1068 tient, and these devices

Letters

to

the Editor

same, we have

before,

nor

have

yet widely available. All the regression of this type of lesion reported by others, and we think

are not

never seen we seen

it

potential for strict metabolic control in diabetics with late complications should stimulate diabetologists to try out these devices and provide an incentive for manufacturers to improve them. that the

REVERSAL OF FLORID DIABETIC RETINOPATHY your editorial’

on insulin delivery systems for diathat the postponement or prevention of longterm complications is a major advance that may now be within reach. Having achieved near normoglycxmic control in this way in an unstable diabetic who experienced improvement in vision and loss of severe neuropathic pain,2 we tried this approach, as an alternative to pituitary ablation, in a diabetic threatened with blindness from severe proliferative florid

SIR,-In

betics you

state

retinopathy. This 24-year-old female had had poorly controlled, very unstable, insulin-dependent diabetes since the age of 7. She had been nearly blind for 6 months before admission to our hospital in May, 1979. The daily blood-glucose profile ranged from 114 to 457 mg/dl (18 mg/d=l mmol/1) and she had two or three hypoglycaEmic episodes per week (HbAI 16.8%). Both eyes showed the typical retinal changes of florid retinopathy with new vessels spreading -preretinally, severe leakage on fluorescence angiography, large non-perfused areas, and several haemorrhages. She had oedema of the legs (5-14 g renal protein loss per day). Motor nerve conduction velocity was severely reduced. We preprogrammed a portable Siemens insulin delivery sysprovide insulin infusion rates with additional square of insulin for an hour immediately before meals. In the first 3 weeks we achieved metabolic control, with a bloodglucose range of 110-150 mg/dl (mean ± SEM for all values 118±5). As soon as she could read glucose strips in an ’Eyetone’ reflectance meter and could handle the pump system herself she was discharged, and she achieved normoglycxmia as an outpatient for 120 days with daily blood-glucose measurements in the range 88-120 mg/dl (97 ± 1) (see table). tem to waves

DIABETIC STATE ON ADMISSION IN AFTER

150

MAY,

1979, AND IN OCTOBER,

DAYS ON INSULIN MINIPUMP

Dr Franetzki, Dr Kresse, and Herr Prestele of Siemens (Erlangen) constructed, supplied, and improved the technical devices. Dr Thurow, Dr Schone, Dr Geisen, and Dr Enzmann (Hoechst AG, Frankfurt) overcame the difficulties with insulin plugs which had been a major obstacle to long-term application. Metabolic Unit and Boltzmann Research Institute for Metabolism and Nutrition,

KARL IRSIGLER HARALD KRITZ CLAUDIA NAJEMNIK

City Hospital, Vienna-Lainz, 1130 Vienna, Austria

Ophthalmology Department, University Clinic,

HEINZ FREYLER

Vienna

VITREOUS FLUOROPHOTOMETRY AND BLOOD-SUGAR CONTROL IN DIABETICS

SiR-Vitreous

fluorophotometry

is

a

technique

for

measur-

ing the permeability of the blood-retinal barrier in diabetes mellitus. After intravenous injection, there is a greater than normal leak of fluorescein into the vitreous of diabetic patients. This alteration occurs before diabetic retinopathy can be detected by any other method. Diabetic patients (even without detectable retinopathy) can be separated from the normal population with this technique.’,2 We have recently studied a small group of diabetic patients taking multiple, daily insulin injections after repeatedly checking their own blood sugars. Vitreous fluorophotometry values in the five patients who had achieved excellent control with close-to-normal blood sugars and haemoglobin Alc (HbA1d measurements below 8% (group 1) had fluorescein levels similar to those in our control population (group 3). However, values in the six patients with HbAlc values above 8% (group 2) were comparable to those in diabetic patients with early background retinopathy (group 4) (table). Duration of diabetes was 10 years in group 1 and 7 years in group 2. VITREOUS FLUOROPHOTOMETRY AND

Improved vision enabled her to resume her work as a bank clerk. She has no difficulties with reading, albuminuria has decreased considerably, the oedema has disappeared, and she has gained 6 kg in weight. She has easily kept blood-sugar values in the range 83-120 mg/dl and low blood-sugars are better tolerated. The patient adjusts insulin delivery by the minipump according to changing dietary habits. Apart from three catheter obstructions, which the patient overcame by rinsing the catheter with saline, and a few machine breakdowns necessitating changes to a reserve pump, the same polyethylene catheter inserted in a central vein by the subclavian route was still functioning after 150 days. Fluorescence angiography of the retinal vessels has demonstrated regression of previously severe lesions. There was hardly any leakage and perfusion was much better, with recapillarisation of previously non-perfused zones and regression of newly formed preretinal vessels. Management of insulin therapy with an infusion delivery system may offer a real chance of success in the diabetic threatened with blindness from proliferative or florid retinopathy. The handling of mechanical insulin delivery systems on an outpatient basis demands cooperation and skill from the pa1. Editorial. New insulin-delivery systems for diabetics. Lancet 1979; i: 1275. 2. Irsigler K, Kritz H. Long-term continuous intravenous insulin therapy with a portable insulin dosage-regulating apparatus. Diabetes 1979; 28: 196.

HbAIC VALUES

Vitreous fluorophotometry allows us to evaluate quantitatboth the earliest ocular changes in diabetes mellitus and the effects of diabetic control. Multiple daily injections of insulin with normal HbA1c values appear to correct the earliest ocular vascular abnormalities of diabetes.

ively

Departments of Ophthalmology and Pediatrics, and Clinical Research Center,

Washington University School of Medicine, St. Louis, Missouri 63110, U.S.A.; and St. Louis Children’s Hospital

STEPHEN R. WALTMAN JULIO SANTIAGO THEODORE KRUPIN PAUL SINGER BERNARD BECKER

Department of Medicine, Brooklyn Hospital,

Brooklyn, N.Y.

SHELDON BLEICHER

1. Waltman SR, Oestrich C, Krupin T, Hanish S, Ratzan S, Santiago J, Kilo C. Quantitative vitreous fluorophotometry: A sensitive technique for measuring early breakdown of the blood-retinal barrier in young diabetic patients. Diabetes 1978; 27: 85-87. 2. Cunha-Vaz J, Faria De Abreu JR, Campos AJ, Figo GM. Early breakdown of the blood-retinal barrier in diabetics. Br J Ophthalmol 1975; 59: 649-56.

Reversal of florid diabetic retinopathy.

1068 tient, and these devices Letters to the Editor same, we have before, nor have yet widely available. All the regression of this type of le...
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