Diabetic Retinopathy : A re-look at where can we do better

Dr Ian Yeo, Consultant Ophthalmologist, Vitreo Retinal Service, Singapore National Eye Centre

As an vitreoretinal surgeon, I get to manage the patients with the most severe stages of diabetic retinopathy. These patients have somehow been overlooked in our medical system and present very late. Often both eyes have proliferative diabetic retinopathy with one eye presenting with a vitreous hemorrhage. These are not just the old and illiterate patients, many of them are young and educated! It is this very reason that I am writing this article. It pains me to see young patients in the prime of their lives going blind. Even if they do not go entirely blind, many are so severely incapacitated that their normal work becomes impossible, as such their entire lives becomes turned upside down. There must be something we can do for them.

Proliferative diabetic retinopathy with vitreous hemorrhage: don’t wait for your patient’s diabetic retinopathy to become this bad before you send them for eye screening.

Is screening the answer?

It certainly helps to pick up patients early. But screening is only one part of the equation. Once we detect clinically significant disease that require treatment, there is a need for a team approach to manage these patients. No amount of laser and surgery will be able to help a patient with uncontrolled diabetes who makes no effort to control his diabetes.

So control of diabetes is the answer

Yes, but we need to ensure that patients are adequately monitored. It is very surprising to hear from my patients that they have never had any blood tests done except for the occasional finger prick random hypocount. I routinely ask for and conduct my own HBA1c tests to monitor my diabetic patients. I write to their primary care physicians to ask about their patients overall control over the past few years, some never reply to my request, others quickly do a battery of tests and send them to me. Many doctors now monitor their patients better, but some doctors still rely on the random blood sugar only.

Even when faced with a poorly controlled diabetic with a very raised HBA1c, some doctors do not bother to take action. Just telling the patient that their diabetes is not well controlled and prescribing the same medication isn’t going to help the patient at all. What is needed is to have some form of family conference, diabetics that are poorly controlled need some form of family support to help them with diet, exercise and encouragement. Patient and family education is an essential part of diabetic control.

Patients are no angels

Some doctors tell me that they are doing their best but patients do not bother to come for tests except to pick up medication, if at all. Some patients tell me that they have done their very best to control their diets and exercise but to no avail, their diabetes still remain very poorly controlled. In the past, I use to sympathize with such patients, some of these patients become very angry in my clinic lamenting that they have done their utmost but the medication and diet do not work at all. Of late, I have resorted to admitting patients to the ward and checking their blood sugar control myself. It has surprised me time and time again, once admitted and on a low calorie diabetic diet, these so called uncontrolled diabetics became under control!

The problem really still remains that medication alone really is not the cure for diabetes. Patients need to be constantly reminded about diet and the need for exercise and weight control. This unfortunately is easier said than done. I prefer working with immediate family members. Educating the patient together with the family is far more rewarding than working with the patient alone. I make it a point to review all patients with advanced diabetic retinopathy with their family members.

Early detection and good diabetic control

Often patients do not see the need to have their eyes screened. Even worse, some patients with fairly advanced disease choose not to have any laser treatment because in the patients own words:”I can still see well what!” Patients have the misconception that laser makes the eye worse, a message they get from other diabetics whom I have no doubt waited too long before treating their eyes or have not gotten their diabetes under control.

I emphasise to the patients that for diabetic retinopathy, there is a concept of the point of no return. The later you detect the disease, the worse the damage to the eyes. At some point in the disease, the diabetic retinopathy has reached such an advanced stage that despite any form of intervention patients will still end up blind. I tell that to all my patients to implore on them to control their diabetes.

While I have had many successes with patients changing their lifestyle altogether and bringing their diabetes totally under control, regrettably many patients and their family only recognise the importance of good control after a major lifestyle event happens like a stroke, renal failure or amputation.

Diabetic registry to ensure we screen for all

It would be great if we can get a registry for all diabetics in Singapore. This would allow us to screen every single patient for not just diabetic retinopathy but every other potential complication from diabetes. Primary care physicians must be vigilant and insist on routine and regular HBA1c testing as well as diabetic retinal photography to pick up early disease. Once diabetic retinopathy is detected, I would like to see ophthalmologists working closely with the patient’s physician to help the patient to control their blood sugar levels.

Ultimately, the management of diabetes is still a team effort. The team comprises not just the doctors and nurses, but the patient and their family play an intergral part as well. I hope we can all work together to reduce the morbidity from diabetes mellitus.