Welcome to Insulin Dependent Diabetes Trust

There are still many misunderstandings about eyes and the roles of the various healthcare professionals who look after them. Some of these misunderstandings mean that people sometimes worry unnecessarily. To some extent the blame lies with the professionals involved for using terms and language that people don’t understand and for nor spending enough time explaining conditions of the eyes in a simple and straightforward way.

Many people are quite nervous when they have their eyes examined and this does not just apply to people with diabetes. Our eyes provide sight which is probably the most important of our 5 senses and so it is understandable that we are all a little nervous that when we have our eyes examined – the underlying fear of ‘bad news’.

In this section we hope that we provide some clear explanations of the common conditions that can affect the eye, especially those that apply to people with diabetes. At the same time perhaps we can dispel some of the myths and misunderstandings that occur.

It must be strongly emphasised that it is important that everyone should have regular, full eye examinations but especially for people with diabetes. Early detection and diagnosis of many eye conditions means that treatment can start early in order to preserve sight. In the UK everyone with diabetes is entitled to a free eye test.

Before considering diabetic eye disease we need to understand a little of how the anatomy of the eye and how the eye works.

· IRIS - this regulates the amount of light that enters the eye. It is the coloured part of the eye across the front of the lens. Light enters through a central opening called the pupil.

· PUPIL – is the circular opening in the centre of the iris through which light passes. The iris controls dilation and constriction of the pupil.

· CORNEA- is the clear circular part of the front of the eyeball. It refracts the light entering the eye on to the lens, which then focuses it on to the retina. The cornea is extremely sensitive to pain.

· LENS - is a transparent crystalline structure behind the pupil of the eye. It helps to refract incoming light and focus it on to the retina. A cataract is when the lens becomes cloudy, and then the lens can be removed and replaced with a plastic intra-ocular lens.

· RETINA - is a light sensitive layer that lines the interior of the eye. It is made up of light sensitive cells known as rods and cones. The rods are necessary for seeing in dim light. And the cones best in bright light and are essential for receiving a sharp accurate image. Cones can also distinguish colours. The retina works much in the same way as film in a camera.

· MACULA - Is the yellow spot on the retina at the back of the eye and is the area with the greatest concentration of cone cells. It is the area of greatest acuity of vision such as reading.

· OPTIC DISK - is the visible portion of the optic nerve on the retina. The optic disk is the start of the optic nerve where messages from cone and rod cells leave the eye and pass along nerve fibres and so transfer all the visual information to the brain. The optic disk is also known as the 'blind spot'.

For sight to take place light must be able to pass to the retina at the back of the eye. The light passes through cornea and enters the eye through the pupil. It then passes through the lens and the vitreous to be focussed on the retina. The focussed light or images of what we have been looking at, are then passed down the optic nerve to the brain.

A review of retinopathy by the University of York NHS Centre for Reviews and Dissemination published in Effective Health Care, August 1999, provides the following information:

· Diabetic retinopathy is the leading cause of blindness in people of working age in industrialised countries. It is estimated that 12% of people who are registered blind or partially sighted in the UK have diabetic eye disease.

· Twenty years after diagnosis almost all those with Type 1 diabetes and 60% of those with Type 2 diabetes will have some degree of retinopathy.

· British screening studies suggest that around 5-10% have sight-threatening retinopathy and up to 40% of people with newly diagnosed Type 2 diabetes have some retinopathy.

· Over the past 15 years laser treatment has been shown to be helpful in either stopping the progress of the condition or in maintaining sight.

· There are two vulnerable groups of people susceptible to retinopathy – firstly, pregnant women and secondly, children and adolescents. In the long term children and adolescents are at greater risk of microvascular and macrovascular complications of diabetes. It is recommended [ref1] that surveillance for the earliest evidence of microvascular disease [this includes retinopathy] should begin at puberty and after 3 and 5 years of diabetes.

Retinopathy is usually classified according to its severity. This may not be the same in both eyes. There are two classifications of diabetic retinopathy:

This is the first stage of the development of retinopathy and it is rare before 8 to 10 years of diabetes duration. At this stage the vision is normal and sight is not threatened. If there are diabetic changes present such as small haemorrhages, fatty deposits [exudates] or abnormal blood vessels [microaneurysms] then this is a sign that the retinopathy is worsening and the doctor will be alerted to arrange more frequent follow ups.

