Can Retinopathy be caused by improved control?

[SiGreenwood]

I've been Type 1 for almost 25 years now. My control is very good and for the last 18 months my A1c's at 6 monthly intervals have been 5.1%, 5.4% and 5.0%. I am on the pump and use Apidra and generally I never see double figures unless I get my carb counting wrong. I very rarely get post meal spikes of >7.5 one and two hours after eating. I am quite active, my BP is normal, my BMI is correct as is my Cholesterol but I do take Thyroxine.

For the last 2 eye screenings in 2009 and 2010 the results came back saying that I had background Retinopathy in both eyes. I discussed this with my GP and Consultant and was told that this is to be expected given the amount of time I have had Diabetes and not to worry. Anyway my last result, taken in January this year, came back saying that I have Pre-Proliferative retionpathy in my right eye I have been called in to see the Eye specialist in March.

I am really worried and also a bit shocked as if anything I thought that my tight control would have improved my eyes and even possibly reduced or removed the signs of Background Retinopathy, not made them worse.

Now it's worth adding that about 2 years ago My A1c was 6.7% but I know that I also had post meal spikes and that my BG did swing high and low so realistically my BG was probably anywhere between 11 and 4 at any given time. Looking further back by control has always been ok with A1c's typically between 6 and 7. Typically now my A1c appears to be between 5 and 5.5 but I don't get the high and low swings and I do sit in the 'normal' BG region.

Now the question I have is could it be the improved control that has exasperated by Retinopathy and this is just a period of worsening before stabilisation or even improvement occurs? I have read and heard of cases where people suddenly tighten their control and as a result develop Retinopathy problems, pregnant women is one group as are people who have developed other Diabetic complications and dramatically improved their control another. Now my A1c has only come down by 1.5% or so but I know that my control overall is a lot better thanks to Apidra, the pump and some hard work. I also know that over the last 18 months my blood flow has got much better around my body in general.

Any experience or comments would be welcome. TIA.

 

[noblehead]

Hi Si,

Drastically improving control can effect the eyes and this is why the advice is to improve control slowly, however in your case reducing it from 6.7 to 5 over two years doesn't sound too drastic and would be surprised if this is the cause of your retinopathy. It could well be due to the time you have had type 1 diabetes, but as I am no expert I cannot say for certain and your best bet would be to speak with your Ophthalmologist and discuss.

Nigel

 

[totsy]

hya,
sadly some diabetics can have brilliant control and are just unlucky as they still develop complications :?

 

[Unbeliever]

Yes . This actually happened to me. I understand it is quite common. When I was first prescribed a glimepiride my blood sugar fell overnight from 11-14 down to 4 or 5 There was great rejoicing at this until I was found to have suffered a massive retinal bleed. The really annoying thing was that the amazing improvement in my bg was only very short lived.
I understand that this outcome is far more common in a case like mine where there is a sudden
improvement in bg after a lengthy period of high bg.
I suppose it is only possible to generalise.. As someone else has said some people can have excellent control and are still unfortunate.
Don't despair though. Treatment is improving all the time. I should know - I have had most of it.
One piece of advice. Don't be rushed into treatment. I know it is natural o assume that immediate treatment is essential but it is important to get the best treatment not just to allow hem to sick a plaster on it as it were.
I suffered as a result of being rushed into laser treatment. I now know that this will no work if there is oo much fluid in the eye . anot only that but it can cause damage. I believe that the popularity of laser treatment in all cases is declining . There are newer alternatives.
When you are advised of the risks these are not "worse case scenario" but quite common.
Good luck with your treatment. I really believe that things are improving in the reatmen of reinopathy.

 

[the_anticarb]

I am a pregnant woman and had diabetes 18 years, some slow-developing retinopathy but nothing too serious, didn't need any laser or anyting. Then fell pregnant and now at 8 months I have had three lots of laser, two in the past month alone. I did tighten up my control pretty fast, and err on the side of too low rather than too high to protect the baby. However there are other factors with pregnancy, lots of growth hormones around, so I've been told it's not all due to the improved control. Sounds like you were not really out of control to begin with though - I'd be happy with a hba1c of 6.7. Sounds like maybe you have just been unlucky with your eyes. Best of luck with whatever treatment you go for.

 

[SiGreenwood]

Thanks for the replies, I'll have to wait and see I suppose.

The frustraiting bit is that my BG control was probably ok but not brilliant for the first 20 ish years. I certainly went trhough phases early on where I had no idea what my control was like because quite simply there weren't the tools to check it but I never had any problems at all, short or long term. Since tightening up my control I have had neuropathy problems that have come and now gone which my consultant has put down to Nerve regeneration, even though i never lost any sense of touch or had any neuropathy problems, and now I seem to be developing Retinopathy.

It's as though tightening up my control has caused problems to develop.

 

[Gjimmy]

Bad BG control causes retinopathy not good control , obviously.
Having good control from a period of very bad control does not suddenly cause retinopathy, it's the years of poor control that's done that . It's simply the body normalizing it's cells.
Trust me on this. The longer the bad control the worse the damage, it's as simple as that.
People who develop complications from diabetes who say they have good control, just think they have good control, they don't.
People who control their Blood sugar as close as possible to that of a non diabetic DO NOT develop complications. That's why non diabetic people don't develop complications.

