Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease

Abstract

This paper identifies best practice recommendations for managing diabetes and sight-threatening diabetic eye disease. The authors provide an update for ophthalmologists and allied healthcare professionals on key aspects of diabetes management, supported by a review of the pertinent literature, and recommend practice principles for optimal patient management in treating visual impairment due to diabetic eye disease. In people with diabetes, early optimal glycaemic control reduces the long-term risk of both microvascular and macrovascular complications. The authors propose more can and should be done to maximise metabolic control, promote appropriate behavioural modifications and encourage timely treatment intensification when indicated to ameliorate diabetes-related complications. All people with diabetes should be screened for sight-threatening diabetic retinopathy promptly and regularly. It is shown that attitudes towards treatment adherence in diabetic macular oedema appear to mirror patients' views and health behaviours towards the management of their own diabetes. Awareness of diabetic macular oedema remains low among people with diabetes, who need access to education early in their disease about how to manage their diabetes to delay progression and possibly avoid eye-related complications. Ophthalmologists and allied healthcare professionals play a vital role in multidisciplinary diabetes management and establishment of dedicated diabetic macular oedema clinics is proposed. A broader understanding of the role of the diabetes specialist nurse may strengthen the case for comprehensive integrated care in ophthalmic practice. The recommendations are based on round table presentations and discussions held in London, UK, September 2016.

Figure 1

Expected diabetes prevalence (diagnosed and undiagnosed) for England in 2015 by gender, ethnicity, and age group. A Public Health England (PHE). Diabetes Prevalence Model. Public Health England, September 2016. Contains public sector information licensed under the Open Government Licence v3.0. The 2016 PHE diabetes prevalence model incorporates more up-to-date data sources and population estimates than previously published diabetes prevalence models. The previous model published in 2012 underestimated undiagnosed diabetes, suggesting that the overall prevalence estimates were probably low.

Figure 2

Percentage of all people with diabetes in United Kingdom and Wales achieving all three treatment targets (HbA1c ≤58 mmol/mol (7.5%), blood pressure ≤140/80 mm Hg, and cholesterol <5 mmol/l) by diabetes type and age group, 2014–2015. National Diabetes Audit 2013–2014 and 2014–2015. Report 1: Care Processes and Treatment Targets. Published 28 January 2016 by the Health and Social Care Information Centre (HSCIC), also known as NHS Digital. Contains public sector information licensed under the Open Government Licence v3.0.

Figure 3

Retinal screening grading pathway, NHS England. Public Health England. Public health functions to be exercised by NHS England. Service specification No 22. NHS Diabetic Eye Screening Programme. Department of Health, NHS England, November 2013. Contains public sector information licensed under the Open Government Licence v3.0. Abbreviations: M0, no maculopathy; M1, maculopathy; R0, no retinopathy; R1, background retinopathy; R2, pre-proliferative retinopathy; R3a, active proliferative retinopathy; R3s, stable proliferative retinopathy.

Figure 4

Characteristic psychological profiles of diabetes patients, covering attitudes to diabetes and its treatment. Three distinct types of diabetes patient were identified, which match DMO patient profiles, with the threat of blindness or experience of visual impairment creating an additional profile—‘Transformed'.

Figure 5

Type 1 and type 2 diabetes: diabetes specialist eye nurse care pathway, University Hospitals of Leicester. Abbreviations: BMI, body mass index; CK, creatine kinase; DR, diabetic retinopathy; FFA, fundus fluorescein angiography; F/U, follow-up; HbA1c, haemoglobin A1c; LDH, lactate dehydrogenase; OHAs, ocular hypertensive agents; TFTs, thyroid function tests; U&E, urea and electrolytes; VA, visual acuity. Reproduced with permission from UHL ophthalmology department.