jurnal diabates retinopati

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Diabetic retinopathy is a common

microvascular complication o

diabetes (Donnelly et al, 2000).

It is also the leading cause o blindness in

people o working age in the UK (Kohner

et al, 1996), with an estimated prevalence in

people with diabetes o almost 60% (Watkins,

2003). Through optimising some o the risk

actors o diabetic retinopathy, the progression

o retinopathy can be minimised (Diabetes

Control and Complications Trial Research

Group, 1993; UK Prospective Diabetes Study

Research Group, 1998).

As early as 1997, the worldwide prevalence

o diabetes was predicted to increase two- to

three-old by 2010 (Amos et al, 1997). There

are now approximately 2.5 million people

in the UK with diabetes, and this fgure isexpected to rise to 4 million by 2025 (Diabetes

UK, 2010).

With the expected increase in the prevalence

o diabetes in the coming years, the burden o

diabetic retinopathy workload and the number

o people aected by retinopathy is expected to

rise accordingly.

In recognition o these actors, the Diabetes

Eye Nurse Project – a joint venture between

the ophthalmology and diabetes departments

at the University Hospitals o Leicester NHS

Trust – was undertaken to optimise the care

o people with diabetes and related eye disease.

This article describes the project and the results

o a subsequent audit undertaken to evaluate

its eectiveness. Box 1 outlines the fve stages

o diabetic retinopathy and Figure 1 shows a

schematic diagram o the eye.

Retinal screening in LeicestershireRetinal eye screening is an integral part

o diabetes care, and annual screening is

Diabetic retinopathy:

Role o the diabetesspecialist eye nurse

Author details can be oundat the end o this article.

Traditionally, there is minimal cooperation between ophthalmology and diabetes departments. However, during the implementationphase o the diabetes National Service Framework in Leicestershire,people with diabetes expressed a wish or a “joined-up” diabetesservice, giving rise to the Diabetes Eye Nurse Project – a joint venture between the diabetes and ophthalmology departments.

The project has reduced the mean HbA 1c and serum lipid levels ina cohort o more than 100 people with diabetic eye disease, thereby reducing the risk o progression o the condition and other micro-and macrovascular complications. This article reviews this initiativeand demonstrates the value o a diabetes specialist eye nurse.

Article points

1. The Diabetes EyeNurse Project – a jointventure between theophthalmology anddiabetes departments atthe University Hospitals o Leicester NHS Trust – wasundertaken to optimise thecare o people with diabetesand related eye disease.

2. An audit was undertakento evaluate the eectivenesso the service in reducingHbA

1cand lipid levels over

the frst 12 months.

3. Glycaemic controlimproved in all cohorts,as did serum lipid levels.

4. Diabetes eye care deliveredby a diabetes specialist eye

nurse is a new, innovativeservice and is one o themany good examples o theexcellent multidisciplinary approach to the care o people with diabetes.

Key words

- Diabetes specialisteye nurse

- Eye- Ophthalmology - Retinopathy

Sabera Khan, Sam Wong, Rosi Gorrod,

Ismail Gangat, Stephen Hiles, JamesDeane, Ian Lawrence

292 Journal o Diabetes Nursing Vol 14 No 8 2010



recommended or all people with diabetes (NICE, 2004; 2008). In

people with type 1 diabetes, retinopathy develops gradually over timeand it is unusual or any changes to be seen within the frst 5 years. In

comparison, one third o people with type 2 diabetes may already have

some orm o retinopathy at diagnosis. It is thereore important that all

people with diabetes have access to retinal screening when diagnosed.

Retinal screening is dierent rom a general eye examination at the

opticians, which ocuses on the general health o the eye and whether

the person can see properly. I spectacles are required, the correct ones

are then prescribed. It is thereore important to highlight to people

with diabetes that they still need to visit the optician in addition to

their annual retinal screening i they wear spectacles.

The English National Screening Committee Programme or

Diabetic Retinopathy (ENSPDR, 2006) requires all retinal screenersto have either a NVQ or a Diploma in retinal screening. Locally, the

diabetes specialist eye nurse (DSEN) is responsible or the training,

assessment and mentoring o the retinal screeners. In addition, the

DSEN ensures that the screeners are able to understand the principles

and practice o testing the individual’s visual acuities and instilling

the correct eye drops. Once the competencies are met, the screeners

are then registered to undertake the City & Guilds Level 3 Certifcate

in Diabetic Retinopathy Screening.

