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Asteroid hyalosis vignette PDI 2003

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The diagnosis and management of hypertension can
be complex, made even more so by guidelines describing different blood pressure thresholds for initiating
pharmacological treatment and targets to aim for. In
my role as co-ordinator for a course on cardiovascular
risk for nurses, it is my experience that health professionals in the UK use the recommendations from the
third edition of the British Hypertension Guidelines.
Unfortunately the management of hypertension in
type 2 diabetes appears not to be uniform across practice. Perhaps this is a reflection of the debate that surrounds certain clinical trials allowing pharmaceutical
companies to attach ‘spin’ to the results. The authors
of this thorough résumé of the evidence base for the
management of hypertension in type 2 diabetes present the current undetermined issues along with some
practical clinical recommendations.
The article is presented well, using commonly
asked questions that are relevant to both nurses and
doctors. The resulting discussions are slightly challenging at times. Although the details of the many clinical
trials are quite difficult to follow, the reader is
rewarded with some interesting insights. A paper on
the oscillometric blood pressure device used in the
HOT study is highlighted, which states that this device
underestimated blood pressure. The importance of
choosing a validated blood pressure device in clinical
practice and ensuring that the operator is skilled is
essential since so many medical decisions depend on
accurate readings. Also of particular note was the discussion surrounding the value of identifying patients
with microalbuminuria. In our practice, we have introduced screening for microalbuminuria as part of the
type 2 diabetes annual review and do find that it highlights patients at special risk. Cardiovascular risk factors are targeted and the patient is given medication to
block the renin-angiotensin system. Perhaps if, as this
article seems to suggest, all type 2 diabetes patients are
to be treated as secondary prevention then identifying
those at most risk would not be necessary.
The authors indicate that more clinical trials are
needed to answer specific questions on treatment
issues. However, they are clear that hypertension as a
major cardiovascular risk factor should be taken at
least as seriously as glycaemic control. A blood pressure consistently over 140/90mmHg should be lowered to below 140/80mmHg with lifestyle changes
and pharmacological treatments, which should usually include an ACE inhibitor or angiotensin II-receptor blocker. This article will be of interest to all those
managing patients with type 2 diabetes.
Susan Kennedy
Practice Nurse, Glasgow
Diabetes Vignette
Asteroid hyalosis
No. 29 in a regular educational series of brief illustrated descriptions of interesting
or unusual diabetes-related cases and conditions
This 81-year-old male patient had
had type 2 diabetes for 12 years,
well controlled on diet (all HbA1c values within one per cent of upper
limit normal value), with normal lipid
profile and controlled, treated
hypertension. On dilated fundoscopy, his right fundus had many
beautiful, light, shiny spots in the
vitreous humour, not retina, characteristic of asteroid hyalosis (see
Figure 1).
Asteroid hyalosis comprises brilliant reflecting asteroid bodies, surrounded by a tightly adhering network of fibrils; the asteroids are composed of hydroxyapatite.1
Some studies show an association
with diabetes mellitus, hypertension
and dyslipidaemia,2 but others do
not.3 It is more common in males and
in the elderly.2,3
Ray Sheridan, MRCP and Simon
Croxson, MD
Diabetes in Later Life Department,
Bristol General Hospital, Bristol BS1
Figure 1. Dilated fundoscopy
revealed asteroid hyalosis in the
right fundus
Generally, the asteroids are of no
clinical relevance, but treatment by
vitrectomy may be indicated for
marked asteroid hyalosis if visual
acuity is impaired,4 visualisation of
the retina is obscured5 or if asteroids
deflect laser therapy.5
1. Winkler J, Lunsdorf H. Ultrastructure and
composition of asteroid bodies. Invest
Ophthalmol Vis Sci 2001; 42 (5): 902–907.
2. Bergren RL, Brown GC, Duker JS.
Prevalence and association of asteroid
hyalosis with systemic diseases. Am J
Ophthalmol 1991; 111 (3): 289–293.
3. Moss SE, Klein R, Klein BE. Asteroid hyalosis
in a population: the Beaver Dam eye study.
Am J Ophthalmol 2001; 132 (1): 70–75.
4. Parnes RE, Zakov ZN, Novak MA, Rice TA.
Vitrectomy in patients with decreased visual
acuity secondary to asteroid hyalosis. Am J
Ophthalmol 1998; 125 (5): 703–704.
5. Lambrou FH Jr, Sternberg P Jr, Meredith TA,
et al. Vitrectomy when asteroid hyalosis prevents laser photocoagulation. Ophthalm
Surg 1989; 20 (2): 100–102.
Practical Diabetes International invite you to submit your favourite slide with clinical details for possible publication in this series.
Pract Diab Int September 2003 Vol. 20 No. 7
Copyright © 2003 John Wiley & Sons, Ltd.