Complications of diabetes: screening for retinopathy and management of foot ulcers

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Abstract
This paper is based on Effective Health Care, volume 5, number 4,1 which is based on two systematic reviews undertaken to inform national clinical practice guidelines for type 2 diabetes.2 3 The first part of the article looks at screening for diabetic retinopathy and the second at the prevention and treatment of diabetic foot ulcers. Two of the most common complications of diabetes are visual problems caused by retinopathy, and problems with the feet, particularly persistent ulcers. These result from microvascular and macrovascular complications, often exacerbated by chronically raised blood glucose levels. Around 2% of the UK population are believed to have diabetes, of whom perhaps 200 000 have type 1 (insulin dependent) diabetes, and more than a million have type 2 (non-insulin dependent) diabetes.4Quality in Health Care 2000;9:137–141 Diabetic retinopathy is the leading cause of blindness in people of working age in industrialised countries.5 Twenty years after diagnosis, almost all of those with type 1 diabetes and 60% of those with type 2 diabetes will have some degree of retinopathy.6 The condition is due to small blood vessels in the retina becoming blocked, swollen, or leaky, which causes oedema (swelling) and haphazard growth of new fragile vessels. This process can continue for years without causing visual symptoms or visual impairment; during this period, retinopathy can only be detected by eye examination. If left untreated, bleeding and scarring will lead to progressive loss of vision. The condition can, however, be treated by laser photocoagulation, and large trials have shown that this type of treatment can prevent blindness if it is given before significant visual loss has occurred.7 8 Meta-analysis of studies of screening, followed by treatment of sight threatening retinopathy, shows a high level of effectiveness.9 10 This cuts the frequency of …