This is where the blood vessels [capillaries] block and starve the retina of nutrients causing new vessels to grow. These new vessels grow either in front of the retina on to the back of the vitreous or occasionally on to the iris. These new vessels are fragile and may bleed into the vitreous. This then affects the sight and may cause floaters, dots or lines and if severe may cause clouding of the vision or loss of vision.

If the vessels grow on the iris, they can cause a rise in pressure in the eye and severe, painful glaucoma. The new vessels eventually cause scar tissue and this can lead to a retinal detachment where the retina becomes detached from the back of the eye with a resulting severe loss of sight.

· Regular eye checks do not prevent retinopathy but do enable early diagnosis and early treatment and this will benefit your sight.

· Small blood vessels in the retina become blocked, swollen or leaky causing oedema and new, fragile vessels grow haphazardly in the retina. This process can continue for years without causing visual symptoms or visual impairment: during this period, retinopathy can only be detected by eye examination.

· In insulin treated diabetes, annual eye checks should be carried out after about 5 years of diabetes or after the onset of puberty in children and young people.

· In people with diabetes not using insulin, then eye checks should take place annually from diagnosis onwards.

· People who have well-controlled diabetes can develop retinopathy if they have had diabetes long enough.

No, but early ‘good’ diabetic control may slow down the rate of progression of the condition. Improving diabetic control rarely has an effect on diabetic retinopathy itself, but it can prevent further deterioration. Therefore you should:

Two of the major insulin manufacturers have admitted that ‘human’ insulin therapy may cause serious adverse reactions. These are very much in line with the evidence from a large number of patients.

18 years after genetically engineered ‘human’ insulin was introduced, there is still no evidence of any clinical benefit for patients when compared to natural animal insulin and patients in countries around the world have complained of adverse reactions to it. These largely regress with a change to natural animal insulin but this is being systematically withdrawn from the market for commercial reasons. However, patients reporting adverse reactions have been largely ignored by regulatory bodies, doctors and healthcare professionals.

On April 24^th 2000, insulin manufacturer, Aventis Pharmaceuticals, issued the following statement in a press release:

"Human insulin therapy may be associated with hypoglycaemia, worsening of diabetic retinopathy, lipodystrophy, skin reactions (such as injection-site reaction, pruritus, and rash), allergic reactions, sodium retention and oedema."

The statement put in the public domain by the insulin manufacturer themselves, has very serious implications for people with diabetes. The risk/benefit ratio for insulin treatment may have shifted from ‘human’ insulin to animal insulin and present prescribing habits may be putting some people at risk of unnecessary and avoidable complications to which they are already susceptible. Increased risk of retinopathy is a particular worry because diabetes is the largest cause of blindness in the working population. Any increased risk of blindness or visual impairment is unacceptable to patients when there are natural insulins available that have not been said to cause such risks.

You should tell the DVLA and your motor insurers, if you have retinopathy that requires treatment as this can affect your vision or visual fields. It is a condition that should be declared under the item ‘has there been any material change that could affect your driving.’ If you were involved in an accident and you had not declared that you have retinopathy, then you may not be insured and the DVLA could take action because you have not informed them.

Pycnogenol is the extract of bark of a particular pine tree only known to grow in a specific area in France. Apparently French people with diabetes and retinopathy are often treated with a patented pill called Pycnogenol – unheard of in the US and not known to be used in the UK.

Pycnogenol apparently is made up of a particular group of bioflanonoids that have been shown to improve the elasticity of the very small blood vessels [capillaries]. It has also been shown to have antioxidant powers that get rid of the free radicals - these are harmful molecules that lead to vascular and other problems.

An article in Diabetes Interview [March 1999] reports a man who was diagnosed with retinopathy requiring laser treatment in 1982. He searched for a possible solution himself and found Pycnogenol in France – his retinopathy regressed and he has had no laser treatment.

· A study published in Ophthalmic Research in 1996 proved Pycnogenol’s beneficial effects on the retinas of pigs and cows.

· In the Journal of Cardiovascular Pharmacology, October 1998, it was shown to counteract the blood vessel restricting effects of adrenalin, to decrease the clogging of blood vessels by decreasing platelet clustering and adhesion.