 

[tigger]

Unfortunately some complications just happen even with years of good control. It is impossible to have perfect control the entire time, particularly if you have had diabetes for a length of time when there was less emphasis on really tight control, because your body doesn't produce insulin. Some people can have bad control for years and not have complications. Others can have good control and still develop it.

Nowadays retinopathy can be effectively treated with miniminal impact. I have a friend who had laser surgery done about 14 years ago and has had no loss of vision as a result.

Good luck!

Gjimmy your comments are uncalled for and offensive.

 

[Sue Morton]

I had lazer treatment on the 4th Jan this year. I was diagnosed diabetic type 2 March last year and since being diagnosed I have worked had to keep my BS down and to begin with tested every time I eat and my BS varies from 5.7 to 6.4. I had my eyes checked last July and was recalled as they found that I had a blood clot behind my right eye - I then had an appt in November to check on this and they said more was going on behind the eye and had to go back and have this yellow dye put in me and they said that more clots had formed, which would need to be lazered to stop them from bursting as if they burst I could lose my site. Since I was keeping my BS under control and on a low carb diet how is it that more clots appeared. My Hbca1 whatever its called was 6.3 in September and was very pleased about that and only once has my BS gone up and that was this week where I had 4 ginger biscuits and felt a bit giddy about an hour after so did BS and it was 8.8. So no more then 2 ginger biscuits which I usually only have rarely with a cuppa, with 2 my BS has been 6.1.

I have been under a lot of stress over the past months and believe (or hope) that its the stress rather then diabetis. I did have an eye bleed in 2006 which was due to high blood pressure and resolved with tablets.

I really found it hard to believe it was due to diabtics as I have only been diabetic for a year (possibly longer and not known it before I was diagnosed) Could this non diagnostic time been the cause when I was diagnosed my BS was 25.3.

It is puzzelling as to why more blood clots appeared when my control of my BS was good after meals was 5.7 or 6.2 or 6.3 :?

Sue

 

[SiGreenwood]

Bad BG control causes retinopathy not good control , obviously.
Having good control from a period of very bad control does not suddenly cause retinopathy, it's the years of poor control that's done that . It's simply the body normalizing it's cells.
Trust me on this. The longer the bad control the worse the damage, it's as simple as that.
People who develop complications from diabetes who say they have good control, just think they have good control, they don't.
People who control their Blood sugar as close as possible to that of a non diabetic DO NOT develop complications. That's why non diabetic people don't develop complications.

My Diabetes consultant would tell you otherwise, as he did me when I went to see him 18 months ago with Neuropathy symptoms, all of which have now gone given time.
The eye consultant that I saw last week stated that typically people with bad control will present eye problems between 10 and 15 years and those problems will progress rapidly and the progression may be uncontrollable. He also said that, as is my case, people who have been Diabetic over 20 years present some sort of Diabetic change at the back of the eye, 90% was the figure he gave. He said that this was not related to bad control and is managable if caught early enough, which it should be with yearly screening. Incidentally the problem I had in my right eye is no longer evident although I still do have Diabetic changes in both eyes.
Also if you read a book called 'Pumping Insulin' by John Walsh there is a section in there that warns against tightening your control suddenly because it can cause retionpathy. It advises you to tighten your control gradually and reduce your A1c gradually over a period of time which from memory can be as long as a year.

On what do evidence do you base your argument, your opinion?

 

[phoenix]

A couple of quotes from a 'medical education'paper.
http://www.ncbi.nlm.nih.gov/pmc/article ... ool=pubmed

The duration of diabetes is the main factor for the development of diabetic retinopathy. In a study of 5596 persons with diabetes in Germany in the years 2002 to 2004, the prevalence of diabetic retinopathy was found to be 17% in persons with type 1 diabetes who had received their diagnosis before age 30 and had been ill for less than 5 years. Among patients who had had diabetes for 15 years or longer, the prevalence of retinopathy was 90%

Both of these studies (DCCT, UKPDS) showed, however, that the rapid optimization of blood sugar values may lead at first to an accelerated progression of diabetic retinopathy. This “early worsening” is now known to reverse itself, and, indeed, the long-term prognosis is better if the blood sugar is immediately brought under good control

If you look up 'early worsening' there are lots of papers.

Here in France before you go on a pump you have to have a fluorescein angiogram rather than a normal retinal check. Presumably, they want as much info on the state of the retina as possible so that they are ready to intervene at any sign of progression. I thought it was a bit OTT for me as I already had a very low HbA1c, and I was going on the pump to enable me to exercise without hypos.
Nevertheless the angiogram showed some minor 'diabetic changes' which don't show up on the normal examination. Since diagnosis I have never had an HbA1c above 5.9% so I can only assume that damage was caused pre diagnosis (possible as I have LADA and went undiagnosed for some time) or simply because I have diabetes.