Diabetic retinopathy is a common. Diabetic retinopathy: Role of the diabetes specialist eye nurse

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1 Diabetic retinopathy: Role of the diabetes specialist eye nurse Sabera Khan, Sam Wong, Rosi Gorrod, Ismail Gangat, Stephen Hiles, James Deane, Ian Lawrence Article points 1. The Diabetes Eye Nurse Project a joint venture between the ophthalmology and diabetes departments at the University Hospitals of Leicester NHS Trust was undertaken to optimise the care of people with diabetes and related eye disease. 2. An audit was undertaken to evaluate the effectiveness of the service in reducing HbA 1c and lipid levels over the first 12 months. 3. Glycaemic control improved in all cohorts, as did serum lipid levels. 4. 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. Key words - Diabetes specialist eye nurse - Eye - Ophthalmology - Retinopathy Author details can be found at the end of this article. Traditionally, there is minimal cooperation between ophthalmology and diabetes departments. However, during the implementation phase of the diabetes National Service Framework in Leicestershire, people with diabetes expressed a wish for a joined-up diabetes service, 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 in a cohort of more than 100 people with diabetic eye disease, thereby reducing the risk of progression of the condition and other microand macrovascular complications. This article reviews this initiative and demonstrates the value of a diabetes specialist eye nurse. Diabetic retinopathy is a common microvascular complication of diabetes (Donnelly et al, 2000). It is also the leading cause of blindness in people of working age in the UK (Kohner et al, 1996), with an estimated prevalence in people with diabetes of almost 60% (Watkins, 2003). Through optimising some of the risk factors of diabetic retinopathy, the progression of 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 of diabetes was predicted to increase two- to three-fold by 2010 (Amos et al, 1997). There are now approximately 2.5 million people in the UK with diabetes, and this figure is expected to rise to 4 million by 2025 (Diabetes UK, 2010). With the expected increase in the prevalence of diabetes in the coming years, the burden of diabetic retinopathy workload and the number of people affected by retinopathy is expected to rise accordingly. In recognition of these factors, the Diabetes Eye Nurse Project a joint venture between the ophthalmology and diabetes departments at the University Hospitals of Leicester NHS Trust was undertaken to optimise the care of people with diabetes and related eye disease. This article describes the project and the results of a subsequent audit undertaken to evaluate its effectiveness. Box 1 outlines the five stages of diabetic retinopathy and Figure 1 shows a schematic diagram of the eye. Retinal screening in Leicestershire Retinal eye screening is an integral part of diabetes care, and annual screening is 292 Journal of Diabetes Nursing Vol 14 No

2 recommended for all people with diabetes (NICE, 2004; 2008). In people with type 1 diabetes, retinopathy develops gradually over time and it is unusual for any changes to be seen within the first 5 years. In comparison, one third of people with type 2 diabetes may already have some form of retinopathy at diagnosis. It is therefore important that all people with diabetes have access to retinal screening when diagnosed. Retinal screening is different from a general eye examination at the opticians, which focuses on the general health of the eye and whether the person can see properly. If spectacles are required, the correct ones are then prescribed. It is therefore important to highlight to people with diabetes that they still need to visit the optician in addition to their annual retinal screening if they wear spectacles. The English National Screening Committee Programme for Diabetic Retinopathy (ENSPDR, 2006) requires all retinal screeners to have either a NVQ or a Diploma in retinal screening. Locally, the diabetes specialist eye nurse (DSEN) is responsible for the training, assessment and mentoring of the retinal screeners. In addition, the DSEN ensures that the screeners are able to understand the principles and practice of 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 Certificate in Diabetic Retinopathy Screening. In Leicestershire, there are approximately people with diabetes. To cater for this population there is a systematic diabetic eye screening service delivered in primary care. The University of 