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Diabetes self-management still possible with vision loss
Patients with diabetic eye disease present a unique challenge to health care providers not only in terms of disease progression, but also in terms of using devices or treatment regimens designed primarily for sighted patients.
“Patients with vision loss or blindness face limitations in using tools developed for the sighted with diabetes, and in their ability to visually perform many of the daily self-care practices needed to maintain their health and optimize blood glucose,” Anna Simos, MPH, MS, diabetes education and prevention program manager at Stanford Health Care, Stanford University Medical Center, told Endocrine Today. “Additionally, the emotional impact of blindness on an individual is a complex subject, as it affects multiple levels of the caregiving delivery process.”
Diabetes has various damaging effects on the eyes, and diabetic eye disease is a key contributor to vision loss and blindness.
“Diabetes is the leading cause of blindness for American adults and globally,” Marina Basina, MD, clinical associate professor at Stanford University Medical Center’s division of endocrinology, gerontology and metabolism, told Endocrine Today. “The number is expected to rise further due to the increasing prevalence of diabetes, aging of the population and increasing life expectancy in individuals with diabetes.”
Causes of diabetes-related vision loss
Retinopathy is the most prevalent cause of diabetes-associated vision loss, but it is far from the only one, Basina said.
“Having diabetes also increases the risk for developing cataracts, glaucoma, macular edema and several other eye conditions that can cause severe visual impairment,” she said.
According to Simos, visual damage can occur because of uncontrolled blood glucose, high cholesterol levels and hypertension. She emphasized the importance of preventing the onset and progression of vision loss by educating patients about these factors.
“As a diabetes educator, it is essential to explain the risk of poorly controlled blood glucose and other factors that will lead to eye disease and eye-related complications,” she said.
Regularly checking and controlling blood glucose is an important means of preventing vision loss in patients with diabetes. Simos also advises patients to undergo annual dilated eye exams, measure their cholesterol level and control their blood pressure. Lifestyle changes, such as smoking cessation and regular exercise, are also valuable, she said.
Everyday obstacles
In addition to the inherent challenges of living with diabetes, patients with diabetes-related vision loss may face barriers to their own self-management. The ability to effectively use devices or implement necessary self-care regimens may be compromised in a patient with vision loss.
“These challenges may include difficulty with blood glucose testing, rotation of insulin shots, manipulation of insulin pumps and changing of sets or placement of a continuous glucose monitor, and sensory-visual inspection of all wearable technology to ensure delivery is not being hindered by a misplaced or faulty connection,” Simos said.
Insulin pumps and CGM appear to be particularly difficult for patients with vision loss.
“Insulin dosing and diabetes self-management are challenging for visually impaired patients,” she said. “Despite the known benefits of insulin pumps and CGM, use is low in patients with visual impairment due to inherent limitations.”
Patients with visual impairment may struggle with assessing the integrity of the insulin injection site, delivering the complete insulin dose, accurately using the blood glucose meter and completing a visual check of the device site.
“Safety concerns, as well as the practicality of being able to accurately and autonomously interface with the device, prevent insulin pump and CGM therapy from being realized in the visually impaired population,” Simos said.
In addition to these vision-related limitations, there is a significant emotional component to vision loss and diabetes. Patients may feel anxious or depressed about limited vision and may become discouraged about playing an active role in their own care, Simos said.
“Loss of vision has an impact on the diabetic patient’s outlook on life, which can include their motivation to take care of themselves, as well as emotional issues surrounding depending on others and, ultimately, a lack of autonomy,” she said. “The emotional impact of blindness affects multiple levels of the caregiving delivery process, and also manifests itself in potential depression, frustration, resentment, isolation and dependency, which affects the individual suffering the complications and their home support system.”
Goals, strategies
Simos said to pursue the best treatment for a patient with diabetes-related vision loss, the clinician must first assess the patient’s visual and physical limitations, current HbA1c and glycemic excursions, daily insulin dose and ability to track carbohydrates. The patient’s goals for self-management, problem-solving skills and level of home support should also be considered.
