Systemic and Ophthalmic MANAGEMENT OF DIABETES MELLITUS
Systemic and Ophthalmic MANAGEMENT OF DIABETES MELLITUS
Chris Steele BSc(Hons) FCOptom DCLP DipOC DipTp(IP) FBCLA
Consultant Optometrist Head of Optometry Sunderland Eye Infirmary Sunderland, UK
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Systemic and Ophthalmic Management of Diabetes Mellitus
First Edition: 2019
9789352705870
Printed at
Sam, Isabel, Madeleine and Imogen, my four children.
Anything is possible—never give up.
It is 3 years ago since I was first approached by the original editors of The Eye Essentials series to discuss the possibilities of writing a second edition of the book Diabetes and the Eye, that was first published in 2007 by Butterworth Heinemann. Having initially agreed to start work on this revised edition to the previously published Eye Essentials series, it soon became apparent how much had changed in our knowledge, understanding and management of diabetes mellitus in the past 10 years. Simply updating this original book would not have done justice to all these changes. A significantly expanded new textbook was required with 5 new chapters.
I am an Optometrist by profession and over the past 25 years I have continued to increase my specialist interest in and commitment to medical retina caseloads, involving often advanced clinical roles that relatively few other, nonmedical personnel undertake in a secondary care setting, with the full support of my medical colleagues. The ophthalmic management of diabetic retinopathy has expanded significantly during this time, with many new treatments available, as well as robust screening for diabetic retinopathy in many parts of the world, with the UK leading the way in this regard.
During the planning stages of this textbook I became aware of the limitations to my working knowledge of the systemic medical management of diabetes mellitus. Conversely, it is widely accepted that most doctors, be it general practitioners or hospital-based specialist trainees and consultants, receive extremely limited ophthalmic input to their general medical training, unless they have specifically pursued ophthalmic specialty training to some level, e.g. general practitioner (GP) with special interest, or have specifically chosen ophthalmology as their career path. In a similar way, often their awareness and understanding of ophthalmic management of diabetic retinopathy, as opposed to the systemic management, may be equally limited.
So rather than write a second edition of the original work, I set out to produce a stand alone textbook that would cover all aspects of the Systemic and Ophthalmic Management of Diabetes Mellitus. In doing so my intention was to produce a textbook that would appeal to a broad range of healthcare professionals involved in diabetes care. Put another way, this textbook should contain something for everyone involved in diabetes management.
This book is therefore intended to be an essential introductory reference source for not only optometrists, but also ophthalmology specialist trainees, foundation doctors, specialist registrars in diabetes and metabolic medicine, general practitioners, specialist nurses, medical students, retinal screeners and other healthcare professionals involved in diabetes care. Hopefully it has been written in such a way that gives readers the theoretical, clinical and practical information they need, without being overwhelmed with too much complex detail. For those readers wishing to explore particular areas of interest, there are comprehensive further reading lists at the end of each chapter. Depending on their background some readers may only choose to study certain chapters, whilst others will find every chapter useful.
So why write another textbook on diabetes? The answer is because diabetes is rapidly becoming one of the largest epidemics in the world, with alarming increases in numbers of people worldwide living with diabetes. Consequently, it is imperative that diabetes is taken much more seriously and awareness significantly raised of its potentially devastating effects. Access to appropriate healthcare and diabetes education are key factors in tackling the challenges we are now facing globally. It is vital that each member of the healthcare team fully understands the roles and responsibilities of other members of the team to help ensure seamless continuity of care for people with diabetes. There are few books currently available that combine Systemic and Ophthalmic Management of Diabetes. With this new textbook I hope I address this shortfall.