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 of visual acuity, the individual s pupils are then dilated. Images captured are initially graded by the screeners and then by the ophthalmologist. People with Cornea Anterior chamber (aqueous humour) Iris Pupil Ciliary muscles Suspensory ligament Lens Vitreous humour Retina Choroid Sclera ACTOS 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/ Actos 30mg tablets containing 30mg pioglitazone as hydrochloride - blister packs of 28 EU/1/00/150/ Actos 45mg tablets containing 45mg pioglitazone as hydrochloride - blister packs of 28 EU/1/00/150/ Indications: Monotherapy treatment of Type 2 diabetes mellitus in patients inadequately controlled by diet and exercise for whom metformin is inappropriate because of contraindications or intolerance. As dual oral therapy in patients with insufficient glycaemic control despite maximal tolerated dose of oral monotherapy, in combination with either metformin (particularly in overweight patients) or a sulphonylurea (in patients for whom metformin 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 glycaemic control 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 once daily. 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). Diabetic ketoacidosis. 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. Discontinue pioglitazone 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 increase gradually. Concomitant insulin administration may increase the risk of oedema. Check liver enzymes before starting treatment. Following initiation it is recommended that liver enzymes be 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 levels increase 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 liver enzymes. 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 cardiac failure. Small reductions in haemoglobin and haematocrit, consistent with haemodilution have been noted. Treatment in patients with polycystic ovarian syndrome may result in ovulation. If a patient wishes to become pregnant or if pregnancy occurs, discontinue treatment. An increased incidence in bone 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 of women 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: % 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, heart failure. Oedema reported in 6-9% of patients on pioglitazone over one year, compared to 2-5% in the comparator groups (metformin and sulphonylurea). Oedema was generally mild-moderate and usually did not require discontinuation of treatment. In most clinical trials, reduced total plasma triglycerides 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 with prior 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 did not lead to an increase in mortality. Rare cases of elevated liver enzymes and hepatocellular dysfunction have occurred in postmarketing experience, although causal relationship has not been 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 fractures in 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 sideeffect profile of Actos. Adverse events should be reported. Reporting forms and Information can be found at Adverse events should also be 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 and supply 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: , Fax: AC Please find more information at Figure 1. Schematic diagram of the human eye. Optic disc Fovea Retinal blood vessels Optic nerve References: 1. Campbell IW. Br J Diabetes Vasc Dis 2009; 9: Tan et al. Diabetes Care 2005; 28: Belcher et al. Diabetes Res Clin Pract 2005; 70: National Institute for Health and Clinical Excellence Type 2 diabetes the management of type 2 diabetes. Clinical Guideline 87. London: NICE, Haffner, et al. Diabetes Care 1999; 22: Lincoff et al. JAMA 2007; 298: Takeda Uk Ltd. Actos Summary of Product Characteristics. accessed at accessed date June Data on File at Takeda UK Ltd. AC IMS Health, BPI, December January Journal of Diabetes Nursing Vol 14 No Code: AB100728j Date of Preparation: September 2010

