This is a case of uncontrolled T2DM with hard exudates, hemorrhagic spots in the fundi indicating NPDR, a microvascular complication,refer the case to a Retinal Specialist for further evaluation and laser therapy. But very strict control of DM is mandatory, even 1% reduction in HbA1c is associated with 37% less progression of Retinopathy, in other words if you maintain an HbA1c of less than 7%, one would never develop Retinopathy at all or other wise the development would be very slow, not only maintaining DM, one should also maintain hypertension, Dyslipidemia too.
Dr Alok Singh, that's why I asked this case to refer to a Retinal Specialist for laser therapy, go through my comment please, our duty ceases by sending the case to you, of course we need to meticulously control DM,HTN,Dyslipidemia.
The BMJ logo Toggle top menu ResearchEducationNews & ViewsCampaigns ArchiveFor authorsJobsHosted Research Article Rapid tightening of blood glucose control leads to transient deterioration of retinopathy in insulin dependent diabetes mellitus: the Oslo study. Br Med J (Clin Res Ed)1985;290doi: http://dx.doi.org/10.1136/bmj.290.6471.811(Published 16 March 1985)Cite this as:Br Med J (Clin Res Ed)1985;290:811 ArticleMetricsResponsesPeer review K Dahl-Jrgensen,O Brinchmann-Hansen,K F Hanssen,L Sandvik,O Aagenaes Abstract In a study of retinopathy during one year of tight blood glucose control 45 type I (insulin dependent) diabetics without proliferative retinopathy were randomised to receive either continuous subcutaneous insulin infusion, multiple insulin injections, or conventional insulin treatment (controls). Near normoglycaemia was achieved with continuous infusion and multiple injections but not with conventional treatment. Blind evaluation of fluorescein angiograms performed three monthly showed progression of retinopathy in the control group, transient deterioration in the continuous infusion group, and no change in the multiple injection group. Half the patients receiving continuous infusion and multiple injections developed retinal cotton wool spots after three to six months. These changes regressed in all but four patients after 12 months. Control patients did not develop cotton wool spots. Patients who developed cotton wool spots are characterised by a larger decrement in glycosylated haemoglobin and blood glucose values, more frequent episodes of hypoglycaemia, a longer duration of diabetes, and more severe retinopathy at onset. A large and rapid fall in blood glucose concentration may promote transient deterioration of diabetic retinopathy.
Pre proliferating diabetic retinopathy both eye ffa strict control of diabetes prp three sitting & macular grid strict follow up with nevanec e/d antioxidants with omega3fatt acid
other thing I want to add is to search for other microvascular complications. . diabetic nephropathy and neuropathy. ...
Early worsening of diabetic retinopathy in the Diabetes Control and Complications Trial. Arch Ophthalmol. 1998;116:874-886
But Dr Mohammed Parvez, my comment was on T2DM, your reference is for T1DM, you are the better judge.Thank you.
Good comment Rashid Vora, we should look for the other complications incuding macrovascular, not only microvascular,
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3713071/ Diabetic Retinopathy in T2 DM, worsen initially with strict glycemic control.