· In the journal Free Radical Biology and Medicine, May 1998, it was shown to significantly decease nitrogen monoxide generation [this is important in many disease including diabetes].

· In Biotechnology Therapeutics, 1994-95, it was shown to protect the cells lining the lymphatic vessels and the heart from injury due to oxidation.

· In Phytotherapy Research [15;219-233:2001] 30 people with diabetes were treated with 50-mg doses of Pycnogenol 3 times a day for 2 months and 10 people in a control group were treated with a placebo [dummy pill]. The researchers found that in those who took Pycnogenol there was a slowing down of the progression of retinopathy and in some cases the progression actually halted but in the control group using the placebo, retinopathy only got worse. This study should be treated with some caution because it was only small.

Despite efforts to achieve near normal blood glucose levels, in industrialised countries diabetic retinopathy is still the leading cause of blindness in the working population. This emphasises the need to investigate all possible avenues to prevent people from becoming blind or visually impaired. Therefore IDDT welcomes the findings of this last study and believes that it should not be dismissed simply because Pycnogenol is a herbal remedy. There needs to be further independent studies using Pycnogenol involving greater numbers of participants over a greater duration of time.

To those that either have or are at risk of retinopathy, every avenue of possible prevention or stabilisation should be considered and explored. We now have laser treatment but this does not mean that we should be complacent and not look for other means of prevention and treatment. It surely must be worth some research funding or a review of published studies.

The use of Pycnogenol must not be a seen as a substitute for ‘good’ control and because of its powerful antioxidant effects should only be used in consultation with your medical adviser, as indeed should all supplements and complementary medicines. It is also essential that the use of Pycnogenol does not replace essential regular eye examinations.

More information is available on the manufacturer’s website www.Pycnogenol.com or if you would like copies of the IDDT Newsletters containing the original articles about Pycnogenol, contact IDDT, PO Box 294, Northampton NN1 4XS, tel. 01604 822837 or e-mail enquiries@iddtinternational.org

· There is an estimated 250.000 people in the UK with the condition and it is estimated that only half of the people with glaucoma have been detected.

· Glaucoma is not catching and is not caused by diet, work or any other factors.

· Glaucoma cannot be prevented but having regular eye checks will enable early diagnosis and treatment and this applies particularly to the above categories. In the UK sight tests are free for people with diabetes and for certain blood relatives of people with glaucoma – parents, offspring and siblings of the person affected.

Glaucoma is a condition where there is loss of vision due to damage to the optic nerve that carries the images from the retina to the brain. Usually glaucoma is accompanied by an increased pressure in the eye, but not always. This pressure is called the intra-ocular pressure or IOP. It is this pressure that damages the optic nerve.

Chronic open angle glaucoma – this is most common form of glaucoma. It produces no symptoms - no pain or redness of the eye and the eyesight seems unchanged. It usually affects both eyes and develops slowly so that the loss of sight is gradual.

The whole of the contents of the eyeball are nourished by a fluid, called the aqueous humour. This fluid circulates within the eyeball and leaves the eye by small drainage tubes at the front. If there is an obstruction within this system, then the fluid cannot escape and pressure builds up within the eye. It is this persistent increased pressure that may damage the optic nerve and cause vision loss.

Acute angle glaucoma – is where there is a sudden increase in the pressure [IOP] in one eye. The eye becomes red and painful often accompanied by misty vision and seeing haloes around lights.

Secondary glaucoma – this is a group of conditions where the IOP is raised and this is caused by other diseases of the eye.

NB. Eye pressure is not the same as blood pressure and the aqueous is not the same as tears.

· People of Afro-Caribbean origin are between 5 and 8 times more likely to have glaucoma and it may come on earlier and be more severe.

· People with a family history of glaucoma are more at risk. There is a 6 times greater risk if a near relative has it.

Note: it has been thought that people with diabetes are more susceptible to glaucoma. However, recent research suggests that the higher incidence of glaucoma in people with diabetes is more likely to be due to s greater detection rate because people with diabetes often have more frequent regular eye checks than the general population.