3 Page points 1. Retinopathy is diagnosed through fundus examination (examining the back of the eyes) by instilling dilating drops (tropicamide 1% and phenylepherine 2.5%). 2. It is important to inform people with diabetes that laser treatment is not a cure and cannot restore damaged vision, but can help prevent or delay further damage to the retina in over 90% of cases. ungradeable images, or images that highlight some indication of retinopathy, are invited to a retinal screening clinic in secondary care for further examination. Retinopathy is diagnosed through fundus examination (examining the back of the eyes) by instilling dilating drops (tropicamide 1% and phenylepherine 2.5%). The various stages of 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 inform people with diabetes that laser treatment is not a cure and cannot restore damaged vision, but can help prevent or delay further damage to the retina in over 90% of cases (Diabetic Retinopathy Study Research Group, 1981). In most cases it is possible to preserve the reading and driving vision. There are three types of laser therapy: panretinal photocoagulation, grid photocoagulation and macula focal photocoagulation. Panretinal photocoagulation Panretinal photocoagulation is usually used for the treatment of proliferative retinopathy. After instilling dilating drops and using a contact lens that enlarges the view of the retina, the ophthalmologist points a tiny laser beam into the abnormal part of the retina. Small bursts of laser dots are applied all over the retina (except for between the optic disc and fovea) to stop the Box 1. The five stages of diabetic retinopathy. 1. Background retinopathy This occurs in most people with diabetes approximately 20 years after the onset of the condition and can therefore affect all age groups from late teens onwards. Usually, no symptoms present until there is macular involvement resulting in impairment of central vision to the eye (Figures 2a and b). To ensure that the eye in those diagnosed with early changes does not deteriorate further, 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 of retinopathy (funduscopy dots, blots and hard, waxy exudates), to control their cholesterol levels, and also given dietary advice and treatment from the diabetes clinic. 2. Preproliferative 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 follow-up is not possible or vision in the fellow eye has been lost to proliferative disease (Scott, 2008). 3. Proliferative retinopathy This is the main cause of visual impairment in people with type 1 diabetes. It occurs sooner following the diagnosis of type 2 diabetes, possibly because the diabetes has gone on for longer undetected. In this form of retinopathy, the blood vessels grow into the vitreous humour and bleed, causing a vitreous haemorrhage (Figures 4a and b). Laser therapy, if required, can be used to treat proliferative 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 of 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 scaffold into which the new vessels can grow. If performed early in the development of retinopathy, laser therapy can help to improve visual recovery. 4. Advanced retinopathy This is the end result of uncontrolled proliferative 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 of the iris with major risk of acute glaucoma) improves visual recovery in people with proliferative retinopathy and severe vitreous haemorrhage (Mohamed et al, 2007). The individual also requires management of visual impairment (support from eye clinic liaison officers). 5. Maculopathy This is the main cause of visual impairment in people with type 2 diabetes (Figure 6), and is classified into four types: l Focal/exudative. l Cystoid/diffuse. l Ischaemic. l Mixed. Only the focal/exudative and mixed type of maculopathy can be treated by laser. Cystoid/diffuse maculopathy is difficult to treat by laser and ischaemic maculopathy cannot be treated. 296 Journal of Diabetes Nursing Vol 14 No

4 Figure 2. Normal retina with no diabetic retinopathy (a); background diabetic retinopathy with microaneurysms, haemorrhages and exudates (b). Copyright a b Figure 3. Preproliferative diabetic retinopathy with cotton wool spots, intraretinal microaneurysm and multiple blot haemorrhages. Copyright growth of new blood vessels (Figure 7). This is usually carried out over several appointments within an outpatient eye clinic. Fluorescein angiography is performed in-between sessions to pinpoint remaining affected areas or to establish the need for further laser treatment. If the vision is stabilised after a few sessions of laser treatment, the possibility of further new vessel formation is relatively unlikely. However, the need for annual screening is still recommended to monitor further changes. Grid photocoagulation Grid photocoagulation is used for treating exudative maculopathy. Laser spots are applied in a grid pattern lateral to the fovea. In cases of retinal haemorrhage that do not clear using grid photocoagulation, surgical intervention (vitrectomy) may be performed under a general anaesthetic to remove abnormal tissue. Vision can improve significantly but it is a major operation and can be avoided if effective screening and laser