Rapid Deterioration of Diabetic Retinopathy During Treatment with Continuous Subcutaneous Insulin Infusion

Abstract

The effect of continuous subcutaneous insulin infusion (CSII) on diabetic retinopathy was studied in 19 patients with insulin-dependent diabetes mellitus (IDDM). All had diabetes before age 30. Three patients had no retinal abnormalities at the start of the study, 12 had minimal or mild background retinopathy, and 4 had a preproliferative retinopathy. The follow-up period was 12-14 mo. Fundus photography and fluorescein angiography was performed every 2-6 mo. Despite marked improvement of metabolic control, none of the patients with retinopathy showed reversal of the fundal abnormalities. In seven patients with background retinopathy the abnormalities remained unchanged; in five patients a slight worsening was noted. Four patients with moderate-to-severe background retinopathy showed a rapid and severe progression of the fundal abnormalities into a florid proliferative diabetic retinopathy 3-6 mo after initiation of CSII. A higher incidence of hypoglycemic episodes could not be demonstrated in this group. Two of these patients showed a marked reduction in glomerular filtration rate (GFR), 34% and 38%, respectively, during the course of their follow-up. This is compared with a decrease in GFR by only 5.6% for the group as a whole. The four patients with rapidly progressive retinopathy all had long-standing poorly controlled diabetes with preproliferative retinal changes, diabetic neuropathy, and, with the exception of one patient, signs of nephropathy at the start of CSII. The incidence of these features was nil or very low in the remaining 15 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Different apoptotic responses of human and bovine pericytes to fluctuating glucose levels and protective role of thiamine

“…These findings are consistent with the clinical observation that daily fluctuations in plasma glucose concentrations, which occur in diabetic patients, are correlated to increases in cardiovascular disease [23] and microvascular complications [24]. On the other hand, diabetic retinopathy was demonstrated to accelerate, after reducing blood glucose levels, particularly if a rapid improvement in glycaemic control is achieved [25][26][27][28]. Nevertheless, several reports in the literature show a high sensitivity of bovine pericytes also to a direct exposure to high glucose concentrations [6,17,29].…”

Pericyte Loss in Diabetic Retinopathy: Mechanisms and Consequences

“…However, as already mentioned, human retinal pericytes seem to be more sensible to intermittent than stable high glucose concentrations, due to impairment in the Bcl-2/Bax ratio [51,52], while rapid glucose normalization, explained as "ROS -mediated cellular memory" of vascular stress has been shown in EC and retinal ARPE-19 [56], consistently with the clinical observation that daily fluctuations in plasma glucose concentrations in diabetic patients are related to increased risk of cardiovascular disease [57] and microvascular complications [58]. DR itself has been seen to accelerate after restoration of physiological glycaemic levels, mostly if glycaemic control is rapidly achieved [100][101][102][103].…”

The change of macular thickness measured by optical coherence tomography in relation to glycemic control in diabetic patients

“…For CSMT, group 1 tended to have a greater HbA1c reduction (−2.9% vs −1.2% of THb, p=0.074) than group Introduction Improvement of glycemic control reduced the risk of development and progression of diabetic retinopathy [1,2]. However, paradoxical worsening of retinopathy after rapid improvement of blood glucose level in both type 1 and type 2 diabetes was also reported in several literatures [3][4][5][6][7][8][9][10][11]. The Diabetes Control and Complication Trial (DCCT) demonstrated that early worsening of retinopathy was observed at 6-and 12-month visits in 13.1% of patients assigned to intensive treatment, and in 7.6% of patients assigned to conventional treatment.…”