Very good share Dr Mohammad Parvez, Congratulations
Cases that would interest you
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A 56/M pt present to ED with the c/o moderate uneasiness and heartburn. He had been diagnosed with type 2 diabetes mellitus 4 years earlier. He is suffered from Hypertension, Dyslipidemia, diabetic nephropathy, diabetic retinopathy and peripheral neuropathy. Currently His medications included Telma 40, Ecospirin AV Gold 20 and metformin O/E BP 150/80 mmHg, reduced vibration sense in his feet. ECG is performed, based on ecg findings, Pt denied chest, arm or jaw pain or discomfort; shortness of breath; palpitations; nausea; indigestion or sweating. In view of the ECG changes, What is the most likely diagnosis and treatmentDr. Z. V. Anwer5 Likes19 Answers
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DIABETIC NEUROPATHIES. Diabetic neuropathies are a family of nerve disorders caused by diabetes. WHAT CAUSES DIABETIC NEUROPATHY. Nerve damage is likely due to a combination of factors. 1.METABOLIC FACTORS. : hyperglycemia, long duration of diabetes, abnormal blood fat levels and low levels of insulin. 2.NEUROVASCULAR FACTORS : Neurovascular factors leading to damage of blood vessels that carry oxygen and nutrients to nerves. 3.AUTOIMMUNE FACTORS : Causes inflammation of nerves. 4.MECHANICAL FACTORS : Injury to nerves as in carpel tunnel syndrome. 5.INHERITED TRAITS : That increase susceptibility to nerve disease. 6.LIFESTYLE FACTORS : Smoking, alcohol. SYMPTOMS. Symptoms depends on the type of neuropathy and which nerves are affected.Symptoms involve sensory,motor and autonomic nervous system. 1.Tingling, numbness or pain in the toes,feet,legs,hands,arms and fingers. 2.Wasting of muscles of hand or feet. 3.Indigestion, nausea, vomiting, diarrhea,c constipation. 4. Dizziness or fainting due to a drop in blood pressure after standing or sitting up. 5.Problems with urination. 6.Erectile dysfunction. 7.Weakness. TYPES OF NEUROPATHY. Diabetic neuropathy can be classified as 1.Peripheral neuropathy. 2.Autonomic neuropathy. 3.Proximal neuropathy. 4.Focal neuropathy. PERIPHERAL NEUROPATHY. Peripheral neuropathy,also called distal symmetric neuropathy or sensorimotor neuropathy ,is nerve damage in arms and legs.Symptoms are *Numbness or insensitivity to pain or temperature. *A tingling,burning or prickling sensation. *Sharp pains or cramps. *Extreme Sensitivity to touch. *Loss of balance and coordination. Peripheral neuropathy also causes muscle weakness and loss of refle guyxes.Blisters and sites may appear on the numb areas of the foot because pressure or injury goes unnoticed.I f an infection occurs and is not treated promptly,the infection may spread to the bone and the foot may need amputation.Many amputations can be prevented if minor problems are treated in time. AUTONOMIC NEUROPATHY. Autonomic neuropathy affects the nerves that control the heart,blood pressure and blood glucose levels.Autonomic neuropathy also affects internal organs causing problems with digestion,respiration. urination,sexual response and vision. 1.HYPOGLYCEMIA UNAWARENESS. Normally,symptoms such as shakiness,sweating and palpitations occurs when the blood glucose levels drop below <<70 mg/dl.In people with autonomic neuropathy,symptoms may not occur making hypoglycemia to be recognized. 2.HEART & BLOOD VESSELS. Damage to the nerves in the cardiovascular system interferes with the body's ability to adjust blood pressure and heart rate. Due to this,blood pressuremay drop sharply after standing or sitting,causing a person to feel light headed or faint. Damage to nerves that control heart rate makes the heart rate to stay high , instead of rising and falling in response to normal body functions and physical activity. 3.DIGESTIVE SYSTEM. Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty slowly,a condition called GASTROPARESIS. Gastroparesis can lead to persistent nausea and vomiting,bloating and loss of appetite. Gastroparesis also makes blood glucose levels to fluctuate widely ,due to abnormal food digestion. Nerve damage to the OESOPHAGUS MAKES SWALLOWING DIFFICULT. Nerve damage to bowels can cause constipation alternating with uncontrolled diarrhea, 3.URINARY TRACT & SEX ORGANS. Autonomic neuropathy often affects the organs that control urination and sexual functions. Nerve damage can prevent the bladder from emptying completely , allowing the bacteria to grow in bladder and kidneys causing urinary tract infections. When the nerves of the bladder are damaged,urinary incontinence may result because a person may not be able to sense when the bladder is full or control the muscles that release urine. Autonomic neuropathy also leads to decreased sexual response in men and women. A man may have erectile dysfunction or may reach sexual climax without ejaculating normally. A woman may have difficulty in arousal,lubrication or orgasm. 