At a high street optometrist - there are 3 tests that should be done to but not all optometrists do all three tests, so check when you make your appointment. The 3 tests are:

1. To look at the back of the eye and the optic nerve with a bright light [ophthalmoscope]

2. Measurement of the pressure [often called the puffer test]. A raised pressure at this stage does not necessarily mean you have glaucoma.

3. Field of vision test where you are asked to look at a screen with a series of spots of light and you will be asked which ones you can see.

If there are any abnormalities then the optometrist will refer you to your GP for referral to the hospital.

At the hospital - the following tests will take place at your hospital visit:

The eye is numbed by a drop of anaesthetic and the eye observed through an instrument called a slit lamp. The cornea [the front of the eye] is lightly touched with an instrument that measures the pressure.

Gonioscopy – this allows the doctor to observe the angle between the iris and the cornea.

Visual field measurement – you sit at a screen and keep your gaze fixed on a central light. Other lights flash on and off and you press a button when you see them. This tests detects any blind areas of your visual field indicating where the nerve damage has occurred.

Optic nerve assessment – drops are put in the eye to dilate the pupil so that the doctor can examine the back of the eye more fully to record the health of the optic nerve by the appearance of the optic disk. Retinal photographs may also be taken so that these can be kept in your records to establish any changes in the future.

Note: You should NEVER drive yourself to the hospital because the drops used to dilate your pupils leave the vision blurry for a few hours.

The aim of treatment is to lower the intra-ocular pressure and prevent further vision loss. Most people with glaucoma require life-long treatment, usually with eye drops.

In some cases the intra-ocular pressure can be reduced by opening up the draining channels with laser treatment or by surgery to make a small drainage hole at the top of the eyeball. In these cases the need for ongoing treatment may be removed but not all cases are suitable and the majority of people with glaucoma need eye drops for the rest of their lives.

In some cases tablets may be given to reduce the amount of aqueous produced. Initially these tablets increase the amount of urine passed.

The Medical Director of the Glaucoma Foundation in the US says that there is research that shows that frequent activity such as swimming or brisk walking can lower the pressure within the eye. But he warns against sports that involves turning upside down – certain yoga positions and scuba diving, can raise the pressure. [Reported in Health Which? December 2000]

If glaucoma is diagnosed then you should inform the DVLA in Swansea and your motor insurers. It is a condition that should be declared under the item ‘has there been any material change that could affect your driving.’ If you were involved in an accident and you had not declared that you have glaucoma, then you may not be insured and the DVLA could take action because you have not informed them.

International Glaucoma Association
Woodcote House
15 Highpoint Business Village
Henwood, Ashford
Kent
TN24 8DH

Sightline (helpline) number is: 01233 64 81 70
Administration number is: 01233 64 81 64
Website is: www.glaucoma-association.com

Perhaps there are more misunderstandings about cataracts than any other condition of the eye. Many people are frightened and fear that they are going to lose their sight, but understanding what a cataract is helps to offer reassurance of what can be done.

· Cataracts are usually formed as part of the normal aging process but they can be formed as a result of injury to the eye. Cataracts can be present from birth.

· Cataracts are more common in people with diabetes and can develop at an earlier age than in the general population.

· Cataract cannot be caused by overuse of the eyes and ‘resting’ the eyes will not stop cataracts from developing or getting worse.

In a normal eye the lens behind iris and pupil is clear and transparent but when a cataract forms the lens becomes cloudy or opaque so preventing the light that passes through the pupil from reaching the retina. The image or picture on the retina is fuzzy and blurred.

Cataracts usually develop in adult life and are cause by the normal aging process in which the lens becomes harder and cloudy. As this happens there may be a need to have new, stronger glasses more frequently but when the cataract worsens stronger glasses will not improve vision.

Surgery is usually very successful in most people with cataracts and is performed when the vision has dropped to the point where it is interfering with daily activities. Even though cataracts usually form in both eyes, the surgery is carried out on each eye at different times with the worst eye being treated first.

The surgery is usually carried out without an overnight stay in hospital. Most cataract operations are carried out under local anaesthetic and the ophthalmologist performs the operation with a microscope. The lens is removed through a tiny hole in the cornea and a permanent clear plastic lens is implanted. Occasionally very fine stitches are used to close the wound and these may be painlessly removed later. The implanted plastic lens corrects the vision of the eye but many people still need reading glasses after the operation.

