1. Copyright ©2000 BMJ Publishing Group Ltd. Stratton, I. M et al. BMJ 2000; 321:405-412

2. Copyright ©2000 BMJ Publishing Group Ltd. Stratton, I. M et al. BMJ 2000; 321:405-412

3. Copyright ©2000 BMJ Publishing Group Ltd. Stratton, I. M et al. BMJ 2000 ;321:405-412

9. Diabetic Retinopathy Stages of Diabetic Retinopathy 1.background diabetic retinopathy – vascular leakage, swelling and edema of the retina. 2. proliferative diabetic retinopathy: hypoxia results in angiogenesis, new vessels leak and hemorrhage easily. 3. final stage results in retinal detachment and glaucoma, which develops with continued abnormal vessel growth and scarring. How a road sign would appear with diabetic retinopathy.

10. Retinopathy typically seen with Diabetes Mellitus ● Hard exudates --These yellow flecks lie deep in the retina and reflect leakage of incompetent pre-capillary retinal arterioles. ● Dot Hemorrhages lie deep in the retina. Commonly seen in association with diabetic or hypertensive retinopathy.

13. Normal VisionDiabetic Retinopathy

14. Diabetic Nephropathy Nephropathy develops progressively in diabetic patients: ◘ Incipient nephropathy (hyperfiltration and persistent microalbuminuria) - after ~ 18 years ◘ Overt nephropathy (persistent proteinuria and decline in glomerular filtration rate (GFR) - after ~ 29 years ◘ Endstage renal disease (ESRD) requiring dialysis or kidney transplant - after ~ 39 years ◘ Median survival - ~ 45 years Diabetes is a common cause (30%) of chronic renal failure

16. Diabetic Neuropathy About 50% of patients with diabetes have some form of neuropathy, with or without symptoms. Diabetic neuropathy is most common in patients who have: ● have had diabetes for at least 25 years ● poor control of blood-glucose levels ● high lipid levels ● high blood pressure ● overweight ● over age 40 Peripheral neuropathy, which affects the arms and legs, is the most common type of neuropathy. It can cause pain or numbness in the toes, feet, legs, hands, and arms. Patients with peripheral neuropathy may have the following symptoms, which usually worsen at night: ● Numbness or decreased sensitivity to pain or temperature ● Tingling, burning, or prickling sensation ● Sharp pains/cramps ● Extreme sensitivity to touch ● Loss of balance and coordination

18. Decreased blood flow and decreased sensation from peripheral neuropathy can lead to ulcers.

19. Peripheral Vascular Disease The incidence of peripheral vascular disease (PVD) is about four times greater in patients with diabetes than patients without diabetes. Peripheral vascular disease is a condition in which the arteries in the legs, and sometimes the arms, are narrowed by atherosclerosis. It contributes to lower-extremity ulceration, impaired wound healing, and decreased ability to fight infection. In addition to diabetes, other risk factors for PVD include hypertension, smoking, dyslipidemia, obesity, and family history. It is difficult to assess symptoms involving pain or discomfort in patients with neuropathy because they may not realize any sensation. Symptoms: ● Claudication (pain on exercise) ● Feet cold to touch ● Pain at rest or at night ● Absent pulses ● Blanching (whitening) of skin on elevation ● Delayed venous filling (>25 seconds) after elevation ● Atrophy of subcutaneous fatty tissue ● Shiny skin ● Hair loss on foot and toes ● Thickened nails ● Nonhealing ulcer or gangrene