“After an assessment is completed, an appointment should be scheduled with the physician, educator, patient and a family member,” she said. “A discussion of viable options should be presented, and the training requirements for each should be outlined. Realistic expectations should be discussed, and measurable goals should be set.”
According to Basina, patients with vision loss can empower their self-management by optimizing their devices and equipment.
“There are many assisting devices, such as insulin pens, syringe magnifiers and talking glucometers, that can help patients self-manage their diabetes,” she said. “While there are no insulin pumps currently available that have speech output, most of the pumps have an audio bolus feature. For patients who would like to use an insulin pump, this option is feasible, but it is important to work with the diabetes team to choose the right device.”
Insulin-delivery options
For patients with diabetes-related vision loss, preserving health and attaining independence in self-management requires mastery of insulin administration, Basina said.
“Whether this is through the use of multiple daily insulin injections, a combination of oral medications and basal insulin, premixed insulin, or continuous insulin infusion via insulin pump, precision in insulin administration is very important,” she said.
The simplest and least expensive means of insulin administration — through insulin syringes — is difficult for patients with limited vision.
“Despite the availability of the magnifier devices for drawing the dose, the challenges of picking the right vial, checking for air bubbles in the syringe and knowing when insulin is getting low in the vial remain unresolved,” Basina said.
Similarly, insulin pens present challenges in terms of choosing the correct pen, counting the clicks to get the correct dose, priming the needle and injecting correctly.
Despite the cost and complexity of insulin pumps, a patient with vision loss can use these devices with close guidance and monitoring by the health care team, Basina said.
“We presented a case report at the annual 2016 American Diabetes Association meeting, regarding successful use of the OmniPod insulin pump in a legally blind type 2 diabetes patient,” Basina said. “He used a phone application that translated text instructions from the personal diabetes manager (PDM) into speech. The patient’s HbA1c decreased from 9.8% to 6.9% after 6 months’ use of the insulin pump.”
An inhaled form of insulin, Afrezza (MannKind Corp.), also is available.
“However, this needs further investigation for use in visually impaired patients,” Basina said.
A team approach
Ultimately, Simos said, a patient with diabetes and impaired vision needs a dedicated and involved team to succeed in self-management.
“Often, it is the health care team that conveys the information about new technologies that can optimize diabetes-related outcomes and quality of life,” she said. “The health care team can ensure that patients perform their home regimen safely, streamline their care plan with tools to create autonomy and optimize diabetes-related outcomes.”
According to Basina, approaches to successful diabetes self-management should be customized and multifaceted.
“There is no one best approach for the treatment of these individuals; it requires a multidisciplinary approach involving physicians, diabetes educators, social workers and, frequently, a psychologist,” she said. “Family help and support are also extremely important.”
Improvements to diabetes technology are likely to ensure safer self-management, but the need for a committed care team remains, Simos said.
“We have arrived at a place in diabetes-related technology where we are streamlining the amount of self-care in patients with diabetes. Still, the ability to easily access and integrate this technology is limited for visually impaired patients,” she said. “Successful diabetes management in the visually impaired individual takes partnership and commitment from the health care team, the individual and their home support team in the training, management, follow-up and maintenance of the diabetes care plan.” – by Jennifer Byrne
Reference:
Simos A, et al. 75-OR. Presented at: American Diabetes Association’s Scientific Sessions; June 10-14, 2016; New Orleans.
For more information:
Marina Basina, MD, can be reached at 300 Pasteur Drive, Suite A175, Stanford, CA 94305; mbasina@stanford.edu.
Anna Simos, MPH, MS, can be reached at 211 Quarry Road, Palo Alto, CA 94304; asimos@stanfordhealthcare.org.
Disclosure: Basina and Simos report no relevant financial disclosures.