels to constrict, so raising blood pressure and putting pressure on the heart. ACE inhibitors prevent the action of angiotensin resulting in a lowering of blood pressure. However, there is evidence that the use of ACE inhibitors in people who start to show small amounts of protein in the urine, helps to reduce the progression to macroalbuminuria. In other words the use of ACE inhibitors has a protective effect on the kidneys, even in people whose blood pressure is normal.

What does the research show?
A meta-analysis [Ann Intern Med 2001 March ; 134[5] 370-9] was published on this subject. This is an analysis of studies to provide better evidence than just looking at individual studies. In this case, the studies were selected on the following basis:

1. They included at least 10 people with Type 1 diabetes who had microalbuminuria and normal blood pressure.
2. They had a control group who were not treated with ACE inhibitors [placebo group]
3. They had follow up results at least a year later.

12 studies were selected with a total of 698 patients. The results showed:

• The progression to macroalbuminuria was reduced in patients receiving ACE inhibitors.
• After two years the albumin excretion rate was 50.5% lower in treated patients than in those receiving a placebo [no treatment].
• For patients with normal blood pressure, Type 1 diabetes and microabluminuria, ACE inhibitors significantly reduced progression to macroalbuminuria and also increased the chances of regression back to normal where no proteins were found in the urine.
• The beneficial effects of ACE inhibitors were weaker at lower levels of protein excretion.

This has lead to some debate amongst the medical profession about when ACE inhibitors should be prescribed and to whom. While there are differing views on the use of ACE inhibitors to protect the kidneys, it is clear that early detection and early intervention is the way to prevent, treat and even regress problems with protein in the urine. The debate appears to be centred around whether or not people with diabetes should start taking low dose ACE inhibitors before there is any sign of protein in the urine or raised blood pressure to try to prevent the development of microalbuminuria. If people who are at risk of developing kidney disease can be identified, then there appears to be is a case for prescribing ACE inhibitors for these people.

Note: ACE inhibitors can have fairly mild side effects, the common one being an irritating cough. They are not suitable for everyone and so this needs to be discussed with your doctor. They are not recommended for pregnant women.

Kidney Failure

AS we have said above, each kidney contains about I million nephrons to carry out the filtration of the waste products. If the number of nephrons is reduced by damage to the kidneys then the remaining nephrons work harder and the overall kidney function is maintained. However, once a certain amount of kidney tissue has been damaged the surviving nephrons are under increased pressure, become damaged and kidney function declines.

What can be done if my kidneys fail?
If your kidneys fail then you will be treated like any other kidney patient.

• Dialysis. There are two forms of dialysis which remove extra water from the body and the waste products that have built up in the blood. This keeps you ft and well while you are waiting for a transplant.
• Kidney transplantation replaces the lost kidney function. It is a treatment not a cure. For many people it provides the optimum method of treatment because it removes the constraints of dialysis and restores a ‘normal’ lifestyle. There are two barriers to widespread successful kidney transplantations – a shortage of donor organs and rejection after surgery by the body’s immune system.
• Dietetic advice on what foods can help to make you feel better.
• Medications from your doctor to help other problems such as blood pressure and water removal.

Useful Organisations

The British Kidney Patient Association
Bordon
Hants
GU35 9JZ

tel: 01420 472021/2
website: www.britishkidney-pa.co.uk

The National Kidney Research Fund
Kings Chambers
Priestgate
Peterborough
PE1 1FG

helpline: 0845 300 1499
website: www.nkrf.org.uk

Another useful website: www.kidneyoptions.com