In Leicestershire, there are approximately 47000 people with

diabetes. To cater or this population there is a systematic diabetic

eye screening service delivered in primary care. The University o Leicester NHS Trust employs 22 retinal screeners who are

placed in GP surgeries to carry out digital retinal imaging, as

recommended by the ENSPDR (2006).

Following assessment and documentation o visual acuity, the

individual’s pupils are then dilated. Images captured are initially

graded by the screeners and then by the ophthalmologist. People with


Diabetic retinopathy: Role o the diabetes specialist eye nurseACTOS ® pioglitazone

Prescribing Information

(Refer to Summary of Product Characteristics before prescribing) Actos ® tablets

(pioglitazone) Presentations: Actos 15mg tablets containing 15mg pioglitazone as

hydrochloride - blister packs of 28 EU/1/00/150/001 £25.83. Actos 30mg tablets containing

30mg pioglitazone as hydrochloride - blister packs of 28 EU/1/00/150/004 £35.89. Actos45mg tablets containing 45mg pioglitazone as hydrochloride - blister packs of 28

EU/1/00/150/012 £39.55. Indications:Monotherapy treatment of Type 2 diabetes mellitus inpatients inadequately controlled by diet and exercise for whom metformin is inappropriate

because of contraindications or intolerance. As dual oral therapy in patients with insufficientglycaemic control despite maximal tolerated dose of oral monotherapy, in combination with

either metformin (particularly in overweight patients) or a sulphonylurea (in patients for whommetformin is not tolerated or contraindicated). As triple oral therapy with metformin and a

sulphonylurea in patients (particularly overweight patients) with insufficient glycaemic control

despite dual oral therapy. In combination with insulin in patients with insufficient glycaemiccontrol on insulin for whom metformin is not tolerated or contraindicated. Dosage: 15mg or

30mg once daily with or without food. Dose may be increased in increments up to 45mg oncedaily. In combination therapy with insulin the current insulin dose can be continued. If patients

report hypoglycaemia, the dose of insulin should be decreased. Elderly & renal impairment(Cl creatinine > 4 ml/min): No dosage adjustment required . No information is available from

dialysed patients therefore pioglitazone should not be used. Children and adolescents(under 18 years): Not recommended. Contraindications: Hepatic impairment.

Hypersensitivity. Cardiac failure or history of cardiac failure (NYHA stages I to IV). Diabeticketoacidosis.Warnings and precautions:Can cause fluid retention, which may exacerbate

or precipitate heart failure. Observe patients for signs and symptoms of heart failure, weight

gain or oedema particularly those with reduced cardiac reserve or on insulin. Discontinuepioglitazone if deterioration in cardiac status occurs. For patients with at least one risk factor

for congestive heart failure, start therapy with the lowest dose of pioglitazone and increasegradually. Concomitant insulin administration may increase the risk of oedema. Check liver

enzymes before starting treatment. Following initiation it is recommended that liver enzymesbe monitored periodically based on clinical judgement. Do not start treatment in patients with

increased baseline liver enzyme levels (ALT > 2.5 x upper limit of normal [ULN]). If ALT levelsincrease to 3 x ULN, reassess as soon as possible. If ALT levels remain > 3 x ULN or jaundice

is observed, discontinue therapy. If symptoms suggest hepatic dysfunction, check liverenzymes. Advise patients to adhere strictly to a calorie-controlled diet and monitor weight. In

some cases, an increase in weight may be a symptom of card iac failure. Small reductions inhaemoglobin and haematocrit, consistent with haemodilution have been noted. Treatment inpatients with polycystic ovarian syndrome may result in ovulation. If a patient wishes to

become pregnant or if pregnancy occurs, discontinue treatment. An increased incidence inbone fractures in women has been observed in a pooled analysis of safety data involving

pioglitazone treatment. The risk of fractures should be considered in the long term care ofwomen treated with pioglitazone. Interactions: Use with caution during concomitant

administration of cytochrome P450 2C8 inhibitors (e.g. gemfibrozil) or inducers (e.g.rifampicin). Monitor glycaemic control. Pregnancy and lactation: Do not use. Potential risk

unknown. Undesirable effects: Suspected adverse reactions reported as more than an

isolated case in double-blind studies listed below. Very common: >10%, common: 1-10%,

uncommon: 0.1-1%, rare: 0.01-0.1% and very rare: < 0.01%. In monotherapy: Common:visual disturbance, upper respiratory tract infection, weight increased, hypoaesthesia.

