Previously, we discussed monitoring for chronic kidney disease in patients with diabetes. In this final part of our series, we’ll discuss screening to prevent impairment to the patient’s mobility and sight.
CASE CONTINUED
Mr. W is appreciative of your efforts to improve his health, but he fears his quality of life with diabetes will suffer. Because his father experienced impaired sight and limited mobility during the final years of his life, Mr. W is concerned he will endure similar complications from his diabetes. What can you do to help safeguard his abilities for sight and mobility?
Detecting peripheral neuropathy
Evaluation of Mr. W’s feet is an appropriate first step in the right direction. Peripheral neuropathy—one of the most common complications in diabetes—occurs in up to 50% of patients with diabetes, and about 50% of peripheral neuropathies may be asymptomatic.40 It is the most significant risk factor for foot ulceration, which in turn is the leading cause of amputation in patients with diabetes.40 Therefore, early identification of peripheral neuropathy is important because it provides an opportunity for patient education on preventive practices and prompts podiatric care.
Screening for peripheral neuropathy should include a detailed history of the risk factors and a thorough physical exam, including pinprick sensation (small sensory fiber function), vibration perception (large sensory fiber function), and 10-g monofilament testing.7,8,40 Clinicians should screen their patients within 5 years of the diagnosis of type 1 diabetes and at the time of diagnosis of type 2 diabetes, subsequently scheduling at least annual screening with a full foot exam.7,8
Further assessment to identify risk factors for diabetic foot wounds should include evaluation for foot deformities and vascular disease.7,8 Findings that indicate vascular disease should prompt ankle-brachial index testing.7,8
Patients are considered at high-risk for peripheral neuropathy if they have sensory impairment, a history of podiatric complications, or foot deformities, or if they actively smoke.8 Such patients should have a thorough foot exam during each visit with their primary care provider, and referral to a foot care specialist would be appropriate.8 High-risk individuals would benefit from close surveillance to prevent complications, and specialized footwear may be helpful.8
How to Screen for Diabetic Retinopathy
Also high on the list of Mr. W’s priorities is maintaining his eyesight. All patients with diabetes require adequate screening for diabetic retinopathy, which is a contributing factor in the progression to blindness.41 Referral to an optometrist or ophthalmologist for a dilated fundoscopic eye exam is recommended for patients within 5 years of a diagnosis of type 1 diabetes and for patients with type 2 diabetes at the time of diagnosis.2,7,8 Prompt referral is need for patients with macular edema, severe nonproliferative diabetic retinopathy, or proliferative diabetic retinopathy. The ADA considers the use of retinal photography in detecting diabetic retinopathy an appropriate component of the fundoscopic exam because it has high sensitivity, specificity, and inter- and intra-examination agreement.8,41,42
