From Orange County, USA:
I have recently gone on the pump and have been diagnosed with retinopathy requiring laser treatment. I have heard that in some patients retinopathy gets worse with tighter control. Do you have any suggestions?
Early findings in insulin pump patients on the relationships between improved metabolic control, as measured by HbA1c, and diabetic retinopathy indicated that there was a transient deterioration of background retinopathy in these patients, most marked in those in whom the metabolic control improved most in the shortest period of time. Now, years later, after a more number of prospective reports on intensified treatment and using pumps over longer period of time, it can be affirmed that only those patients with proliferative retinopathy actually continued to deteriorate while others only show minor and transient deterioration, with no difference in progression between patients on pumps or other forms of intensified insulin treatment.
In summary, prolonged good control is only of moderate benefit in those patients who already have retinopathy, especially if the proliferative one. This is perhaps not unexpected, since it would be difficult to reverse prolonged anatomical changes which take 15 years at least to develop, so that they disappear over 3 to 5 years. In animal models also, institution of good control does not alter the progression of retinopathy once retinopathy is present. On the other hand, good control as early as from diagnosis can perhaps prevent development of diabetic retinopathy.
Additional Comment by Dr. QuickOne of the paradoxes in diabetes management is the fact that retinopathy transiently worsens when patients are put on tight control programs. This phenomenon was seen in the DCCT study, and is well-known to occur when young women with diabetes start aggressive diabetes management programs during early pregnancy, or when other people with diabetes (such as yourself) start an intensive insulin programs for any reason. The worsening of the retinopathy soon stabilizes but can be very nerve-wracking, and may sometimes need laser therapy.
Interestingly, in the DCCT, it was noted that people who remained on traditional less-intense insulin programs had progressive deterioration in their retinopathy whilst people who were placed on intensive programs (and who had sudden deterioration as discussed above) had relative stabilization of the retinopathy after a while, so that the end effect was that people with less-intense programs had much worse retinopathy than those on tight-control programs after a few years.
What to do? First, if you're already on a tight-control program, stay on it: the rate of progression of retinopathy is less after the initial change in therapy. Second, if you're planning to start a tight-control program, and don't have any dramatic reason (such as pregnancy) to do so rapidly, slowly phase the program in over time. And finally: get a full eye exam before starting (or soon after starting) an aggressive diabetes program, and perhaps get retinal photographs for future comparison.
Original posting 13 Jan 98
Additional comment added 28 Jan 98
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