Sir,

Broader messages on diabetic eye care are deducible from the review by Chowdhury et al1 evaluating the role of serum dyslipidaemia in diabetic maculopathy. The evidence they have surveyed indicates that dyslipidaemia has somewhat congruously joined poor glycaemic control and hypertension as cardiovascular risk factors that affect macular health in diabetes. In contemporary practice, a characterisation of risk factors for diabetic maculopathy is of monumental importance in public health terms. Type 2 diabetes is now manifesting its explosive demography in Britain with an astonishing volume of diabetic eye disease, of which maculopathy is a foremost concern. This iatrogenic fear is generated, for example, by the many patients with advanced ischaemic diabetic maculopathy who have disease untreatable by laser. Exudative maculopathy is similarly not always responsive to laser and noticeably problematic are the larger lipid deposits (especially plaques) that form in the central macula. In some diabetic eye services in Britain, the prevalence of this fundal picture is striking. Gross lipid exudation invites the same therapeutic nihilism associated with ischaemic maculopathy, because regardless of whether the tissue insult is ischaemic or exudative, the end-organ damage becomes irredeemable. In the wake of the UKPDS, preventative strategies therefore are eminently rational and a manipulation of the lipid profile as a potential adjunct to laser seems particularly compelling.

Moreover, it is arguable that ophthalmologists should develop more than a passing interest in cardiovascular risk factors since beyond the eye these factors are a leading cause of systemic morbidity and death. After all, in counterbalance, physicians undertake retinopathy screening with modest equipment. Rather than being a perfunctory exercise, a purposeful inquiry into a patient's prevailing glycaemic control, blood pressure, and lipid status (among other factors) in an ophthalmic consultation will stimulate remedial referral patterns. Indeed, even in its simplest guise the interchange with the ophthalmologist should be an opportunity to reiterate the messages behind diabetes care to our patients. By judiciously checking blood pressure and glucose on clinical suspicion, or looking up glycaemic and lipid indices, we are not (as may be the criticism) becoming diabetologists, but rather contributing in managing an unwieldy and major public health problem. This approach ought to be the strategy for any ophthalmologist examining diabetic retinopathy and not exclusively the mantra of those providing a medical retina service. To contextualise the issue for ophthalmologists yet again, diabetic eye disease is by far the most common cause of poor vision in our society among people of working age. Since the 1970s our selectively efficacious solution for maculopathy remains a Hamletesque ‘to laser or not to laser’ (a stabilising intervention), and even this decision is sometimes debatable and subject to the treatment ethos of a given clinician or department.

Beyond reducing macrovascular complications, an expansion of the remit of lipid-lowering therapy in managing maculopathy would represent a highly desirable therapeutic convenience in diabetis care. A large randomised controlled trial to pass final judgement on this wishful speculation can conceivably be the next landmark study in the medical management of diabetic retinopathy.