Diabetic Retinopathy Case

Running head: DIABETIC RETINOPATHY CASE1

Diabetic Retinopathy Case

Ben Davisson, Donna Bloom, Karen Burns Mary Ivey, Erica Simms

Stephen F. Austin State University

DIABETIC RETINOPATHY CASE1

On November 11, 2001, a 54 year old man had his annual diabetic visual evaluation. He had no complaints of his vision. He had stated that his normal blood sugar normally reads around 155mg/dl and on occasion he would get a reading of 220mg/dl. It was two years prior that he had his last eye exam. Records from this particular visit noted that the man had a diagnosis of mild non-proliferative diabetic retinopathy without clinically significant macular edema. All of this man’s ocular history was great except it was noted that he had hard exudates in the posterior pole, but away from foveal tissue.

His medical history included renal insufficiency, depression, hyperlipidemia, hypertension, cellulitis of the leg and type II diabetes with renal and ophthalmic manifestations. Medications include insulin injections b.i.d., dressings to treat cellulitis of the leg, Zestril (Lisin-opril, AstraZeneca) and Zocor (Simvastatin, Merck).

Entering his examination, his acuities were 20/40-2 OU and was best corrected at 20/25 OU. His tonometry showed that he had intraocular pressure of 12mm Hg OD and 15mm Hg OS. His results found no rubeosis, mild cataract development OU, and exudates and hemorrhages within 500 microns of the fovea OD with retinal thickening. Microaneurysms and hemorrhages were present in all four quadrants. This visit noted a diagnosis of mild/moderate non-proliferative diabetic retinopathy (NPDR) and clinically significant macular edema, also known as CSME (retinal swelling and cysts formation in the macular area).

A fluorescein study on March 4, 2002 showed scattered perfusion from microaneurysms O.S. greater than O.D. (see figure 2). The patient was treated with focal grid argon laser, with 27 burns O.D. and 57 O.S.

In September 2002,six months later, the patient returned for a follow up visit and had entering acuities of 20/30 OU. The assessment included type II DM, moderate NPDR and minimal CSME O.U. The retinal practitioner believed that the problem, CSME OS was resolving so they rescheduled another follow up visit four months later.

Almost four months later, in January 2003, the man returned for his visit and complained about blurry vision and reported that he had to stop driving. He also reported that his glucose levels were normal and measured 113mg that morning. The man said that after his last surgery, his vision was stable but could no longer find use in his glasses. Entering acuities were counting fingers at five feet OD and 20/60 OS. Diagnosis was altered to type II DM with severe NPDR and diffuse CSME OU. After further testing the same day, a marked increase in retinal edema was noted.

Five months later, in May 2003, he returned for another follow up visit and received a laser treatment of 1400 burns OD and 1450 burns OS.

In July 2003, his examination showed an entering acuity of bare light perception OU and proliferative changes and diagnosed type II DM with sever PDR OU were noted.

The practitioners questioned the dramatic change in this patient’s vision. This case illustrates why you must conduct an objective analysis of a patient's underlying medical condition. Upon careful review of this case, several important findings were noted. The most important was the patient’s glucose control over the past several years. The data on his glucose levels were collected and his Hemoglobin A1c counts. This analysis revealed the patient’s poor dietary compliance over several years.

A patient is considered a suspect for diabetes when fasting serum glucose levels reach between 100 and 140mg/dl. The diagnosis is likely when that number is over 140mg/dl. Further, the hemoglobin A1c count is also utilized. If elevated above 7.0, a positive diagnosis is likely. The patient had both of these extremely elevated over many years. When a practitioner takes this information into account, there becomes no point in ocular treatment option because the disease is already out of control. The patient needs to want to help themselves first.

This case study ends with suggestions to prevent and/or postpone vision loss. It also provides excellent visuals for a person to better understand the situation. Actual glucose/A1c levels should be available. Practitioner reports that patients can be easily misled by at-home readings which can often seem reasonable without considering the A1c levels from a lab. A1c counts are a better indication of a patient’s plasma glucose levels over the past three to four months. They provide a better indication of the patient’s compliance. Also, careful clinical examination is vital to monitor and treat ocular conditions. The practitioners say that patient education can never be overstated. When a patient realizes the severity of the situation and the implications that are held, it can help to motivate the patient to practice a higher form of control over the diabetes.

References

(Gibb & Olafsson) (Cassin, 2006, p. 87) (Levak, p. 132)Gibb, R., & Olafsson, H. (2006, September). Case study: Rapid progression of diabetic retinopathy. Retrieved from

Cassin, B. (2006). Dictionary of eye terminology (p. 87). Gainesville, FL: Triad Publishing Company.

Levak, N. (n.d.). Low vision: A resource guide with adaptations for students with visual impairments (p. 132). Austin, TX: Texas School fo the Blind and Visually Impaired.