treatment is maintained. Macular focal photocoagulation Focal photocoagulation of clinically significant macular oedema substantially reduces the risk of visual loss. Focal treatment also increases the chance of visual improvement, decreases the frequency of persistent macular oedema and causes only minor visual field loss (Early Treatment Diabetic Retinopathy Study Research Group, 1985). Clinically significant macular oedema is defined as retinal thickening that involves or threatens the centre of the macula (even if visual acuity is not yet reduced) and is assessed by stereo contact lens biomicroscopy or stereo photography. Role of the DSEN: The Diabetes Eye Nurse Project Traditionally, there is little or no major cooperation between ophthalmology and diabetes departments. During the implementation phase of the diabetes National Service Framework (NSF; Department of Health [DH], 2001) in Leicestershire, people with diabetes expressed a wish for a joined-up diabetes service. They highlighted a need for Figure 4. Proliferative retinopathy with new vessels at the optic disc (a); proliferative retinopathy with preretinal and vitreous haemorrhages. Copyright a diabetes expertise in the ophthalmology clinics, where many people were attending with diabetic eye disease, including diabetic retinopathy. Pump-priming funding through a pharmaceutical company led to the appointment of a DSEN working in both the diabetes and ophthalmology clinics in This new routine service is in line with Standards 10, 11 and 12 of the diabetes NSF (DH, 2001): l Standard 10: all young people and adults with diabetes will receive regular surveillance for the long-term complications of diabetes. l Standard 11: the NHS will develop, implement and monitor agreed protocols and systems of care to ensure that all people who develop long-term complications of diabetes receive timely, appropriate and effective investigation and treatment to reduce their risk of disability and premature death. l Standard 12: all people with diabetes requiring multi-agency support will receive integrated health and social care. Most people are referred from the district retinal screening service; some from other diabetes retinal clinics. The other ophthalmologists were introduced to the diabetes eye service and the referral protocol via a presentation delivered by the DSEN (Box 2). This collaboration has helped raise the profile of the diabetes eye service as the eye department now consists of 14 consultant ophthalmologists, maintaining varied specialist eye clinics, and who have been able to access diabetes expertise as needed. Following initial assessment of the person by the DSEN, other elements are then reviewed: l Baseline biomedical parameters (HbA 1c level, renal function, lipid profile and urine albumin excretion). b 298 Journal of Diabetes Nursing Vol 14 No

5 Figure 5. Advanced retinopathy fibrous proliferation. Copyright Figure 6. Diabetic maculopathy with haemorrhages and circinate exudates and multiple blot haemorrhages. Copyright Figure 7. Laser treatment laser dots around the retina. Copyright 1st Retinal Screening Ltd. Box 2. Referral protocol. l Blood pressure. l Lifestyle (including smoking cessation, basic dietary review, physical activities and alcohol consumption). l Current medications. l Provision of individual diabetes education, including self-monitoring of blood glucose. Intervention is provided for any identified diabetes-related problems to delay further progression of eye disease and other diabetesrelated complications. Follow-up care for titration of medication is maintained through telephone contact. The first telephone call is usually within 1 2 weeks of the initial contact and a further 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 of the supervising diabetes physician, alongside the DSEN and diabetes dietitian. Audit Aim and methods An audit was undertaken to evaluate the effectiveness of the service in reducing HbA 1c levels over the first 12 months after implementation. The case notes of 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 for 6- and 12-month follow-up. Results and discussion Baseline data separated into three cohorts: white European origin (53.6%; n=97); south Asian l People with at least background (or more serious) diabetic retinopathy. l People with HbA 1c levels of 7.5% ( 58 mmol/mol; changed to 9.1% [ 76 mmol/mol] after the service was established). l Poorly controlled hypertension. l Raised lipid parameters. l Microalbuminuria, smoking or obesity. l Other major concerns regarding the individual s diabetes care that may adversely