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March 18, 2006

Complications

Question from Hamden, Connecticut, USA:

After living with diabetes for 42.5 years, today, I was diagnosed with one microaneurysm in my right eye. Do these ever resolve themselves? I have been using an insulin pump for over 23 years and my A1cs have been in the low 6s the past few years. My last A1c was 5.7. I just can't do any better than I have been, so I don't know how to help avoid additional eye issues. My blood pressure stays between 110/60 or 90/60. It was 130/60 on two occasions, so I was put on 16 mg of Atacand. I also was told I don't need another eye exam until one year from today. Does this sound right? My doctor is a retina specialist, but I'm considering seeing another specialist to confirm and advise.

Answer:

You are doing fabulously well. The vast majority of people with diabetes have some diabetic retinopathy (DRT) after 20 years. Microaneurysm formation is the earliest stage of retinopathy; a single microaneurysm is no big deal whatsoever, and poses no threat to your vision. Your glycosylated hemoglobin levels are fabulous and your blood pressure is excellent.

From a metabolic standpoint, the only thing you might want to keep an eye on (pun intended) is blood glucose variability. There is growing evidence that fluctuating blood sugar levels cause more retinal damage than do more constant levels, irrespective of your glycosylated hemoglobin which, you must remember, is only an average. For instance, an A1c of 5.7% is equivalent to an average blood plasma glucose of 124 mg/dl [6.9 mmol/L], home blood glucose readings of 120 mg/dl [6.7 mmol/L], 128 mg/dl [7.1 mmol/L], 136 mg/dl [7.6 mmol/L] and 112 mg/dl [6.2 mmol/L, give a 124 mg/dl [6.9 mmol/L] average, but so do readings of 236 mg/dl [13.1 mmol/L], 44 mg/dl [2.4 mmol/L], 170 mg/dl [9.4 mmol/L] and 46 mg/dl [2.6 mmol/L]. A person with widely fluctuating blood sugars (like example two) is much more likely to develop retinopathy than is the first person (in fact, the DCCT proved exactly this). Other preventative strategies for retinopathy worth considering, but not yet proven, include statin therapy (approved for lowering bad LDL cholesterol), ARB drugs (angiotensin receptor blockers – used to lower blood pressure and protect diabetic kidneys) and benfotiamine (a fat soluble form of vitamin B1 that prevented retinopathy in laboratory animals).

For mild/minimal retinopathy such as yours, the standard of care is an annual dilated retinal examination, so your doctor is exactly correct. It takes time for more severe retinopathy to develop, so checking you more frequently is not helpful. Keep doing what you’ve been doing and be thankful for good genetics. The overwhelming majority of people with diabetes will have more serious retinopathy after over 40 years with diabetes, even with excellent control. In fact, ask your retinal specialist about this; I bet he/she can count on one hand the number of diabetics with diabetes over 40 years who have such mild retinopathy. Congratulations!

PC