Note: for some people a plastic lens implant is not suitable in which case a contact lens is fitted or special glasses are prescribed some weeks after the operation to remove the lens.

· After the operation the eye will be covered for protection for up to a day but it is advisable to wear the protective eye shield in bed for a month after the operation.

· Eyelids must be cleaned regularly and drops are given to prevent infection and help to reduce any post-operative inflammation. The drops may be necessary for two months after surgery.

· It is advisable to avoid heavy work or lifting but people not in strenuous occupations should be able to return to work couple of weeks after surgery.

· The eye takes a few weeks to settle down and you will be advised when it is time to have an eye test for glasses.

Macular degeneration affects the macula at the back of the eye and impairs central vision. The macular is a small area on the retina where detailed central vision takes place eg reading. The cells in the macula deteriorate and the central part of vision becomes blurred but what is seen around the blurred area is relatively clear because the peripheral area of the retina is not affected.

Macular degeneration accounts for about 50% of all visual impairment in the developed countries. It usually affects people over 50years and so is known as Age-related macular degeneration [AMD].

· macular dystrophy which is damage to the macula, is rare and tends to run in families

Dry - develops very slowly over a number of years with gradual fading of central vision

If your optician, or GP suspects that you have AMD, then you will be referred to the hospital where you will have one or more of the following checks:

· photographs of the back of the eye [this means the doctor has an accurate record for future comparisons

· fluorescein angiogram is used only occasionally. Your pupils are dilated and a small amount of fluorescein dye is injected into a vein your arm. It circulates through the body and so the network of blood vessels at the back of the eye can be seen and if there are any leaks of the dye, then it shows the vessels are damaged or new vessels have developed. This occasionally causes nausea and the skin yellows for 3-6 hours and the urine for up to 24hours.

So far there is no treatment for the dry type of macular degeneration. Laser treatment may occasionally halt the progress of the wet type if you are seen at the early stages of development.

There have been reports that nutritional supplements may help to treat AMD but they cannot sure or restore vision. The Drugs and Therapeutics Bulletin [DTB] is an independent journal that provides independent evaluations of treatments and the management of disease for doctors and health professionals. The February 2006 edition expressed concerns that promotion of certain nutritional supplements that claim to improve or slow down macular degeneration may be medicinal and that these claims are aimed at people who are worried about macular degeneration.

In particular DTB has reported the claim that ‘Viteyes’ can ‘slow macular degeneration’. DTB says that there is some evidence to support the use of a specific combination of antioxidant vitamins and zinc, the so-called AREDS formula, in specific groups of patients with macular degeneration - those with advanced disease in one eye only but this formula can only be found in a few products - ‘VisiVite Original Formula’, ‘Viteyes AREDS Formula’ and ‘Ocuvite PreserVision’. The use of other nutritional supplements, or use in other groups of people, cannot be recommended.

DTB's advice to people with macular degeneration includes to stop smoking and eat a healthy diet rich in green vegetables.

Warning note: manufacturers based outside the UK can continue to make inappropriate claims for their supplements because they fall outside the MHRA’s jurisdiction.”

The law requires that you must inform the DVLA in Swansea and your motor insurers if there are any changes in health or sight that could affect your ability to drive safely. Failure to do this could result in prosecution and your motor insurance being invalid.

To drive a car, you are required to be able to read a number plate at 25 yards or 20.5 metres with both eyes together, in good daylight and with glasses if worn. You must also have an adequate field of vision. The DVLA may require a report from your ophthalmologist about your eye condition. You must NOT drive until your specialist has confirmed that you meet the required standards.

Dispensing opticians – are qualified to fit and measure for glasses and to examine conditions that affect the outside of the eye. They are not allowed to test the eyes for glasses or to examine the inside of the eye – for example with an ophthalmoscope. They are allowed to fit and supply contact lenses to a supplied prescription.

Ophthalmic Opticians or Optometrists – are different titles for the same qualifications. This group is qualified to fully examine the eyes. If there are any abnormalities or suspected abnormalities then they refer the person to their GP or directly to the hospital if it is an emergency situation. They also test for glasses and to fit and supply them. They may be ‘high street’ opticians or hospital based.