Diabetes is presented in various forms with some types being more prevalent than others. Currently diabetes mellitus is usually classified into two main types: type 1 (T1DM) and type 2 (T2DM). The most common type of diabetes in the general population is T2DM that often develops from prediabetes. This is inexorably linked to unhealthy diets, weight gain and very concerning rising levels of obesity caused mainly by high dietary sugar intake. There are several other important factors as well. These main types of diabetes and their causes are discussed in detail in this textbook. Latest research findings from Scandinavia, however, suggest that these two main types of diabetes could actually be classified as five separate diseases. A refined classification could in the future give rise to a powerful means of individualizing or tailoring treatment strategies. This will identify people with diabetes who carry the greatest risk of complications at diagnosis. A total of 5 distinct clusters of patients with diabetes has been suggested (Ahlqvist et al., published in the Lancet, March 2018): “Cluster 1” is generally comparable to T1DM and represents a relatively severe autoimmune form of diabetes. “Cluster 2” refers to people with diabetes who have severe insulin deficiency when the failing immune system is not the cause. “Cluster 3” includes those people with severe insulin resistance related to being overweight. “Cluster 4” is mild obesity related diabetes. Finally, “cluster 5” includes mild age-related diabetes.
This latest research suggests that the three most severe forms of diabetes mellitus (1–3) require a more intense approach to treatment than the other relatively milder clusters (4 and 5). This suggested new classification could help personalize treatment strategies ever more so in future, thus leading to what has been described as “precision medicine” in diabetes for the first time. Many of the latest clinical guidelines from various parts of the world have already emphasized the need for individualizing care for diabetic patients. This not only applies to the systemic management of diabetes, but also increasingly to ophthalmic management. This involves various established and emerging pharmacological treatments (in addition to laser treatments) now available for diabetic retinopathy and maculopathy in particular. These increasingly utilize, e.g. treat and extend (T&E) regimes, which are all discussed in detail in this textbook.
I hope readers, from a broad range of healthcare backgrounds, find this textbook accessible and valuable in their diagnosing, management and general understanding of diabetes mellitus. The enormous global health threat caused by diabetes mellitus and its consequences for demands on, often very limited, healthcare resources around the world, should not be under-estimated, unless more is done to tackle this rapidly growing problem.
I could not have completed this book without the continued support of all my contributors and Jaypee Brothers Medical Publishers, New Delhi, India, who have all helped make this new textbook a reality.
Chris Steele.
Acknowledgments
During my career, I have been fortunate to work with some inspirational and very supportive colleagues, who, over the years have enabled and encouraged me to develop extended clinical roles for both myself and the team of dedicated hospital optometrists with whom I work.
In particular, I am indebted to David Steel, Consultant Ophthalmologist and Vitreoretinal Surgeon and Jim Deady, Consultant Ophthalmologist (now retired), for all their support over the past 24 years in helping me to establish and develop very advanced optometric medical retina clinical roles, which are probably unique to Sunderland Eye Infirmary in their scope and extent.
I am also most grateful to my other medical retina consultant colleagues who have all provided help and encouragement during the writing of this book and who continue to provide invaluable support and guidance within the medical retina team at SEI, within which I am honored to work. These are Maged Habib, Ajay Kotagiri, Jonathan Smith, Deepali Varma and Teresa Sandinha (now at St Paul's Eye Unit, Royal Liverpool Hospitals). These individuals are not just colleagues, but people I consider my friends.
Much has changed in the systemic and ophthalmic management of diabetes mellitus in the last few years, which I hope is reflected within these pages. I have been fortunate enough to be able to call on the extensive skills and experience of some of my Consultant Diabetes and Metabolic Medicine colleagues within City Hospitals Sunderland NHS Foundation Trust, who have collectively provided expert clinical guidance on the content and accuracy of the earlier chapters regarding the systemic management of diabetes (chapters 2–6) and diabetes in pregnancy (chapter 14). Of course not being medically qualified myself, I am very grateful to Peter Carey and Rahul Nayar for their help and influence, which was greatly appreciated.
I also wish to thank Helen Bone and her team within the Sunderland and South of Tyne Diabetic Eye Screening Programme, as well as Hugh Harris, Medical Photographer at SEI. They have helped me with proofreading and collecting many of the images used throughout this textbook.
I would also like to thank Sandip Doshi, PhD for initially inspiring and encouraging me to write this book.
My sincere gratitude to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Ms Chetna Malhotra Vohra (Associate Director—Content Strategy) and production team of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, in publishing the book.
Finally, my special thanks go to my wife Fiona, for her help, understanding and support through the many long hours it has taken in the writing of this textbook.