Improved understanding of the role of hypertension in the pathogenesis of diabetic retinopathy presents both a challenge and an opportunity for ophthalmologists and other diabetic healthcare professionals to improve patient care. Around 40% of patients with type 2 diabetes are hypertensive, the proportion increasing to 60% by the age of 75.1 Recent reports from the United Kingdom Prospective Diabetes Study (UKPDS) have focused attention on the links between hypertension and sight loss in diabetes. These reports in type 2 diabetes accord with previous observational studies in type 1 diabetes 3 4 and demonstrate both hypertension as a risk factor for diabetic retinopathy and the beneficial eVects of tight blood pressure control. This review summarises recent papers, including the UKPDS reports, and discusses the implications for management of people with diabetes. Prevalence of hypertension in diabetesDiabetes and hypertension are among the commonest diseases in developed countries, and the frequency of both diseases rises with age. In the Wisconsin study examining patients with type 1 diabetes, hypertension was defined by current antihypertensive treatment or a mean blood pressure >160/95 (or >140/90 in those under 25 years). The prevalence of hypertension at baseline was 17.3%, and the 10 year incidence was 25.9%.5 Hypertension is more common in type 2 diabetes, and in the UKPDS 38% of newly diagnosed patients with type 2 diabetes had hypertension defined as repeated blood pressure >160/90 (or >150/85 in those on antihypertensive medication). 6 In the years after diagnosis of type 2 diabetes the incidence of hypertension is higher than in the age matched general population.In type 1 diabetes the development of diabetic nephropathy may play a major role in the subsequent development of hypertension since microalbuminuria is present in about 80% of type 1 diabetic subjects before the onset of hypertension. 7 The pathogenesis of hypertension in type 2 diabetes is not so clear, with a lesser significance for nephropathy, with microalbuminuria predating hypertension in approximately 25% of type 2 diabetic subjects with hypertension.7 Other relevant factors in type 2 diabetes are decreased baroceptor sensitivity, increased peripheral vascular resistance from enhanced smooth muscle contractility, and vascular structural changes including protein glycosylation and increased type IV collagen. Additionally, hyperglycaemia causes increased function of the sodium/glucose proximal convoluted tubule cotransporter leading to sodium retention. Over and above the action of hyperglycaemia, other factors including insulin resistance and hyperinsulinaemia may be aetiologically important in the development of hypertension in type 2 diabetes as insulin itself has sodium retaining properties. Reaven's syndrome (also known as the metabolic syndrome or syndrome X) describes this association of hyperinsulinaemia, insulin resistance, obesity, hypertension, and hyperlipidaemia in type 2 diabetes.

Aim: To assess, against a checklist of specific areas of required information and using standard published criteria, to what extent leaflets given before cataract surgery provided patients with enough information to give adequately informed consent. Method: Twelve ophthalmology departments in the West Midlands region were asked to submit the cataract information leaflets given to their patients at the preoperative assessment for analysis. Using criteria published by the General Medical Council, British Medical Association, and Medical Defence Union the leaflets were assessed for their contribution to informed consent for patients considering cataract surgery. Leaflets were scored according to the information they provided on: diagnosis, prognosis, treatment options, costs to the patient, details about the procedure, its purpose, likely benefits, how to prepare for it, what to expect during and after the operation, and the common as well as serious complications that may occur. The readability of the information was also assessed. Results: All the units' leaflets provided information on diagnosis, the lifestyle changes required postoperatively, and cost involved to the patient. Only five units had leaflets that mentioned the risks involved in cataract surgery. The other areas of information were covered by 50-75% of the leaflets. Fifty per cent of the leaflets included a diagram. The average SMOG readability score was high. Conclusion: Although present cataract information leaflets make some contribution to the process of informed consent, most do not address important areas outlined by the General Medical Council. Many of the areas of information that are required for informed consent could easily be covered, and should be borne in mind when designing patient information leaflets. Resources are available on the internet including toolkits, guides, and means of assessment for the production of patient information leaflets.

Six cases of ocular perforation after peribulbar anaesthesia are reported. They were referred to our vitreoretinal unit from other hospitals over a 6 week period. Some recent reports of ocular perforation with peribulbar anaesthesia suggest a good prognosis. In this series all six required surgical intervention and most cases associated with a retinal detachment had a poor outcome. This study highlights the dangers of ocular perforation and emphasises the need for supervised training of peribulbar anaesthesia and early referral should ocular perforation occur.

Background In recent years there have been significant developments in the diagnosis and treatment of glaucoma. We conducted a study to determine whether there has been an associated change in trabeculectomy rates in England over this period.

SUMMARYA survey of local anaesthetic related ocular perforation in the United Kingdom is reported. A total of 531 consultant ophthalmologists were sent a postal ques tionnaire and there was a 71% response rate. Thirty respondents reported 39 perforations occurring under their care during the previous year. Details of the cases are presented. The rate of local anaesthetic related ocular perforation is higher than in previous reported series. Efforts to reduce the incidence will require consideration of alternative techniques, audit, and training.

SUMMARYThe prevalence of hypothyroidism in British patients with primary open angle glaucoma (POAG) was examined. A recently reported study from Montreal had shown a significant increase (p<0.004) in biochem ical hypothyroidism (23.4 %) in a population of 64 POAG patients compared with controls (4.7%). Mechanisms for a possible causal association between the two diseases are discussed, including mucopolysac charide deposition in the trabecular meshwork and vasculopathy altering ocular bloodflow. Reports of improved glaucoma control following treatment of hypothyroidism are discussed. This study examined 100 consecutive patients with POAG in a specialist glaucoma clinic. All patients were questioned regarding symptoms of thyroid dysfunction and previous thyroid disease. All patients not already taking thyroxine underwent an assay of thyroid stimulating hormone. The 4% (95% CI 1.1-9.4%) prevalence of overt hypothyroidism in our study shows no clinically significant increase either over controls in the Montreal study or over our local population. We conclude that in our local population there is no evidence for a clinically important association of hypothyroidism with glau coma. METHODSPatients attending a glaucoma special clinic were studied for evidence of hypothyroidism. One hun- RESULTSIn the study population there were 52 men and 48 women with a mean age of 65 years. There were 85 patients with POAG and 15 glaucoma suspects requiring treatment. Eighty-eight of the subjects were of Caucasian origin, 11 Afro-Caribbean and 1 Asian.Of the 100 patients interviewed and examined in the glaucoma group, 3 were on thyroxine replace ment. A fourth had a history of thyroiditis but was clinically and biochemically euthyroid without

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