Insulin pumps & diabetic
retinopathy, with a case report
David Kinshuck
Why is an ophthalmologist
interested in insulin pumps?
 Prevention
or
slowing of
retinopathy
 retinopathy still
disabling
This patient asked…would
an insulin pump help me?
This patient asked…would
an insulin pump help me?
Answer given: help you &
and your eyes if you
achieve better control,
and it is likely to improve
your control,
in the long term
What is an insulin pump?
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Battery operated pump size of mobile phone
Worn eg round waist
Insulin in a vial is injected (through a tiny tube) into cannula
inserted under the skin
pump is is programmed to deliver insulin constantly
patient determines rate
no other insulin injections, but still need to test glucose levels
4-6 x day (& adjust infusion rate)
‘bolus’ insulin at meal times (amount  size of meal)
basal rates otherwise (variable rate)
much more flexibility over your life
change cannula every 2 days (disconnect to swim etc)
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1968 DOB, 1976 IDDM
1998 background retinop,
6/5, 6/5
1999 proliferative, lots of
laser, HbA1c 7.9%
works at ……………. husband
very helpful/positive
2000 indirect laser, sight
worse = macular oedema,
cannot drive
6/24 then 6/60 both eyes
HbA1c 7.3%, but widely
fluctuating sugars
Insulin pump 2000
2002 retinopathy not active,
minor problems only, working
6/24, well, controlled
Patient: 1
All photos
2000
A bad result…….
Each patient with poor sight makes you think
• was the laser OK?
•diabetic control………..could we have done
better?
•European centres with good results have
2 monthly patient/DSN contact………how
can we improve without this?
•These clinics laser 1% diabetic patients,
versus UK average 10% (Gouda, Holland)
•1/365 nurse/adult patient ratio
(Holland), Good Hope 1/1333
Identifying progression of
retinopathy
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Exudates/oedema =
leakage
New Vessels
An ‘early’ sign =
haemorrhages
An
increase in
any of these
Photos useful for
haemorrhages
especially
Progressing………why?
Retinopathy is linked
to:
DCCT
study
1% HbA1c =
37% progression rate
Retinopathy is linked
to:
1mmHg =
1.1% progression rate
Retinopathy is linked
to:
Retinopathy is linked
to:
Genetic = 25% Retinopathy
Family history heart
disease, stroke, blood
pressure
Retinopathy is linked
to:
Smoking 20/day =
300% progression rate
Passive smoker gets 25%
of the smoke
Retinopathy is linked
to:
Statin reduces heart
problems by
25-50% (estimate)
Treat even if normal,
especially if there are
exudates
Retinopathy is linked
to:
ACE inhibitors
reduce
retinopathy
by 50%
Retinopathy is linked
to:
Retinopathy is linked to:
Retinopathy progression
Retinopathy is linked to:
Renal function
decrease
Retinopathy is linked to:
pregnancy
Progressing, HbA1c > 7.0%
Why?
Suitable regime?…………
young patients on bd insulin?
 Basal bolus, but sugars fluctuate, hypos
 This patient read about pumps and bought one
herself
 Do I mention pumps?
 First patient’s retinopathy halted
 Insulin pumpers web site, advice from retinopathy
experts at European meetings
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www.insulin-pumpers.org
Balance
resources
motivation
the wrong time or an
unenthusiastic patient
Flexible dose insulin regime
Pump probably best for very dedicated (and rich)
patients (HbA1c 6.0-7.0%), controversial
 Best results are if you test your blood sugar 4-6
times a day, and adjust insulin
 A typical new regime: lantus (glargine) longacting
insulin for basal insulin; analogue for meals
(lispro/novorapid)
 5% of patients are already on this new regime
 Should be able to achieve HbA1c 7.0% with good
nursing help, without dangerous hypos
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Patient 2
Patient 2
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1969 DOB, 1977 IDDM
professional, lives alone, sports++++
1995 background retinopathy, 6/5, 6/5
1995 proliferative, bd insulin
1995-99 lots of laser, 6000/burns/eye
2000 HbA1c 8.4%
2000 vitreous haemorrhage
mediocre control/severe hypo
proliferation continues, laser
2001 Insulin pump, well, controlled, happy
2002 retinopathy not active
6/9 driving/sports…some problems
Patient 3
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1968 DOB, 1984 IDDM
1998 background retinopathy, 6/5, 6/5
1999 HbA1c 9.7%
(similar for years, alcohol++)
2000 maculopathy lasered, 6/5
2001 proliferative, lots of laser, HbA1c 8.0
2002 struggled with pump, HbA1c 7.6
Insulin pump, making wrong decisions re
insulin, not in contact with other IDDM
patients
got married, HbA1c 8.1
ischaemic maculopathy, will get worse
ACE inhibitor
?would starting pump while intellectual
function better have helped
Patient 4
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1966 DOB, 1971 IDDM
1999 proliferative retinopathy++, 6/5, 6/5
1999, lots of laser, HbA1c 7.7%,
smoked and stopped re retinopathy
weight increased
? Using insulin to diet/food issues
HbA1c 7.7%, but widely fluctuating sugars
Insulin pump, a real struggle
2002 6/12, macular ischaemia still, 7.3%
retinopathy less active
would have had poor result without
What should we
achieve?
resources
motivation
Support people
here
the wrong time
unenthusiastic patient
Help change behaviour
May have no
choice to
accept
Summary
5
patients, have HbA1c about 1% less or fewer hypos
4 with stable or nearly stable retinopathy
Many others not keen on pump
Hard work for 3, real struggle for 2 (& DSNs)
All have severe retinopathy scarring
Logically,
better control earlier would be best
Improved decision making without retinopathy?
(re patient adjusting own insulin)
10 years behind European centres
Need 1-2 monthly contact with DSN
Desperately short of DSNs (& pumps)