Managing Diabetes with Vision Loss: Tools and Techniques 

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Diabetes is a disease that requires 24-hour, 7-day-a-week self-management. It demands constant monitoring. Blindness or low vision may present challenges but aren’t necessarily barriers to effective and successful diabetes self-management if you have the right guidance, tools, and training. Remember — informed self-care is the best healthcare!   

Self-Monitoring Blood Sugar 

Self-monitoring blood sugar is an essential skill for people with diabetes. The information obtained from regular and accurate finger-stick testing allows you and your doctor to adjust your diet, exercise, and medications to achieve your blood glucose control goals. People with diabetes know that monitoring blood sugar is important, but theymay resist doing it. Here are some common reasons people with vision loss give for not testing as often as the doctor recommends:   

  1. It hurts to poke my fingers.   
  1. My fingers get sore and calloused.   
  1. It is difficult to get a good drop of blood.   
  1. I have trouble finding the blood drop.   
  1. I waste a lot of test strips trying to get an accurate reading and the strips are expensive.  

Tips For Successful Blood Sugar Testing When Blind or Low Vision 

As with learning any new skill, it is important to have the right equipment, instruction, and support. With practice, blood sugar monitoring can become a quick and routine procedure that helps manage blood sugar and avoid the complications of diabetes.   

  • How to choose the site: Develop a method of rotating your fingers so they do not get poked as often. One method is to begin with the left first finger on Monday, the second on Tuesday, and the third on Wednesday. Move to your right first finger on Thursday, second on Friday, and third on Saturday. For Sundays, use the baby fingers. You can also rotate the sides of the fingers, the side facing the thumb for morning and the pinky side for evening. This gives your fingers a chance to heal, avoiding soreness and callouses, and does not require the use of vision. 
  • How to get the blood drop:  Increase the blood flow to the site by washing your hands with soap in warm water. Then, hang your hand down and shake it a couple of times. Massage your finger to warm it up. This helps bring blood to the fingertip to obtain an adequate blood drop to test. If you still have trouble getting a good-sized drop of blood, you may want to try wrapping a rubber band around the finger’s middle joint, holding the band in place with your thumb – like a tourniquet. After poking the finger, release the rubber band so blood will fill the fingertip, and the site will bleed. Don’t squeeze the site; “milk” the finger gently instead.  
  • How to find the blood drop: Poke the finger along the sides, avoiding the finger pads. There are fewer nerve endings and more blood vessels on the sides. If you have trouble seeing the drop of blood, it will be easier to find if you use the sides of the fingers and visualize where the puncture site is in relation to the nail bed. Usually, a slow scooping motion, with the strip in the meter, along the side of the finger will find the drop of blood. Check out the Thumb Guide Technique to learn another method to find the drop.  
  • Use the right lancing technique: Adjust the lancing device to the right depth and purchase lancets with the smallest-sized needle that gets the job done. The larger the needle’s gauge, the smaller it is. Most blood glucose strips now require micro amounts of blood, so there is no need for large, deep sticks. Ask your pharmacist or diabetic educator for a few lancet samples so you can experiment to figure out the best size and depth for you.  
  • Ensure accuracy: Meters are designed to detect errors in testing and give feedback. Be familiar with your meter error messages so you can correct them. Avoiding mistakes means fewer finger sticks and fewer strips wasted. The Food and Drug Administration offers information about meters and the most common testing errors at Blood Glucose Monitoring Devices.  
  • Work with your insurance provider: Insurers cover blood sugar testing supplies under the durable medical equipment policy. This includes prescription items ordered by your doctor for home use. If you require a special type of meter and strips, or more strips than are allowed monthly on the policy, you can ask your doctor to fill out the medical necessity form and send documentation as evidence to support your request for the insurance to make an exception. Generally, insurance companies have rules to provide what is “medically necessary” or an appropriate substitute. Also, co-pays for test strips are often less if you use a mail-order service instead of a retail pharmacy. Check with your insurer about this option. Supplies are conveniently delivered to your home and are cheaper. 
  • Get help through Accessible Pharmacy. Accessible Pharmacy is a mail-order pharmacy designed for blind or low vision individuals. They provide phone and video education/ medication identification through the specialized help section of the  Be My Eyes app, accessible packaging options, and can supply continuous glucose monitors (CGMs) (Freestyle Libre and Dexcom 6) and Prodigy talking glucometers. Contact them at 215.799.9900. 