5.SWEAT GLANDS. Nerve damage may cause improper working of sweat glands.It can also result in profuse sweating at night or while eating. 6.EYES. Due to autonomic neuropathy,pupils become less responsive to changes in light.A s a result,a person may not be able to see well when light is turned on In a dark room or have trouble driving at night. PROXIMAL NEUROPATHY. Proximal neuropathy//lumbosacral plexus neuropathy //femoral neuropathy //diabetic amyotrophy causes pain in the thighs,buttocks,hips or legs,usually on one side of the body. FOCAL NEUROPATHY. Focal neuropathy appears suddenly and affects specific nerves,most often in the head,torso or leg. Focal neuropathy is painful and unpredictable.and occurs most often in older adults with diabetes. However,it tends to improve itself over weeks or months and does not cause long term damage. Focal neuropathy can cause *Inability to focus the eye. *Diplopia. *Aching behind the eye. *Bell's palsy. *Severe pain in the lower back and pelvis. *Pain in the front of the thigh. *Pain in the chest and stomach. *Pain on the outside of the shin or inside of the foot. *Chest pain and abdominal pain is mistaken for heart attack or appendicitis. CAN DIABETIC NEUROPATHIES BE PREVENTED. THE BEST WAY TO PREVENT NEUROPATHY IS TO KEEP BLOOD GLUCOSE LEVELS AS CLOSE TO THE NORMAL RANGE AS POSSIBLE.MAINTAINING SAFE BLOOD GLUCOSE LEVELS PROTECTS NERVES THROUGH OUT THE BODY.Dr. Suvarchala Pratap16 Likes25 Answers
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44 yr male with history of diabetes and hypertension on Telma H and T Glynase MF. OBESEITY present. Pls see the reports and discuss the managementDr. Govvinda N0 Like9 Answers
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A 38 year old patient presented for a routine exam. He has no complaints. He has a medical history significant for diabetes mellitus type 2. On exam, his vision is 20/30 and his intraocular pressure is normotensive. What is your favorite diagnosis and management?Dr. Vishal Kumar0 Like9 Answers
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Friends today I am discussing about a very common disease .Known as Diabetes . Types of Diabetes Mellitus Diabetes mellitus (or diabetes) is a chronic, lifelong condition that affects your body's ability to use the energy found in food. There are three major types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes. All types of diabetes mellitus have something in common. Normally, your body breaks down the sugars and carbohydrates you eat into a special sugar called glucose. Glucose fuels the cells in your body. But the cells need insulin, a hormone, in bloodstream in order to take in the glucose and use it for energy. With diabetes mellitus, either your body doesn't make enough insulin, it can't use the insulin it does produce, or a combination of both. Since the cells can't take in the glucose, it builds up in your blood. High levels of blood glucose can damage the tiny bloodvessels in your kidneys, heart, eyes, or nervous system. That's why diabetes -- especially if left untreated -- can eventually cause heart disease, stroke, kidney disease, blindness, and nerve damage to nerves in the feet. Type 1 Diabetes Type 1 diabetes is also called insulin-dependent diabetes. It used to be called juvenile-onset diabetes, because it often begins in childhood. Type 1 diabetes is an autoimmune condition. It's caused by the body attacking its own pancreas with antibodies. In people with type 1 diabetes, the damaged pancreas doesn't make insulin. This type of diabetes may be caused by a genetic predisposition. It could also be the result of faulty beta cells in the pancreas that normally produce insulin. A number of medical risks are associated with type 1 diabetes. Many of them stem from damage to the tiny blood vessels in your eyes (called diabetic retinopathy), nerves (diabetic neuropathy), and kidneys(diabetic nephropathy). Even more serious is the increased risk of heart disease and stroke. Treatment for type 1 diabetes involves taking insulin, which needs to be injected through the skin into the fatty tissue below. The methods of injecting insulin include: Syringes Insulin pens that use pre-filled cartridges and a fine needle Jet injectors that use high pressure air to send a spray of insulin through the skin Insulin pumps that dispense insulin through