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10. Screening and treatment
of microvascular complications
The questions to be answered are the following:
• Should a screening of the diabetic retinopathy be carried out? With which technique and
how often?
• Is a diabetic nephropathy screening to be done? How often should it be carried out? What
methods are to be used?
• Which is the treatment for patients with DM 2 and microalbuminuria?
• Which is the treatment for painful diabetic neuropathy?
• Which is the treatment for erectile dysfunction in a type 2 diabetic patient?
10.1. Diabetic retinopathy screening
Diabetic retinopathy is the first cause of blindness for people under 60 and one of
the main causes of blindness among the elderly. 20 years after diabetes is diagnosed,
more than 60% of type 2 diabetic patients will suffer from retinopathy. In
type 2 diabetics, maculopathy is the main cause of sight loss (215).
The risk of sight loss and blindness can be reduced through programs which
combine methods for screening with diabetic retinopathy effective treatment
(215). It is essential, both to determine which technique is best and how often the
retinopathy screening is to be carried out.
The effectiveness of the non-mydriatic retinal camera as a screening method
to detect the presence and severity of diabetic retinopathy has been described in
several studies (216; 217). The technique requires only one photograph which
includes the papilla and the macula, and is interpreted by professionals. In a study
carried out in our field (218), the non-mydriatic 45º retinal camera showed 91.1%
of sensitivity and 89.7% of specificity, in contrast to the standard method (biomicroscopic
technique with an ophthalmoscope with a 78D lens) and was cheaper
for the patient. The non-mydriatic retinal camera is more sensitive than the screening
with an ophthalmoscope when compared with seven standardised photographs
(217).
In order to establish the optimal interval for retinopathy screening through
a photograph from a non-mydriatic camera, a cohort study was carried out across
4,770 type 2 diabetic patients derived from primary care (219). The accumulated
incidence of sight-threatening retinopathy, according to the initial level of retinopathy
(without retinopathy, mild preproliferative retinopathy, severe retinopathy)
was assessed. In patients without initial retinopathy, the retinopathy-accumulated
Studies of
diagnostic
tests
II
Cohort
study
2++
CLINICAL PRACTICE GUIDELINE ON TYPE 2 DIABETES 87