SComment_512.qxd 3/9/03 3:22 pm Page 2 C OMMENTARIES 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 6SY, UK References 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. 236 Pract Diab Int September 2003 Vol. 20 No. 7 Copyright © 2003 John Wiley & Sons, Ltd.