Note: If you have diabetes and you are having an eye check with an optician/optometrist, it is important that he/she carries out an eye examination with drops to enlarge the pupil so that he/she can observe more of the retina. If necessary, you should ask for this to be done, especially if you are not having this done at the hospital as part of your diabetes care.

Consultant Ophthalmologist – this is the hospital consultant to whom the GP refers people with suspected abnormalities and he/she carries out the necessary treatment or surgery.

Eye tests are free in the UK for all people with diabetes, for people with glaucoma and their close relatives and for people over 60 years old.

As we all know, sight is probably one of the most important of the 5 senses that we have and any threat to this is frightening. We all know that retinopathy is one of the complications of diabetes but knowing this is a risk and actually having it diagnosed are totally different things, especially if the diagnosis is of proliferative retinopathy that can threaten sight. Knowing the risk does not prevent the shock of diagnosis, the denial [this can’t be happening to me, the anger, the feelings of guilt perhaps for past indiscretions with food, drink, blood sugar control or the ‘why me?’ feelings. Nor does it prevent the panic at the possibility of changes in lifestyle – just the simple thing of losing your driving licence can mean having to take a whole new look at your life and/or work and that of your family. Perhaps at this stage it is important to remember that early diagnosis and treatment of retinopathy can slow down it’s progression. It is also important to remember that achieving better diabetic control may also slow down the progression. Nevertheless, diagnosis itself can bring about this range of feelings but for the vast majority of people in this situation, there is time to adjust to the diagnosis and to adjust to perhaps looking at the future differently.

Understandably some people do not want to read about the complications diabetes because it is upsetting and depressing - perhaps especially those that may affect sight. But the reality is that there are many people already with retinopathy and we cannot ignore their needs – they and their family carers need information and reassurances that there is help available to them. Perhaps by looking at the help and support that is available to people who are partially sighted or blind, it may even help to allay some of the fears we all have.

Registering is a big step and it may feel like the biggest step you have ever taken. Emotionally it means admitting that you have sight problems that are making your life difficult, but registration could provide you with just the help that you need. If you are in this situation, you may have thought about registering but don’t know what the benefits are or where to start. We hope that this article will give you the confidence to seek the help you need.

· It entitles you to certain benefits and makes it more likely that you will receive the help you need.

· Your local authority keeps a register of blind and partially sighted people in your area. The register is held by the Social Services department or the local voluntary society for the visually impaired acting as an agency for your local authority. Whoever keeps the register it is important to know that it is entirely confidential.

· The purpose of the register is to help local authorities provide people with what they need and are entitled to.

If you are under an eye specialist [ophthalmologist] at the hospital then you should speak to him/her to see if your sight makes you eligible for registration. Your eye specialist will certificate you as partially sighted or blind. You should also discuss this with you GP who can refer you for further help.

Naturally if you are considering registering as partially sighted, you need to know what the advantages are from doing so. You may be entitled to more than you think. There are five main agencies involved that can give you help in all sorts of areas and we are providing some of the details for you under each agency.

The RNIB can offer general and information about practical help that may be available to you. IDDT has made contact with the RNIB [Royal National Institute for the Blind] and arranged for any of their information leaflets to be available to you through IDDT. They have large print leaflets to suit the needs of people with visual impairment covering issues such as available financial benefits and products that can improve your quality of life. These include the following:

Benefits and information leaflets

Practical information leaflets

· Coming to terms with sight loss

· Sight problems

· Services for the visually impaired

· What is community care?

· Staying at home

· Money for pensioners with sight problems

· Registering as blind or partially sighted

· Meeting blind people/local support groups

· Shopping made easy

· How to use better lighting to make things easier to read

· Seeing at home

· Leisure at home

· Magnifiers

· Fact sheet on specialist reading services

· Keeping safe

If you would like to receive any of the above leaflets contact Beverley Sharpe at IDDT, PO Box 294, Northampton NN1 4XS or tel 01604 822837, fax 01604 622838 or e-mail beverley@iddtinternational.org

Or you can contact the RNIB yourself at 224 Great Portland Street, London W1W 5AA or tel 0845 766 9999 or visit their website at www.rnib.org.uk

Visual difficulties can affect people with or without diabetes but the one thing that insulin-treated people have to do is be able to inject the accurate amount of insulin. While visual difficulties may not prevent many activities, not being able to do your own injections [and blood glucose tests] results in a loss of independence, especially for people who live alone. There are also many everyday things that fully sighted people take for granted but these become difficult or impossible for people with visual impairment.