Devices for Managing Diabetes and Medications  

The cornerstone of diabetes management is keeping blood sugar levels under control (80 -130 mg/dcl) to help prevent complications of diabetes. In addition to healthy eating, stress management, and physical activity, diabetes medications are another way to help manage blood sugar levels.  

Various medications are used to treat diabetes. Some people use only pills, while others use insulin from vials, preloaded injection pens, or programmable pumps. Still, others may use a combination of oral drugs, insulin, and other injectable drugs.  

If you have type 1 diabetes, your body no longer produces the hormone insulin to control your blood sugar levels. You must take insulin either by injections, inhalation, an insulin pump, or a system like the OmniPod.  

If you have type 2 diabetes and require medications to help control your blood sugar levels, there are many options, from oral medications to injections.  

Taking your medications safely and correctly is critical to avoid dangerously low or high blood sugars. Taking your medications properly also helps avoid the complication of vision loss from diabetic retinopathy. For more information about diabetes medications, visit the American Diabetes Association.  

Adaptive Devices for Insulin Measurement   

Insulin is a hormone made by the pancreas. Its main function is to regulate glucose (sugar) metabolism by moving glucose out of the bloodstream and into cells where it can be used for energy. Insulin directly lowers glucose levels by increasing glucose uptake into muscle and fatty tissue and reducing the release of glucose from the liver.  

If you have type 1 diabetes, you will be taking insulin because your pancreas has lost the ability to produce insulin. If you have type 2 diabetes and your pancreas cannot produce enough insulin and other medications cannot regulate your blood sugar levels properly, then it may be time for insulin.  

Insulin doses are drawn up from a vial using a syringe, administered by an insulin pen, inhaled through the throat, or delivered through an insulin pump, depending on the type of insulin. Insulin pens are the most accessible option for people with low or no vision.  

When administering insulin, you inject it into the subcutaneous (fatty) tissue on your abdomen, legs, back of arms, or buttocks. It is important to rotate injection sites to prevent the formation of scar tissue.  

Insulin can’t be taken in pill form because your digestive system would break it down like you digest food. That means the insulin wouldn’t make it to your bloodstream where it’s needed.  

Several adaptive devices currently available can help with insulin measurement if you are blind or have low vision. The most accessible way to draw up and administer insulin is by using an insulin pen. However, if pens are not an option for you, some adaptive devices can be used. Please note: Always consult with your diabetes healthcare team before purchasing and using any adaptive insulin measurement device, including insulin pens.   

Measuring Insulin with Low Vision  

If you have low vision, you can use a syringe magnifier in combination with a flexible-arm task lamp. Be aware, however, that syringe magnification offers minimal magnification.   

Fixed Insulin Measurement  

Fixed-dose insulin measurement devices are appropriate for individuals whose insulin dosage remains consistent from day to day:   

  • The Safe Shot Syringe Loader has one pre-set dosage step and is available in different colors. Note, it is currently unavailable for purchase.  

Flexible-dose insulin measurement devices are appropriate for individuals who need to vary their daily insulin dosage due to changing blood glucose levels and/or carbohydrate intake:   

  • The Prodigy Count-a-Dose accommodates a smaller dose (up to 50 units). It holds one or two vials of insulin and makes a distinctive click that can be heard and felt with each unit increment. It requires a B-D 50 unit/ ½ cc syringe.   

Insulin Pens 

Insulin pens provide another non-visual measurement option. Many are disposable and pre-filled with insulin, while others are refillable. All pens make a distinctive click that can be heard and felt with each unit. A 2010 study provided evidence of the safe use of insulin pens by persons with vision loss, despite earlier disclaimers that persons using insulin pens could not do so independently without supervision. Insulin pens require a doctor’s prescription.    

Insulin Pump  

An insulin pump is a computerized device – approximately the size of a deck of cards – that administers insulin, via flexible plastic tubing, to a small needle inserted just beneath the skin. The device provides 42/7 delivery of insulin. It is programmed to closely mimic the body’s normal release of insulin from the pancreas. Some models have tactile controls and audio features, but not all features are accessible by individuals who are blind or have low vision.   

  • Alternative insulin delivery systems are known as a “patch pump” or wearable insulin delivery systems. These systems consist of a “patch” that you fill with insulin, attach to your body (usually on your abdomen) and it provides you with insulin for 24 to 72 hours without the need to draw up and administer insulin several times a day.    