Uncommon: sinusitis, insomnia. With metformin: Common: anaemia, weight increased,

headache, visual disturbance, arthralgia, haematuria, erectile dysfunction. Uncommon:

flatulence.With sulphonylurea: Common: weight increased, dizziness, flatulence. Uncommon:glycosuria, hypoglycaemia, increased lactic dehydrogenase, appetite increased, headache,

vertigo, visual disturbance, sweating, proteinuria, fatigue. With metformin and sulphonylurea:

Very common: hypoglycaemia. Common: weight increased, blood creatinine phosphokinase

increased, arthralgia. With insulin: Very common: oedema. Common: hypoglycaemia,bronchitis, weight increase, back pain, arthralgia, dyspnoea, hear t failure. Oedema reported

in 6-9% of patients on pioglitazone over one year, compared to 2-5% in the comparatorgroups (metformin and sulphonylurea). Oedema was generally mild-moderate and usually

did not require discontinuation of treatment. In most clinical trials, reduced total plasmatriglycerides and free fatty acids, and increased HDL-cholesterol levels were seen, with small,

but not clinically significant, increases in LDLcholesterol levels. In clinical trials the incidence

of elevations of ALT > 3 x ULN was equal to placebo. In an outcome study of patients withprior major macrovascular disease, the incidence of heart failure was 1.6% higher with

pioglitazone than with placebo, when added to therapy that included insulin. However, this didnot lead to an increase in mortality. Rare cases of elevated liver enzymes and hepatocellular

dysfunction have occurred in postmarketing experience, although causal relationship has notbeen established. There have been a small number of post marketing reports of macular

oedema. Be alert for disturbances in visual acuity. An increased incidence in bone fracturesin women has been observed in a pooled analysis of safety data involving

pioglitazone treatment.

Please refer to the summary of product characteristics for details on the full side-

effect profile of Actos. Adverse events should be reported. Reporting forms and

Information can be found at www.yellowcard.gov.uk . Adverse events should alsobe reported to Takeda UK Ltd.

PI Date Code: Jan 2010 Legal category: POM. MARKETING AUTHORISATION HOLDER:

Takeda Global R & D Centre (Europe) Ltd. Takeda UK Ltd. is responsible for the sale andsupply of ACTOS in the UK. Actos is a registered trademark owned by Takeda

Pharmaceutical Company Ltd. For further information contact: Takeda UK Ltd. Takeda House,Mercury Park, Wycombe Lane, Wooburn Green, High Wycombe, Bucks HP10 0HH.

Tel: 01628-537900, Fax: 01628-526617. AC091241

Please find more information at www.T2Dresource.co.uk

1. Campbell IW. Br J Diabetes Vasc Dis 2009; 9: 53-63.

2. Tan et al. Diabetes Care 2005; 28: 544–550

3. Belcher et al. Diabetes Res Clin Pract 2005; 70: 53 – 62

4. National Institute for Health and Clinical Excellence Type 2 diabetes—themanagement of type 2 diabetes. Clinical Guideline 87. London: NICE, 2009

5. Haffner, et al. Diabetes Care 1999; 22: 562-568

6. Lincoff et al. JAMA 2007; 298: 1180-11887. Takeda Uk Ltd. Actos Summary of Product Characteristics.

accessed at www.emc.medicines.org.uk. accessed date June 2010

8. Data on File at Takeda UK Ltd. AC200901

9. IMS Health, BPI, December 2007 - January 2010

References:

Code: AB100728jDate of Preparation: September 2010

Figure 1. Schematic diagram o the human eye.

Cornea

Anterior chamber(aqueous humour)

IrisPupilCiliary muscles

Suspensory ligamentLens

Vitreous humour

Retina

Choroid

Sclera

Optic disc

Fovea

Retinal blood vessels

Optic nerve



ungradeable images, or images that highlightsome indication o retinopathy, are invited to

a retinal screening clinic in secondary care or

urther examination.