flexible tubing to a catheter under the skin of the abdomen A periodic test called the A1C blood test estimates glucose levels in your blood over the previous three months. It's used to help identify overall glucose level control and the risk of complications from diabetes, including organ damage. Having type 1 diabetes does require significant lifestyle changes that include: Frequent testing of your blood sugar levels Careful meal planning Daily exercise Taking insulin and other medicationsas needed People with type 1 diabetes can lead long, active lives if they carefully monitor their glucose, make the needed lifestyle changes, and adhere to the treatment plan. Type 2 Diabetes By far, the most common form of diabetes is type 2 diabetes, accounting for 95% of diabetes cases in adults. Some 26 million American adults have been diagnosed with the disease. Type 2 diabetes used to be called adult-onset diabetes, but with the epidemic of obese and overweight kids, more teenagers are now developing type 2 diabetes. Type 2 diabetes was also called non-insulin-dependent diabetes Type 2 diabetes is often a milder form of diabetes than type 1. Nevertheless, type 2 diabetes can still cause major health complications, particularly in the smallest blood vessels in the body that nourish the kidneys, nerves, and eyes. Type 2 diabetes also increases your risk of heart diseaseand stroke. With Type 2 diabetes, the pancreas usually produces some insulin. But either the amount produced is not enough for the body's needs, or the body's cells are resistant to it. Insulin resistance, or lack of sensitivity to insulin, happens primarily in fat, liver, and muscle cells. People who are obese -- more than 20% over their ideal body weight for their height -- are at particularly high risk of developing type 2 diabetes and its related medical problems. Obese people have insulin resistance. With insulin resistance, the pancreas has to work overly hard to produce more insulin. But even then, there is not enough insulin to keep sugars normal. There is no cure for diabetes. Type 2 diabetes can, however, be controlled with weight management, nutrition, and exercise. Unfortunately, type 2 diabetes tends to progress, and diabetes medications are often needed. An A1C test is a blood test that estimates average glucose levels in your blood over the previous three months. Periodic A1C testing may be advised to see how well diet, exercise, and medications are working to control blood sugar and prevent organ damage. The A1C test is typically done a few times a year. Gestational Diabetes Diabetes that's triggered by pregnancy is called gestational diabetes (pregnancy, to some degree, leads to insulin resistance). It is often diagnosed in middle or late pregnancy. Because high blood sugar levels in a mother are circulated through the placenta to the baby, gestational diabetes must be controlled to protect the baby's growth and development. According to the National Institutes of Health, the reported rate of gestational diabetes is between 2% to 10% of pregnancies. Gestational diabetes usually resolves itself after pregnancy. Having gestational diabetes does, however, put mothers at risk for developing type 2 diabetes later in life. Up to 10% of women with gestational diabetes develop type 2 diabetes. It can occur anywhere from a few weeks after delivery to months or years later. With gestational diabetes, risks to the unborn baby are even greater than risks to the mother. Risks to the baby include abnormal weight gain before birth, breathing problems at birth, and higher obesity and diabetes risk later in life. Risks to the mother include needing a cesarean section due to an overly large baby, as well as damage to heart, kidney, nerves, and eye. Treatment during pregnancy includes working closely with your health care team and: Careful meal planning to ensure adequate pregnancy nutrients without excess fat and calories Daily exercise Controlling pregnancy weight gain Taking diabetes insulin to control blood sugar Otabetes A few rare kinds of diabetes can result from specific conditions. For example, diseases of the pancreas, certain surgeries and medications, or infections can cause diabetes. These types of diabetes account for only 1% to 5% of all cases of diabetes. Homoeopathy can be used effectively in the treatment of diabetes. Here we mainly concentrate on functioning of the pancreas in efficient insulin production. Medicines such as Helonias 200, Iodum 200, Syzygium Jambolanum θ (Mother Tincture) are used by us effectively in the treatmentof all the stages of the diseases.Dr. Rajesh Gupta6 Likes9 Answers