Dr. Joan Giralt: There are teenagers who do not accept their diabetes and often come to you in a very serious condition"

Well, a lot. Many people are unaware of it, but this disease affects a large number of organs and, above all—and sometimes very severely—organs nourished by blood vessels such as the heart, the kidneys and the eyes. The eyes can be very severely and seriously affected.   

It can be controlled with insulin, with pills, and even without treatment at all, and simply with diet and exercise. As I always tell my patients, it is important to be monitored properly…  But being monitored properly doesn't mean you can’t still have complications.  Whilst in other diseases, you follow a treatment and get better, here you can’t do that. The bad thing about diabetes is that, whilst treatment can help you avoid developing complications…it is not necessarily the case. Obviously, if you are not monitored properly, the risk of developing complications is much higher.    

It mainly affects the retina, which is at the back of the eye. It is a layer of nerve tissue that can be affected by ischemia, i.e. lack of oxygen. And the lack of oxygen causes substances to be produced inside the eye, which are designed to produce new blood vessels that provide the oxygen that is lacking.  

And this, which seems like the eye’s defence mechanism to deal with this problem, becomes a real problem, because the vessels grow in a disorganized manner, with poor quality walls that lose whatever they contain on the inside, i.e. blood with oxygen.  And that can lead to vision loss. The patient may experience floaters: the sensation of seeing spots, like cobwebs, which is the blood leaking from these vessels inside the eye.   

Total loss of vision can occur in very advanced cases of severe proliferative diabetic retinopathy.  When these vessels we were talking about before grow, they pull on and drag the retina, and can cause what is known as tractional retinal detachment. 

Macular oedema is also important. This involves an accumulation of fluid in the macula. The macula is the central part of the retina. There are many diseases that affect the macula, and diabetes is one of them: it can lead to the accumulation of liquid in the macula, causing vision loss. 

Diabetic retinopathy can be mild, moderate, severe and very severe, with or without macular oedema. The disease starts with small haemorrhages, microaneurysms, and can progress over time: a build-up of liquid can occur, and there can be infarctions in the retinal nerve fibre layer…which can end up producing these substances that generate neovascularization, these new blood vessels we mentioned earlier.   

Yes, you can go blind.  It is a disease that can be very serious. And the important thing to bear in mind is that very often you can have diabetic retinopathy and not be aware that you have it, because you normally start to have symptoms when the disease is already advanced. This is why regular check-ups are very important for diabetic patients. 

Vision loss, blurred vision…  And, if it gets worse, the blood vessels may bleed.  This is when the patient sees what we were talking about before: spots inside the eye, which are commonly known as floaters, cobwebs… or even complete loss of vision because there has been a major bleed and the eye is full of blood.  In very advanced cases, retinal detachment may occur, leading to very serious vision loss. 

(LAUGHS) Irreversible... As I always say, in medicine there is no such thing as always or never! The later it is caught, the less chance you have of getting better, right?  We have treatments, but sometimes you can stop the disease progressing but not cure it.  It can be cured too, but the sooner we treat it the better.

To stop this disease progressing we can use a laser, which is a very important form of treatment, and we have newer drugs that also work very well. These are liquid drugs that we inject into the eye. The problem is that these drugs normally have a temporary effect and have to be repeated. And finally, there is surgery, which is normally carried out when the disease is very advanced.  

It depends on the severity of the case. If the patient had proliferative diabetic retinopathy, and there was just a bleed and nothing else...  

Of course, if there is a large bleed that is not absorbed, the patient can’t see. Then, after surgery, they will see what they saw before the bleed. Or sometimes they see a little less than before, because the surgery also has consequences: treatment with laser can help save the eye, but the patient might lose a little night vision, sensitivity to contrast, or even a little visual acuity. And visual field, too.  

No, but a certain percentage do. That is why check-ups are important. Basically, there are two types of diabetic retinopathy, which can be type 1 and type 2. Normally, when type 1 diabetes is diagnosed, the patient can take 3-5 years to develop diabetic retinopathy. Monitoring or examination by an ophthalmologist is not so important at the beginning.  But 3-5 years after diagnosis it is. Type 2 diabetes is normally diagnosed in older people: these are patients who have normally been diabetic for years, but have not been diagnosed. These patients must be seen immediately, because they may already have retinopathy. It is important.

It is basic. It is the key to trying to prevent these patients from going blind. Prevention is to act on their diabetes, ensuring that it is well treated with stabilized blood glucose levels, to act on risk factors that also influence the disease, such as tobacco, the most important risk factor, hypertension and cholesterol... Controlling these factors is very important. And also fundus examinations to see if the disease develops. 

A lot is done at an institutional level, such as information campaigns for patients. And I think that it is everyone’s responsibility:  the medical professionals’ and the patient’s.  

This Monday, a patient signed a consent form for an operation and she smelled of tobacco. I said to her, “You smoke, don’t you?”. And she said, “Yes”. So, the patient is also responsible... We have teenage boys and girls, especially girls, who do not accept their illness and do not take care of themselves. And it’s terrible, because these patients often come to you in a very serious condition. The relationship with family members is very important, as they should be involved to ensure proper monitoring and to stress the importance of managing the disease and attending regular check-ups. 

Every week, I can have 10 diabetic patients that I monitor. That does not mean that they are ill. Some have a little retinopathy, but they stay well because we check them every six months.  

But things are better than before. It’s good to say that! Fifteen years ago, I had more cases that had to be operated on, and far more severe diabetic retinopathies.  Nowadays, this has gone down a lot, because the monitoring of diabetes has improved: the population is much better cared for by GPs, endocrinologists, etc., so we see fewer cases.  

Now, the most serious cases are normally patients from countries where they have a very sweet tooth, places like Morocco and Pakistan, and who have not been properly monitored. So, they come to us with advanced retinopathy. This is more frequent.  But in reality, globally speaking things have improved compared to the situation a few years ago.

That if they have never seen an ophthalmologist, they should do so, that if they smoke they should stop, and they should ensure their cholesterol and blood pressure are monitored.  But, number 1: they should go to an ophthalmologist if they have not been to one since they were diagnosed.