Retinopathy is diagnosed through undus

examination (examining the back o the eyes)

by instilling dilating drops (tropicamide 1%

and phenylepherine 2.5%). The various stages

o retinopathy progression (Box 1) are then

diagnosed and recorded in the individual’s case

notes. Annual retinal screening is important as

this is how retinal changes are picked up.

Laser therapy

It is important to inorm people with diabetes

that laser treatment is not a cure and cannot

restore damaged vision, but can help prevent or

delay urther damage to the retina in over 90%o cases (Diabetic Retinopathy Study Research

Group, 1981). In most cases it is possible to

preserve the reading and driving vision.

There are three types o laser therapy: pan-

retinal photocoagulation, grid photocoagulation

and macula ocal photocoagulation.

Panretinal photocoagulation

Panretinal photocoagulation is usually used or

the treatment o prolierative retinopathy. Ater

instilling dilating drops and using a contact

lens that enlarges the view o the retina, theophthalmologist points a tiny laser beam into

the abnormal part o the retina. Small bursts o

laser dots are applied all over the retina (except

or between the optic disc and ovea) to stop the


1. Background retinopathy

This occurs in most people with diabetes approximately 20 years ater the onset o the condition and can thereore aect all age groups rom

late teens onwards. Usually, no symptoms present until there is macular involvement resulting in impairment o central vision to the eye

(Figures 2a and b ). To ensure that the eye in those diagnosed with early changes does not deteriorate urther, the person is discharged back to

the retinal call and recall services. Such individuals are advised to have annual check-ups to assess the degree o retinopathy (unduscopy − dots,blots and hard, waxy exudates), to control their cholesterol levels, and also given dietary advice and treatment rom the diabetes clinic.

2. Preprolierative retinopathy

This may develop in the eyes with background retinopathy only (Figure 3 ). The eye requires close observation but is not usually treated

unless regular ollow-up is not possible or vision in the ellow eye has been lost to prolierative disease (Scott, 2008).

3. Prolierative retinopathy

This is the main cause o visual impairment in people with type 1 diabetes. It occurs sooner ollowing the diagnosis o type 2 diabetes, possibly

because the diabetes has gone on or longer undetected. In this orm o retinopathy, the blood vessels grow into the vitreous humour and

bleed, causing a vitreous haemorrhage (Figures 4a and b ). Laser therapy, i required, can be used to treat prolierative retinopathy and aims to

prevent neovascularisation occurring. A laser beam is applied to the retina, as a dead retina will not encourage new vessel growth – scotomas

(areas o lost or depressed vision) present cause little visual impairment (Early Treatment Diabetic Retinopathy Study Research Group, 1985).

Vitrectomy (surgical intervention) can be used in severe cases to remove the haemorrhage and provide a scaold into which the new vessels can

grow. I perormed early in the development o retinopathy, laser therapy can help to improve visual recovery.

4. Advanced retinopathy

This is the end result o uncontrolled prolierative retinopathy (Figure 5 ). The eye can develop retinal tears or a detached retina, which

can lead to blindness. Early vitrectomy and also treating neovascular glaucoma (involvement o the iris with major risk o acute glaucoma)

improves visual recovery in people with prolierative retinopathy and severe vitreous haemorrhage (Mohamed et al, 2007). The individual

also requires management o visual impairment (support rom eye clinic liaison ofcers).

5. Maculopathy

This is the main cause o visual impairment in people with type 2 diabetes (Figure 6 ), and is classifed into our types:

lFocal/exudative.

lCystoid/diuse.

lIschaemic.

lMixed.

Only the ocal/exudative and mixed type o maculopathy can be treated by laser. Cystoid/diuse maculopathy is difcult to treat by

laser and ischaemic maculopathy cannot be treated.

Box 1. The fve stages o diabetic retinopathy.

Diabetic retinopathy: Role o the diabetes specialist eye nurse

Page points1. Retinopathy is diagnosed

through undusexamination (examiningthe back o the eyes) by instilling dilating drops(tropicamide 1% andphenylepherine 2.5%).

2. It is important to inormpeople with diabetes thatlaser treatment is not acure and cannot restoredamaged vision, but can

help prevent or delay urther damage to theretina in over 90% o cases.



growth o new blood vessels (Figure 7 ). This isusually carried out over several appointments

within an outpatient eye clinic. Fluorescein

angiography is perormed in-between sessions to

pinpoint remaining aected areas or to establish

the need or urther laser treatment.