Inhaled insulin  

Afrezza is a rapid-acting orally inhaled insulin with an inhaler and three different insulin doses in cartridge format. Your diabetes healthcare team can provide more information about these devices, including eligibility requirements, insurance coverage, accessibility features, and appropriate training.   

Saving Money on Supplies and Insulin  

During the past few years, the burden of diabetes expenses has increased for the patient in the form of higher co-pays and higher deductibles. Though testing supplies are a smaller expense, there are ways to cut costs. Check out CDC’s recommendations and what Medicare will cover with its new benefit for insulin: “Plans can’t charge you more than $35 for a one-month supply of each Medicare Part D-covered insulin you take, and can’t charge you a deductible for insulin.”  

 Blood Glucose Monitoring Equipment  

Blood glucose monitoring allows you to evaluate the effectiveness of your diabetes treatment plan in maintaining your blood glucose levels within a normal range. Monitoring will also help you determine if your blood glucose level is low and, if so, what quantity of glucose-containing products or foods you must eat to raise your blood glucose levels into a safe range.   

Monitor with a Standard Visual Display   

To perform effective and consistent blood glucose monitoring, you must be able to access the numerical readout on your monitor. Here are some suggestions for individuals who have low vision and use a blood glucose monitor with a standard visual display:   

  • Use a magnifier or an electronic video magnifier with your current monitor.   
  • Use a flexible-arm task lamp and position it near your better-seeing eye.   
  • Place your monitoring equipment on a contrasting surface; for example, place dark equipment on a light-colored tray.   

Monitor with a Larger Print Display   

  • Obtain a monitor that has a larger-print display, backlighting, or contrast/reverse contrast.   
  • To learn about the full range of available blood glucose monitors, check this consumer guide from the American Diabetes Association.   

Monitor with Speech Capability   

If you’ve been certified as legally blind, you’ll likely meet the requirements of most insurers to obtain a blood glucose monitor with speech capability, also called a talking blood glucose monitor. Be aware that talking monitors fall into two categories – those with partial speech and those with full speech. Those with partial speech may only announce your blood glucose result, while meters with full speech not only announce your result but also announce the results in memory, low battery warning, and audible steps to set the time and other monitor features. Current full speech monitors include:   

Even if your monitor has a large print display and/or speech capability, you may still want to use additional low vision, tactile, and/or auditory techniques to help with accurate and effective blood glucose monitoring:   

  • Explore your test strips either (a) visually to identify color differences or (b) by touch to identify textural features. This will help you position the strip in the proper direction before inserting it into the monitor.   
  • Before obtaining a blood drop for self-monitoring of blood glucose, increase blood flow by shaking your hand gently at your side and washing your hands in warm water.   
  • Try this technique for inserting the test strip: (1) Use your left index finger as a “marker” and place it parallel with the slot that holds the test strip; (2) Hold the test strip in your right hand so that it is parallel with, and touching, the left, or “marker” finger; (3) Using the “marker” finger as a guide, insert the test strip into the monitor. Reverse these instructions if you are left-handed.   
  • If you have low vision and find it difficult to locate the blood droplet/sample after lancing your finger, (a) bring your finger closer to your eye; (b) use additional lighting; or (c) hold your finger with the droplet against a white or other contrasting background.   
  • Determine the number of strokes that are required to “milk” your finger and produce a large enough blood sample. Meters are now available that require very small amounts of blood if producing a sufficient blood sample is a problem. To obtain a larger sample, set your lancing device to a deeper penetration, the higher the number the deeper the penetration.   
  • Create a mental map of where you lance your finger in relation to your fingernail to help you locate the blood droplet/sample.   
  • Use a monitor with a “beep” feature that indicates (a) when you have completed a step and (b) when to proceed to the next step.   

Continuous Glucose Monitors (CGMs)   

A continuous glucose monitor (CGM) is a device used to monitor blood glucose levels continuously through interstitial fluid. A CGM takes a blood sugar reading on set intervals via a sensor with a thin, flexible filament inserted just under the skin and held in place by an adhesive. It sends the data to either a reader device, an app, or both. CGMs can be a good choice for people with diabetes and vision loss, as they do not require finger sticks. The readers are not accessible, but the CGMs listed have an app that can be used with Talk Back on an Android phone or Voice Over on an iPhone to make them accessible.    

Note: All phones cannot download the apps. Check your phone’s ability before getting a CGM.   

