Diabetic Eye Care for Older Adults

How diabetes harms the eyes

Diabetic retinopathy. Persistently high blood sugar damages the tiny blood vessels of the retina. In early (non-proliferative) stages, vessels leak or bulge, causing small haemorrhages and fluid. In later (proliferative) stages, the retina, starved of oxygen, grows fragile new vessels that can bleed into the eye or pull on the retina, causing detachment.

Diabetic macular oedema. Fluid leaks into the macula, the central part of the retina that gives sharp vision, causing blurred or distorted central vision. It can occur at any stage of retinopathy and is a common cause of vision loss.

Cataract. People with diabetes tend to develop cataracts earlier and faster; see living with cataract: daily adjustments before and after surgery.

Glaucoma. The risk is higher in people with diabetes, and some new vessel growth can cause a severe form; see glaucoma and macular degeneration: practical home support.

Fluctuating vision. Large swings in blood sugar can change the shape of the lens and cause temporary blurring. Vision may vary through the day.

Other problems: dry eye, nerve problems affecting eye movement and eye infections.

Risk rises with the duration of diabetes, poor sugar control, high blood pressure, high cholesterol, kidney disease, smoking and pregnancy in younger women. In older adults with long-standing type 2 diabetes, retinopathy may already be present at diagnosis, since the diabetes may have been silent for years.

Symptoms (and why you cannot wait for them)

Early diabetic eye disease usually has no symptoms. When symptoms occur, they may include:

• Blurred or fluctuating vision.
• Floaters, dark spots or strings in the vision.
• Dark or empty areas.
• Difficulty seeing at night or colours looking faded.
• Distortion of straight lines.
• Sudden loss of vision.

Because of the silent early stage, everyone with diabetes needs regular eye checks, whether or not they have symptoms.

Urgent warning signs: a sudden shower of new floaters, a red or dark curtain across the vision, sudden loss of vision in one eye, flashes of light or severe eye pain. Go to an eye hospital at once, or call 112 if with weakness, facial droop, speech difficulty or confusion. See signs to watch in the eyes.

How often to have the eyes checked

Guidelines such as those of the American Diabetes Association and NICE advise that people with type 2 diabetes have a dilated eye examination or retinal photographs at diagnosis and then at least every one to two years, or more often if retinopathy is present or progressing. Many eye doctors advise yearly checks for older adults with long-standing diabetes. Your parent's eye doctor will set the interval. Do not skip because the vision seems fine, and keep the appointment even if sugar levels are good. See a hearing and vision check-up schedule after 60.

What the examination involves

1. History and vision test, with and without glasses. 2. Drops to dilate the pupils, which makes the eyes blurry and light-sensitive for several hours. Bring sunglasses and a companion; do not drive afterwards. 3. Examination of the retina with a special lens or camera, looking for bleeding, leaking, new vessels and oedema. 4. Retinal photographs or OCT scan (optical coherence tomography), a painless scan that shows the thickness and swelling of the macula. 5. Eye pressure measurement and a check for cataract and glaucoma. 6. Fluorescein angiography, sometimes, in which dye is injected into the arm to show leaking vessels, causing temporary yellowing of skin and urine. 7. Discussion of the results and the plan.

Ask for a written report and share it with the diabetes doctor, and keep a copy in your health record; see keeping a health record at home.

Treatments

The eye specialist decides which, if any, is needed.

• Observation and tight control of sugar, blood pressure and cholesterol for mild disease.
• Laser treatment to seal leaking vessels or to treat areas of the retina that provoke new vessels, reducing the risk of severe loss. It is usually done in the clinic.
• Injections into the eye of medicines that reduce vessel leakage and growth, repeated at intervals. They are given under local anaesthetic and can stabilise or improve vision in macular oedema.
• Steroid implants or injections in selected cases.
• Surgery (vitrectomy) for bleeding that does not clear or for retinal detachment.
• Cataract surgery when needed; the eye must be stable.

Treatment prevents further loss and does not usually restore all that has been lost, so early detection matters. Treatments need follow-up visits; missing them risks vision.

What families can do at home

1. Support sugar, blood pressure and cholesterol control. These are the foundation. - Follow the diabetes plan, medicines, meals and activity. Never change medicines without the doctor. - Test blood sugar as advised; see how to test blood sugar at home step by step and diabetes after 60: a home care guide. - Check blood pressure; see high blood pressure after 60: a home care guide. - Know that the long-term average sugar (HbA1c) matters more than single readings. Aim for the targets the doctor sets. Very rapid lowering of sugar in someone with existing retinopathy can, in some cases, temporarily worsen it, so the doctor manages changes and may arrange eye checks. - Help with healthy meals; see nutrition for diabetes after 60.

2. Make appointments easy. - Put the yearly eye check in the family calendar. - Accompany your parent; dilation blurs vision for hours. - Bring the medicine list and the sugar log. - Make a note of the doctor's advice.

3. Stop smoking and avoid tobacco; it increases the risk of eye damage.

4. Look after the feet and kidneys too, since diabetic complications travel together; see diabetic foot care at home and diabetic foot ulcers: prevention and early warning signs.

5. Do not change glasses while vision is fluctuating from sugar changes. Wait until sugar is stable before a new prescription, as advised by the optometrist.

6. Protect the eyes with sunglasses and avoid rubbing them; see best sunglasses for seniors.

7. Use drops correctly if prescribed; see eye drops made easy: tips for older hands. Never use steroid or other eye drops bought without a prescription; some can raise eye pressure and worsen cataract and glaucoma.

8. Keep exercise and sleep regular, as advised; see exercise with diabetes in older adults. Heavy straining, as in weightlifting, may be restricted in proliferative disease; ask the eye doctor.

Adapting the home when vision is reduced

• Increase and direct light, reduce glare, and add contrast; see lighting for older eyes: brightness, colour and glare and low vision home safety: contrast, labels and layout.
• Use magnifiers and large print; see magnifier lamps: reading and hobbies with low vision.
• Use a glucometer with a large display or voice if sight is poor; see glucometers: how to choose and use one and home monitoring with poor eyesight or tremor.
• Label medicines, and ensure accurate insulin dosing with suitable devices and supervision; see giving injections and insulin at home.
• Prevent falls; see falls risk assessment at home.

Emotional impact

Learning that diabetes threatens sight is frightening. Provide information, hope and practical help. Many people maintain good vision for decades with good care. Watch for low mood, anxiety and withdrawal; see depression in older adults.

Access and cost in India

Retinal screening, laser and injections are available at eye hospitals, diabetes centres and many camps, with varying cost. Government and charitable programmes may support care; ask the hospital and see government schemes for senior citizens and health insurance for senior citizens in India. Beware of unproven "herbal" or "stem cell" treatments for diabetic eye disease; discuss any such claim with your eye doctor first.

When to ask a professional

See an ophthalmologist or retina specialist for dilated eye examination at least yearly. Ask the diabetes doctor to review sugar, blood pressure and cholesterol. Ask the optometrist about glasses once sugar is stable. Ask an occupational therapist or low vision clinic if sight is reduced. Go urgently for sudden loss of vision, a curtain, new floaters or flashes, or severe pain. Call 112 for stroke signs.