Book Review

Ocular Problems in Diabetes Mellitus

N Engl J Med 1993; 329:286-287July 22, 1993

Article

Ocular Problems in Diabetes Mellitus
Edited by Stephen S. Feman. 287 pp., illustrated. Boston, Blackwell Scientific, 1992. $79.95. ISBN: 0-86542-154-4

Approximately 7 million patients in the United States have been given a diagnosis of diabetes. An additional 6 million may have undiagnosed diabetes. These two groups represent 5 percent of the U.S. population. Since in one study 26 percent of the diabetics who were young at the onset of disease and 36 percent of those who were older at onset had never been examined by an ophthalmologist, it is not surprising that diabetic retinopathy is one of the leading causes of blindness in the United States and may be the leading cause of blindness among the working population.

Ocular Problems in Diabetes Mellitus attempts to address this issue. Multiple randomized clinical trials sponsored by the National Eye Institute have established the efficacy of surgical intervention in preserving and improving vision. In 1976 the Diabetic Retinopathy Study validated the benefits of panretinal laser surgery in preventing serious visual loss from proliferative diabetic retinopathy. The Early Treatment Diabetic Retinopathy Study verified that laser surgery could reduce the risk of visual loss from macular edema by 50 percent. The Diabetic Retinopathy Vitrectomy Study demonstrated that early vitrectomy as compared with deferred surgery for vitreous hemorrhage increases the number of eyes with improved vision. These landmark clinical studies are succinctly reviewed by the editor, Stephen Feman, in the final three chapters and should be required reading for all involved in the primary care of diabetic patients. The color photographs illustrating the various stages and findings associated with diabetic retinopathy enhance the text.

In its attempt to appeal “to anyone involved with the care of individuals who have diabetes,” Ocular Problems in Diabetes Mellitus sets a highly ambitious and often elusive goal. The well-written and clinically oriented chapter on neuroophthalmic disorders will be of interest to primary care physicians and will serve as a brief review for ophthalmologists and residents. Since glaucoma and lens abnormalities are common among diabetics and are associated with increased age, these chapters may also interest primary care physicians. The basic-science-oriented chapter on the cornea has a limited audience and should have been briefer.

The book contains other chapters on subjects ranging from the epidemiology of ocular problems, principles of diabetes treatment, and renal complications to pathogenic mechanisms and the histopathology of diabetic eye changes. Although the book is multiauthored, Dr. Feman has done a good job of editing and preventing repetitious presentations.

Some issues are not covered, although I am not aware that they have appeared in any other textbook, either. Despite major technological advances, why do countless people with diabetes continue to lose their vision? The blindness resulting from diabetic retinopathy is now thought to be due to problems related to a chronic disease. Patients may well feel secure, monitoring their own blood glucose levels at home, and even retain 20/20 vision, yet they might benefit from laser surgery. Since the disease is asymptomatic in its most treatable form, some patients may not know enough to seek care and others may not know whom to consult.

The American Academy of Ophthalmology established the National Eye Care Project to provide referrals to an ophthalmologist. Anyone over the age of 65 who does not have an ophthalmologist can call 1-800-222-EYES, and he or she will be referred to a participating ophthalmologist for examination regardless of whether the person has insurance. Diabetes 2000 is another project of the American Academy of Ophthalmology that attempts to stamp out blindness from diabetes by the year 2000. The Diabetes Control Programs, sponsored by the Centers for Disease Control and Prevention, have supported intervention programs at the state level in similar efforts. Perhaps a future book will report on the successes and failures of these public health projects. Persons with impaired vision may well benefit from low-vision devices, and such services should be publicized and promoted.

For the time being, patients with diabetes should be urged to consult an ophthalmologist at least annually, even if they may have good vision. Readers desiring a brief and up-to-date reference book on the various ways in which diabetes can affect the eye should consider Ocular Problems in Diabetes Mellitus.

Matthew E. Farber, M.D.
Indiana University School of Medicine, Fort Wayne, IN 46805