  • A list of the currently available CGMs can be found on the American Diabetes Association’s consumer guide.   

Selecting an Appropriate Glucose Meter   

Begin by asking your doctor or diabetic educator which glucose meter would be best for you. There are many models available that include accessibility features like larger screens, tactile buttons, speech output, and lighted backgrounds.   

Insurance providers have “preferred” equipment lists. Sometimes, your doctor can write a letter of “medical necessity,” documenting reasons you may require a certain type of glucose meter and insurers will make an exception. For instance, if you have vision impairment or neuropathy of the fingers, you may need a specialized model. Learn more about glucose meters and their accessibility features at ADA Consumer Guide.  

 Proper Foot Care with Vision Loss  

In addition to monitoring and managing blood sugar, proper foot care is a crucial component of diabetes self-management since several diabetes-related complications can cause serious foot problems.  

  • Decreased sensation can lead to foot injuries.   
  • Impaired temperature regulation can cause dry and cracked skin on the feet, which can lead to bacterial infections.   
  • Impaired circulation can lead to impaired healing ability and, in serious cases, amputation.   

Develop a reliable foot inspection and care routine:   

  • Wash your feet daily and dry them carefully, especially between your toes.  Avoid temperature extremes when washing your feet. Apply lotion to your feet, but not between your toes.   
  • Do not soak your feet for a long time unless your physician or podiatrist prescribes it. Taking a bath or shower is fine, however.   
  • Establish a consistent time to check your feet every day, such as after bathing or before bedtime.   
  • If you feel cold at night, wear cotton socks. Do not use hot water bottles or heating pads.   
  • Pay special attention to previous or existing foot problems.   
  • Inspect your feet, but you can perform a tactile foot inspection effectively only if sensation is intact in your hands and fingertips.   
  • Use your fingertips to search for skin and/or foot irregularities, such as cuts, breaks in the skin, blisters, new calluses, swollen areas, bumps, embedded objects, and changes in foot texture and/or shape.   
  • Feel the entire top and bottom surfaces of each foot, using overlapping strokes in an organized pattern. Be sure to check the nail beds, all pressure points, and the areas between your toes.   
  • Run the back of your hand (which is more sensitive to temperature changes) over the top and bottom surfaces of each foot, feeling for excessively cool (impaired circulation) or warm (possibly infected) areas. Compare these areas to other parts of your foot or to your other foot.   
  • Feel changes in the skin texture or shape of your feet.   
  • Note any changes in foot odor when removing your socks and shoes.   
  • Check for wet, moist, or crusty areas on your socks, which can indicate blood or discharge.   
  • Wear socks or stockings that fit properly, keep your feet dry, and do not have raised seams. Be sure to change your socks every day.   
  • To aid your foot inspection, try one of the following adaptations: a task lamp with a flexible arm, or place a dark towel underneath your feet for better contrast.   
  • Inspect the insides of your shoes every day for torn linings, nail points, and other objects that can damage your feet.   
  • Do not walk barefoot or in your stocking feet.   

Have Your Feet Checked by a Physician and/or Podiatrist  

  • Ask your physician to perform a foot inspection during every visit and have a podiatry visit annually.  
  • Ask your podiatrist to cut your toenails or file your toenails. They  should be cut or filed straight across (not cut into the corners) File your nails with an emery board between cuttings, if necessary.  
  • Ask your podiatrist to remove corns or calluses and do not use commercial corn and callus removal products.  
  • Contact your physician or podiatrist if a cut, blister, or sore does not begin to heal after one day; contact your physician immediately if your foot is painful or swollen.   
  • Medicare Part B and Medicaid coverage may be available for biannual foot exams for people with decreased sensation in their feet due to diabetes. Medicare Part B may cover a portion of the cost of one pair of custom-molded shoes (including inserts) and two additional pairs of inserts per year. One pair of depth shoes which provide extra room to allow for differently shaped feet and toes may also allowed each year. A physician’s prescription is required for adaptive footwear or accessories.   

The Lower Extremity Amputation Prevention (L.E.A.P.) Program provides footwear and shoe modification guidelines and provides a free testing kit to assess the feeling in your feet using a stiff nylon string called a monofilament.   

By  Debra A. Sokol-McKay, MS,  CDE, OTR/L, SCLV   

Updated by Kim Ladd, RN, BS, CPHQ, CDCES and Audrey Demmitt, RN, BSN, June 2021