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Type 1 diabetes and retinopathy: no sweet talk

The number of diabetics worldwide has risen from 108 million in 1980 to 463 million today, roughly 10% of the total population of Earth. The international diabetic federation is expecting this number to rise to 700 million by 2045, and that is indeed alarming. Out of the total diabetic population, Type 1 diabetes contributes to being approximately 5-10%. Type 1 diabetes is the most common endocrine and metabolic condition in childhood today, especially in underdeveloped and developing nations. It is a distressing disease, especially in these nations, since it is under-diagnosis and raises financial concerns for treatment. The average monthly expense for a Type 1 diabetic comes to be anywhere between Rs 3000 to Rs 10000 per month including doctor consultation fees and insulin cost, which is ironically more than the monthly income of 40-50% Indians according to the recent PLFC data. Such an economic crisis leads to increased physical, metabolic and psychological complications, which turn out to be even more hazardous to control. then a pound of cure.”

Type 1 diabetes is a genetic condition where the beta cells of the pancreas are unable to produce insulin, a hormone required for the body to use blood sugar. This disease involves more than 50 genes found to date. The risk of a child developing type 1 diabetes is about 5% if the father has it, about 8% if a sibling has it, and about 3% if the mother has it. If one the identical twin is affected there is about a 40% to 50% chance the other will be too. The classical symptoms of the disease include frequent urination, increased thirst and hunger, and weight loss. Eventually, it targets the end organs of the body that is the eyes, the kidneys, and the heart which in turn lead to vicious tribulations. “Doctor, can diabetes can affect my eyes too?!” This is a very common question addressed by our patients in the routine OPDs. Patients are more than often stunned to hear that the cause of loss of their vision is related to their diabetes status, and this is clearly because of a lack of awareness amongst the general population. The problems due to altered sugar can be as minimal as a frequent change in glasses or constant occurrence of infection of the lid (stye, chalazion) to complications like cataract formation, diabetic retinopathy, and retinal detachment, which can often lead to irreversible loss of vision.

Talking about diabetic retinopathy, the most vital risk factors for occurrence of retinopathy is the duration of diabetes, overall control over the years, associated co morbidities like high blood pressure/cholesterol, kidney disease and chronic smoking and tobacco use. Earlier diagnosed and managed, the chances of complications turn minimal over the years to come.

Now let’s understand how diabetes affects our eyes. The blood vessels of the eye are like pipes carrying high-speed liquid and are normally coated with an insulating layer around them, so that the liquid does not leak out during the flow. With an increase in sugar, there are 2 changes that occur. First, the speed of flow decreases as the blood gets thickened, and second, the walls of these vessels weaken over time. Eventually, the fluid leaks out and accumulates on the retina, the light-sensing organ of the eye. This condition of fluid accumulation is called diabetic macular edema. If not treated on time, it can lead to permanent damage to the light-sensing cells of the retina (photoreceptors), thus causing vision loss. All these changes constitute the Non-Proliferative Diabetic Retinopathy (NPDR).

Retina is a tissue which needs a very high amount of blood supply to function normally. Over a period of time, these damaged blood vessels turn frail and stop functioning, leading to lack of blood supply to the retina. Since there is no food for the soul of retina, it starts dying. The brain sees this misery and initiates a different mechanism, wherein it produces new vessels so that it could supply nutrients and blood to the dying retina. Unfortunately, these new vessels are very fragile and they tend to bleed easily, causing retinal and vitreous hemorrhage. This stage is called Proliferative Diabetic Retinopathy (PDR). If not treated in time, it causes massive bleeding inside the eye and lifting up of retina, which is called retinal detachment and which can lead to irreversible loss of vision.