Alison Blackburn has had diabetes for many years and is visually impaired as a result of diabetic retinopathy. She shares with us some of the tips she has picked up over the years that her sight was deteriorating that have enabled her to maintain her independence and ability to do many of the everyday things in life.

· There are a variety of pens available and they have clicking devices so that you can count the clicks to know how many units you are injecting.

· There are pre-filled disposable pens available for some brands of insulin and this means that you do not have to re-load the pen when a cartridge runs out. This can be easier for people with visual impairment [and for people with hand movement problems].

While a pen injector may seem ideal, not everyone likes to use them and many people still prefer to use syringes for their injections. Here are a few of Alison’s tips

· If you take the same dose of insulin regularly, score the outside of the syringe at your dose and then draw up to this mark. If you take two different doses, morning and evening, score two syringes but make sure you keep them in different places.

· If seeing the clear insulin is difficult then hold a coloured card behind the syringe for a better contrast making sure that the colour is one that you can see well. If you ‘haven’t enough hands’ pin the card to the wall or a door.

· Syringes are available in different sizes, 100ml, 50ml and 30ml. If your dose is small enough choose the smallest size syringe because the markings are further apart and easier to see - 30ml are easier to see than 50ml and 50ml easier than 100ml.

· A nurse or relative can draw up a week’s supply of insulin in syringes and leave them in the fridge. Again if the dose or type of insulin is different at different times of the day, make sure that the morning syringes are stored on the top shelf and the evening ones on the bottom shelf. If using longer-acting cloudy insulin, then make sure that you roll the syringe about 20 times to ensure that the insulin is mixed properly before injecting.

· If you make tea or coffee from leaves or powder then use the old-style sugar dispensers that were used in transport cafes. This way you get a limited amount of powder each time you tip up the dispenser. This is also a useful way of measuring custard powder, gravy etc.

· For people with poor eyesight, powders can be stored in large clear coffee jars. If these are held up to the light, it is possible to see the colour of the powder.

· If this doesn’t work then powders and foodstuffs can be stored in jars or canisters that are labeled with tactile buttons that you can feel. Self-adhesive buttons jelly like buttons can be purchased and you can stick different numbers of jars with different contents or place the buttons on a different part of the jar. Rubber bands work just as well and are cheaper! It is important that other members of the family don’t move the buttons or bands otherwise you may be making coffee with gravy powder!

· When storing foods stack in a regular, particular way so that you know the order.

· If you keep cleaning fluids in the house, then smell ALL liquids before you use them for eating or drinking.

· Liquid level indicators are available free to people who are registered blind or partially sighted. They are battery-operated gadgets that clip on the side of a cup or mug and they beep when the liquid is nearly to the top so preventing spilling.

· If you have difficulty with mixing in a cooking bowl [because the contents fly on to the ceiling!] then put the contents into a plastic box with a lid. Fasten the lid well and shake vigorously.

Gas and electricity companies – if visual impairment is developing then gas and electric companies will fit tactile buttons to cookers and other household equipment, such as fires and microwaves. The larger companies are often happy to do this free of charge but if you are registered with Social Services, they are obliged to organise this for you.

The Royal Institute for the Blind [RNIB] offer over 60 different services to help people who are blind or visually impaired. Their helpline number is 0845 766 9999 or visit their website www.rnib.org.uk

In April 2005 a new talking meter was launched for visually impaired and blind people. As members will know, IDDT and other organisations have been lobbying government and manufacturers to try to make sure that this very vulnerable group of people are able to reliably measure their blood sugars and so maintain good control and just as importantly, their independence.

The SensoCard Plus meter is the size of a credit card and costs £149.00 and from 1^st June 2005, the test strips will be available free on NHS prescription. Prior to June they are available from the company, CDx Ltd, for £23.50.

· Memory stores the last 150 results with built in 7-14-28 day period avaerage calculation

IDDT member, Alison Blackburn who is registered blind has tested the meter says:

"The meter is fantastic. Without it, I would have been really stuck on a solo trip to Japan and China. This meter will, quite literally, be a lifesaver for blind and visually impaired people."