May 30, 2013 | POSTED BY | Articles, Clinical Optometry
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Age/Sex/Race

53 years old Hispanic male

Chief Complaint

“My vision started getting blurry in right eye about five days ago. I see this red spot in my vision that is moving.”

Medical History

Last exam was about 1 and 1.5 years ago.

Patient said he was diagnosed with insulin-dependent diabetes in 1992. He said that he didn’t measure his blood sugar on regular basis but he remembers number 12. We assumed hemoglobin A1C was 12.

Ocular History

The patient said his left eye had been blind for past six years, which he was told was due to cataracts at his last exam.

Medications

He was taking insulin once a day.

NKDA

Family History

Cataracts – parents

Social History

Social drinker

Diagnosis and initial plan of action

Fourth year extern was doing the examination and I was observing.  After hearing his history, I thought it might be retinal hemorrhage in right eye that’s causing blurred vision and red spot.

Applicable Testing & Results of Testing

Distance visual acuity (uncorrected)

OD: 20/200 (NIPH)

OS: HM

Near visual acuity (uncorrected) Normal

Cover test: Ortho at distance and near

Confrontation fields: FTFC OD, OS – patient can see hand motion only

Extraocular muscles: Full OU

Pupils: PERRLA, (-) APD OU

Slit lamp examination:

Iris: OD – NVI on the pupillary margin at 3, 7:30 and 9:30 o’clock & OS – No NVI

 

This is not my patient’s eye. NVI was very subtle at the pupillary margin, not this obvious. Picture courtesy of http://www.djo.harvard.edu/print.php?url=/physicians/gr/986&print=1

Gonioscopy: No NVA (neovascularization of angle) OU

IOP: 16 OU

Dilated Fundus Exam

OD – NVD of inferior half of the optic nerve head

This is not my patient’s eye. NVD stayed within the disc margin and it wasn’t so significant. Picture courtesy of http://www.southcoasteye.com/whatsnew.html#retinopathy

Severe, diffuse blot hemorrhaging, exudates and cotton wool spots in all quadrants and optic nerve head

Picture courtesy of http://dro.hs.columbia.edu/ctwool.htm

Picture courtesy of http://dro.hs.columbia.edu/hardex.htm

–          Two large pre-retinal hemorrhages in inferior retina

Picture courtesy of http://dro.hs.columbia.edu/prhem2.htm

OS – little to no view of fundus

–          Moderate PSC

–          Cloudy vitreous, which could be due to an old vitreous hemorrhage

Assessment and Plan

We could not see fundus of left eye clearly but it is possible that patient could have retinal hemorrhages and possible tractional detachment. We referred the patient to an ophthalmologist for further evaluation and possible pan retinal photocoagulation (PRP).

One of the doctors had told me that almost all the diabetics get diabetic retinopathy, it’s just matter of time.

Diabetic retinopathy can be nonproliferative or proliferative. Nonproliferative diabetic retinopathy (NPDBR) can be mild, moderate, severe and very severe.

Mild NPDBR – at least 1 microaneurysm , 5% risk of progression to PDR

Moderate NPDBR – at least 1 microaneurysm and or soft exudates, 15% risk of progression to PDR

Severe NPDBR –  52% risk of progression to PDR, remember 4:2:1 rule

  • Severe retinal hemorrhages in 4 quadrants
  • Venous beeding in 2 quadrants
  • IRMA (intra-retinal microvascular abnormalities) in 1 quadrant

Very severe NPDBR – 2 or more conditions for severe nonproliferative DBR, 75% risk of progression to PDR

 

Proliferative DBR  means presence of neovascularization

Early PDBR – neovascularization of the disc or elsewehere

High-risk characteristics indicate patients with PDR who are at risk for vision loss.

  •  Neovascularization of disc (NVD) > ¼ disc diameter
  • Any NVD or neovascularization elsewhere with a vitreous or preretinal hemorrhage

Patients can also get CSME, clinically significant macular edema, by having one of the following:

  • Retinal thickening at or within 500 microns (1/3 DD) of center of macula
  • Hard exudates at or within 500 microns of center of macula if associated with thickening of adjacent retina
  • Zones of retinal thickening 1 disc area in size at least part of which is within 1 DD of center of macula.

We see many diabetic patients so it’s important that we know what to look for in their eyes. Come visit next month to find out summarized studies on diabetic retinopathy.

 

References:

General guidelines for the management of diabetic retinopathy. American Optometric Association.

Massachusetts Eye and Ear Infirmary