I the vision is stabilised ater a ew sessions

o laser treatment, the possibility o urther

new vessel ormation is relatively unlikely.

However, the need or annual screening is still

recommended to monitor urther changes.

Grid photocoagulationGrid photocoagulation is used or treating

exudative maculopathy. Laser spots are applied

in a grid pattern lateral to the ovea. In cases

o retinal haemorrhage that do not clear using

grid photocoagulation, surgical intervention

(vitrectomy) may be perormed under a general

anaesthetic to remove abnormal tissue. Vision

can improve signifcantly but it is a major

operation and can be avoided i eective

screening and laser treatment is maintained.

Macular ocal photocoagulation

Focal photocoagulation o clinically signifcant

macular oedema substantially reduces the risk

o visual loss. Focal treatment also increases

the chance o visual improvement, decreases

the requency o persistent macular oedema

and causes only minor visual feld loss (Early

Treatment Diabetic Retinopathy Study Research

Group, 1985). Clinically signifcant macular

oedema is defned as retinal thickening that

involves or threatens the centre o the macula

(even i visual acuity is not yet reduced) and is

assessed by stereo contact lens biomicroscopy or

stereo photography.

Role o the DSEN:The Diabetes Eye Nurse Project

Traditionally, there is little or no major

cooperation between ophthalmology

and diabetes departments. During the

implementation phase o the diabetes National

Service Framework (NSF; Department o

Health [DH], 2001) in Leicestershire, people with diabetes expressed a wish or a “ joined-up”

diabetes service. They highlighted a need or

diabetes expertise in the ophthalmology clinics,

where many people were attending with diabeticeye disease, including diabetic retinopathy.

Pump-priming unding through a

pharmaceutical company led to the appointment

o a DSEN working in both the diabetes and

ophthalmology clinics in 2004. This new

routine service is in line with Standards 10, 11

and 12 o the diabetes NSF (DH, 2001):

lStandard 10: all young people and adults with

diabetes will receive regular surveillance or

the long-term complications o diabetes.

l Standard 11: the NHS will develop,implement and monitor agreed protocols and

systems o care to ensure that all people who

develop long-term complications o diabetes

receive timely, appropriate and eective

investigation and treatment to reduce their

risk o disability and premature death.

lStandard 12: all people with diabetes requiring

multi-agency support will receive integrated

health and social care.

Most people are reerred rom the district

retinal screening service; some rom other diabetes

retinal clinics. The other ophthalmologists were

introduced to the diabetes eye service and the

reerral protocol via a presentation delivered by

the DSEN (Box 2 ). This collaboration has helped

raise the profle o the diabetes eye service as the

eye department now consists o 14 consultant

ophthalmologists, maintaining varied specialist

eye clinics, and who have been able to access

diabetes expertise as needed.

Following initial assessment o the person by

the DSEN, other elements are then reviewed:

l Baseline biomedical parameters (HbA 1c level,renal unction, lipid profle and urine albumin

excretion).



Figure 2. Normal retina with no diabetic retinopathy (a); background diabetic retinopathy with microaneurysms,haemorrhages and exudates (b). Copyright 1st Retinal Screening Ltd.

a

b

Figure 3. Preprolierative diabetic retinopathy with cotton wool spots, intraretinal microaneurysm

and multiple blot haemorrhages. Copyright 1st Retinal Screening Ltd.

Figure 4. Prolierative retinopathy with new vessels at the optic disc (a); prolierative retinopathy with preretinal and vitreous haemorrhages. Copyright 1st Retinal Screening Ltd.

a b



l

Blood pressure.lLiestyle (including smoking cessation, basic

dietary review, physical activities and alcohol

consumption).

l Current medications.

l Provision o individual diabetes education,

including sel-monitoring o blood glucose.

Intervention is provided or any identifed

diabetes-related problems to delay urther

progression o eye disease and other diabetes-

related complications. Follow-up care or

titration o medication is maintained through

telephone contact. The frst telephone callis usually within 1−2 weeks o the initial

contact and a urther DSEN advisory clinic

appointment is within 1 month or earlier,

depending on the individual’s needs. Those

with more complex issues are seen in the clinic

o the supervising diabetes physician, alongside

the DSEN and diabetes dietitian.