Coming to the management of diabetic retinopathy, it has 3 wings

  1. Prevention: The first and the most crucial aspect is prevention. It is mandatory for
    Type 1 diabetics to have a comprehensive eye check up every year. It includes checking
    of vision, refraction, intraocular pressure, anterior segment and retina evaluation. A
    check over systemic status is imperative, and the communication with a doctor should
    be handy. A patient with Type 1 diabetes is supposed to maintain HBA1c of <6.5%,
    which has to be checked at least twice a year if not more frequently. Regular exercise,
    brisk walking for 30 minutes a day and involving oneself in sports are highly effective in
    maintaining overall control. An important aspect of any diabetic diet is consistency. To
    maintain a good sugar level, it’s important not to skip a meal, eat small meals at regular
    intervals preferably at the same time every day, and avoid junk, processed and canned
    food. Fruits and nuts travel easily, and a box of chocolates and are great to have on hand
    in times of hypoglycemic crisis. A healthy breakfast can always get your blood sugar back
    up after a night’s rest. Avoidance of smoking, consumption of tobacco and alcohol are
    absolute musts. So the secret is maintaining a balance between your diet, physical activity and medication. It’s not uncommon to see patients with Type 1 diabetes with not even a single speck of complications even after 30 years of the disease, because of a well maintained excellent control via insulin, lifestyle and diet.
  2. Medical management: The management pattern over the years has drastically improved with advancement in drug molecules and techniques. The treatment is based on the pathology and the stage of the disease, and to visualize these changes, we have imaging modalities like the optical coherence tomography (OCT) and the fundus fluorescein angiography. OCT is basically the CT scan of the eye, where we can measure quantity and area of accumulated fluid and can visualize the damage in the retinal layers. FFA is an invasive technique where we inject a dye and look out for various kind of pathological changes occurring on the retina. Today, OCT plays a major role in deciding the type of treatment. If the fluid is visualized on OCT (macular edema),
    we need to reduce the fluid with help of injections inside the eye, which are called intravitreal injections (Anti VEGFs/steroids). If the fluid keeps on recurring, we need to inject frequently till the disease process has stagnated. If there is formation of new vessels (neovascularization) (proliferative stage), we need to destroy these vessels with the help of laser treatment, so that they do not bleed in future. Of course, the
    treatment pattern is not as graceful and straightforward as it sounds. Each and every patient presents differently, and the treatment protocol has to be moderated by the doctor and tailored according to the findings present in each patient, making it case specific.
  3. Surgical management: If the disease is not treated in the early stage, it progresses to a stage of proliferative diabetic retinopathy. For understanding this process, imagine you have a cut and active bleeding on your arm. If you don’t press and stop the bleed, over a period of time, the blood becomes blackish there and forms a clot which is adherent to the skin. Now at this stage, if you try scratching and removing the clot, your skin comes off along with the clot. Similar is the mechanism that occurs inside the eye. The new
    vessels start bleeding on the retina and in the vitreous cavity causing hemorrhage. If not addressed early, the blood starts clotting up and gets adherent to the retina, eventually leading to traction and pull of retina causing a retinal detachment. These cases need surgical intervention, as we need to clear the blood and place the detached retina back to its normal position. Unfortunately, once a retinal detachment occurs, the visual
    rehabilitation is poor and thus it is best that we prevent such an occurrence.

The psychological aspect of the disease is often missed with most of the emphasis given on the strict maintenance of blood sugar. Since most of the patients are diagnosed in adolescent age, adaptation to this condition is often difficult and they are greater risk for emotional and behavioral problems. The treatment burden pervades daily life, complicating other challenges of adolescence, and the regimen often becomes the focus of parent-adolescent conflict, leading to accumulation of stress and further worsening of the disease. Often these people face challenges like bullying at school for using injections, job attaining hardships or marriage proposal rejections. It is thus important for the society to eradicate the stigma of being a diabetic, as these individuals are as normal as others. Maintaining mental and emotional health is extremely indispensable for good diabetes management, and it can be done only if the surroundings are healthy. Feeling physically good is more than half the battle won, as feeling good about yourself allows you to take better care of yourself. It should always be remembered that good compliance can only come when there is good adaptation.

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