affect vision. origin (41.5%, n=75); other (4.9%, n=9). At 12 months, follow-up data were only available for 100 people. Glycaemic control improved in all cohorts (Figures 8 10). Mean HbA 1c levels for the full cohort reduced from 8.67% (71 mmol/mol) at baseline to 8.27% (67 mmol/mol) at 6 months, and at 12 months this had further reduced to 7.64% (60 mmol/mol; P<0.001). Prior to the intervention over 30% of individuals had a baseline HbA 1c of >9% (>75 mmol/mol); following the intervention this number had reduced to 10%. By study end over 50% of individuals had achieved an HbA 1c level of <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; ) 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, ). Conclusion To date, 350 people have been seen as part of the Diabetes Eye Nurse Project, and initial 4-year follow-up data were presented as an abstract at the Diabetes UK Annual Professional Conference in These data are to be written up for publication later this year. The Diabetes Eye Nurse Project has helped to identified high-risk individuals with diabetes often with untreated risk factors. Diabetes eye care delivered by a DSEN 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. n Authors Sabera Khan is Diabetes and Ophthalmic Specialist Nurse, Department of Diabetes and Endocrinology; Sam Wong is Associate Specialist in Ophthalmology, Department of Ophthalmology; Rosi Gorrod is Senior Diabetes Nurse Specialist; Ismail Gangat 300 Journal of Diabetes Nursing Vol 14 No

6 Figure 8. Glycaemic control at baseline, 6 and 12 months for the full cohort. Mean HbA 1c level (%) % (71 mmol/mol) Baseline (n=181) 8.27% (67 mmol/mol) 6 months (n=118) 7.64% (60 mmol/mol) 12 months (n=100) is Clinical Analyst; Stephen Hiles is Diabetes Research Associate, Department of Diabetes and Endocrinology; James Deane is Consultant in Ophthalmology, Department of Ophthalmology; Ian Lawrence is Consultant in Diabetes, Department of Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust, Leicestershire. Acknowledgements Thanks to Indranil Choudhuri, Specialty Trainee, Department of Ophthalmology; June James, Nurse Consultant in Diabetes; Layeni Rotimi, DSN; Shehnaz Jamal, Diabetes Website Development Coordinator, Department of Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust, Leicestershire; 1st Retinal Screening Ltd, Cheshire. Thanks also to sanofi-aventis for their kind and generous funding for the first 3 years of the DSEN post. Amos AF, McCarty DJ, Zimmet P (1997) The rising global burden of diabetes and its complications: estimates and projections to the year Diabet Med 14: Department of Health (2001) National Service Framework for Diabetes: Standards. The Stationery Office, London Diabetes UK (2010) Diabetes in the UK 2010: Key statistics on diabetes. Diabetes UK, London. Available at: tinyurl.com/3xc6wnx (accessed ) Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329: Diabetic Retinopathy Study Research Group (1981) Photocoagulation treatment of proliferative diabetic retinopathy: Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. Ophthalmology 88: Donnelly R, Emslie-Smith AM, Gardner ID, Morris AD (2000) ABC of arterial and venous disease: vascular complications of diabetes. BMJ 320: English National Screening Programme for Diabetic Retinopathy (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 Research Group (1985) Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Arch Ophthalmology 103: Kohner E, Allwinkle J, Andrews J et al (1996) Saint Vincent and improving diabetes care: report of the Visual Handicap Group. Diabet Med 13: s13 26 Mohamed Q, Gillies MC, Wong TY (2007) Management of diabetic retinopathy: a systematic review (2007) JAMA 298: NICE (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 eye problems. Patient UK, London. Available at: tinyurl.com/2wgjw52 (accessed ) UK Prospective Diabetes Study Research Group (1998) Tight blood pressure control and risk of microvascular and macrovascular complications in type 2 diabetes. UKPDS 38 BMJ 317: Watkins PJ (2003) Retinopathy. BMJ 326: 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 Mean HbA 1c level (%) % (69 mmol/mol) 8.33% (68 mmol/mol) 7.55% (59 mmol/mol) Mean HbA 1c level (%) % (73 mmol/mol) 8.25% (67 mmol/mol) 7.77% (61 mmol/mol) 0 Baseline (n=96) 6 months (n=61) 12 months (n=61) 0 Baseline (n=76) 6 months (n=52) 12 months (n=36) Figure 9. Glycaemic control at baseline, 6 and 12 months for all individuals of white European ethnicity. Figure 10. Glycaemic control at baseline, 6 and 12 months for all individuals of south Asian ethnicity. Journal of Diabetes Nursing Vol 14 No