Audit

Aim and methods

An audit was undertaken to evaluate theeectiveness o the service in reducing

HbA 1c

levels over the frst 12 months ater

implementation. The case notes o 181 people

seen at least once in the ophthalmology

clinic were reviewed. Biomedical parameters,

including HbA 1c

levels and total cholesterol,

were measured at baseline and then monitored

every 6 months. The data presented in here are

or 6- and 12-month ollow-up.

Results and discussion

Baseline data separated into three cohorts: white

European origin (53.6%; n =97); south Asian

origin (41.5%, n =75); other (4.9%, n =9). At12 months, ollow-up data were only available

or 100 people.

Glycaemic control improved in all cohorts

(Figures 8–10 ). Mean HbA 1c

levels or the ull

cohort reduced rom 8.67% (71 mmol/mol) at

baseline to 8.27% (67 mmol/mol) at 6 months,

and at 12 months this had urther reduced

to 7.64% (60 mmol/mol; P <0.001). Prior to

the intervention over 30% o individuals had

a baseline HbA 1c

o >9% (>75 mmol/mol);

ollowing the intervention this number had

reduced to 10%. By study end over 50% o individuals had achieved an HbA

1clevel o

<7.5% (<58 mmoL/mol).

Compared with baseline, mean total cholesterol

levels had reduced at 12 months (4.80 mmol/L

vs 4.50 mmol/L, respectively; P =0.001), as had

mean LDL-cholesterol levels at both 6 months

(3.04 mmol/L vs 2.73 mmol/L, respectively;

P <0.05) and at 12 months (3.04 mmol/L vs

2.57 mmol/L, respectively; P =0.001). The

improvement in lipid parameters was seen both

in the white European and south Asian groups,and the south Asian group also had reduced

triglycerides over the 12-month study period

(−0.34 mmol/L, P <0.05).

Conclusion

To date, 350 people have been seen as part o

the Diabetes Eye Nurse Project, and initial

4-year ollow-up data were presented as an

abstract at the Diabetes UK Annual Proessional

Conerence in 2010. These data are to be

written up or publication later this year.

The Diabetes Eye Nurse Project has helped

to identifed high-risk individuals with diabetes

oten with untreated risk actors. Diabetes eye

care delivered by a DSEN is a new, innovative

service and is one o the many good examples o

the excellent multidisciplinary approach to the

care o people with diabetes in Leicester. n

AuthorsSabera Khan is Diabetes and Ophthalmic Specialist

Nurse, Department o Diabetes and Endocrinology;

Sam Wong is Associate Specialist in Ophthalmology,Department o Ophthalmology; Rosi Gorrod is

Senior Diabetes Nurse Specialist; Ismail Gangat


lPeople with at least background (or more serious) diabetic retinopathy.

lPeople with HbA 1c

levels o ≥7.5% (≥58 mmol/mol; changed to ≥9.1%[≥76 mmol/mol] ater the service was established).

lPoorly controlled hypertension.

lRaised lipid parameters.

lMicroalbuminuria, smoking or obesity.

lOther major concerns regarding the individual’s diabetes care that may adversely aect vision.

Box 2. Reerral protocol.

Figure 7. Laser treatment – laser dots around the retina.Copyright 1st Retinal Screening Ltd.


Figure 5. Advanced retinopathy – fbrous prolieration. Copyright 1st Retinal Screening Ltd.

Figure 6. Diabetic

maculopathy with haemorrhages and circinate exudates and multiple blot haemorrhages. Copyright 1st Retinal Screening Ltd.



is Clinical Analyst; Stephen Hiles is Diabetes

Research Associate, Department o Diabetes and

Endocrinology; James Deane is Consultant in

Ophthalmology, Department o Ophthalmology;

Ian Lawrence is Consultant in Diabetes, Department

o Diabetes and Endocrinology, University Hospitals

o Leicester NHS Trust, Leicestershire.

AcknowledgementsThanks to Indranil Choudhuri, Specialty Trainee,

Department o Ophthalmology; June James, Nurse

Consultant in Diabetes; Layeni Rotimi, DSN;

Shehnaz Jamal, Diabetes Website Development

Coordinator, Department o Diabetes and

Endocrinology, University Hospitals o Leicester

NHS Trust, Leicestershire; 1st Retinal Screening

Ltd, Cheshire. Thanks also to sanof-aventis or

their kind and generous unding or the frst 3 years

o the DSEN post.

Amos AF, McCarty DJ, Zimmet P (1997) The rising globalburden o diabetes and its complications: estimates andprojections to the year 2010. Diabet Med 14: 51−85

Department o Health (2001) National Service Framework for Diabetes: Standards . The Stationery Ofce, London

Diabetes UK (2010) Diabetes in the UK 2010: Key statistics on diabetes . Diabetes UK, London. Available at: http://tinyurl.com/3xc6wnx (accessed 30.06.10)

Diabetes Control and Complications Trial Research Group(1993) The eect o intensive treatment o diabeteson the development and progression o long-termcomplications in insulin-dependent diabetes mellitus.N Engl J Med 329: 977−85

Diabetic Retinopathy Study Research Group (1981)Photocoagulation treatment o prolierative diabeticretinopathy: Clinical application o DiabeticRetinopathy Study (DRS) fndings, DRS ReportNumber 8. Ophthalmology 88: 583−600

Donnelly R, Emslie-Smith AM, Gardner ID, Morris AD(2000) ABC o arterial and venous disease: vascularcomplications o diabetes. BMJ 320: 1062−6

English National Screening Programme or DiabeticRetinopathy (2006) UK National Screening Committee Essential Elements in Developing a Diabetic Retinopathy Screening Programme. Appendix 1. NSC Retinopathy Grading Standard . ENSPDR, London

Early Treatment Diabetic Retinopathy Study ResearchGroup (1985) Photocoagulation or diabetic macularedema. Early Treatment Diabetic Retinopathy Study report number 1. Arch Ophthalmology 103: 1796−806

Kohner E, Allwinkle J, Andrews J et al (1996) SaintVincent and improving diabetes care: report o theVisual Handicap Group. Diabet Med 13: s13–26

Mohamed Q, Gillies MC, Wong TY (2007) Managemento diabetic retinopathy: a systematic review (2007)

JAMA 298

: 902−16NICE (2004) Type 1 Diabetes: Diagnosis and Management

of Type 1 Diabetes in Children, Young People And Adults .NICE, London

NICE (2008) Type 2 Diabetes: The Management of Type 2 Diabetes . NICE, London

Scott O (2008) Diabetic retinopathy and diabetic eyeproblems. Patient UK, London. Available at: http://tinyurl.com/2wgjw52 (accessed 30.06.10)

UK Prospective Diabetes Study Research Group (1998)Tight blood pressure control and risk o microvascularand macrovascular complications in type 2 diabetes.UKPDS 38 BMJ 317: 703−13

Watkins PJ (2003) Retinopathy. BMJ 326: 924−6


Figure 8. Glycaemic control at baseline,6 and 12 months or the ull cohort.

Figure 9. Glycaemic control at baseline,6 and 12 months or all individuals o white European ethnicity.

Figure 10. Glycaemic control at baseline,6 and 12 months or all individuals o south Asian ethnicity.

Journal o Diabetes Nursing Vol 14 No 8 2010 301

“Diabetes eye care delivered by a diabetes

specialist eye nurse

is a new, innovative

service and is one of the

many good examples

of the excellent

multidisciplinary

approach to the care

of people with diabetes

in Leicester.”

M e a n H b A

1 c

l e v e l ( % )

10

8

6

4

2

0Baseline(n =181)

6 months(n =118)

12 months(n =100)

8 . 6 7

%

( 7 1 m m o l / m

o l )

8 . 2 7

%

( 6 7 m m o l / m

o l )

7 . 6 4

%

( 6 0 m m o l / m

o l )

P <0.05

P <0.05

M e a n H b A

1 c

l e v e l ( % )

10

8

6

4

2

0Baseline(n =76)

6 months(n =52)

12 months(n =36)

8 . 8 7

%

( 7 3 m m o l / m

o l )

8 . 2 5

%

( 6 7 m m o l / m

o l )

7 . 7 7

%

( 6 1 m m o l / m

o l )

P <0.05

P <0.05

M e a n H b A

1 c

l e v e l ( % )

10

8

6

4

2

0Baseline(n =96)

6 months(n =61)

12 months(n =61)

8 . 4 5

%

( 6 9 m m o l / m

o l )

8 . 3 3

%

( 6 8 m m o l / m

o l )

7 . 5 5

%

( 5 9 m m o l / m

o l )

P <0.05

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jurnal diabates retinopati