Patient will present as → a 64-year-old diabetic patient who is being seen for a routine health screening. On fundocopic exam, you see cotton wool spots, hard exudates, blot and dot hemorrhages, neovascularization, flame hemorrhages, A/V nicking
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Most common cause of new, permanent vision loss and/or blindness in 25-74-year-olds
Most common is diabetic retinopathy: damage to retinal blood vessels leads to retinal ischemia and edema. Excess sugar attaching to proteins such as the collagen of blood vessels (glycosylation) causes capillary wall breakdown
- Diabetic retinopathy falls into two main classes: nonproliferative (early) and proliferative (late, advanced)
Other types of retinopathy are divided by cause – Inflammatory or Infectious
- Inflammatory: Bechet's, Sarcoidosis, SLE, Giant cell arteritis, Polyarteritis nodosa
- Infectious: Syphilis, Herpes simplex, Varicella Zoster, Toxo, and CMV = HIV
Diagnosis is by funduscopy
Nonproliferative type (an early form of the disease)
- Non-proliferative diabetic retinopathy (NPDR) is the early stage of the disease in which symptoms will be mild or nonexistent
- In NPDR, the blood vessels in the retina are weakened
- Fundoscopy: Microaneurysms, hard exudates, cotton wool spots, blot and dot hemorrhages, and venous dilation
Proliferative type (most severe, abnormal blood vessel growth)
- Proliferative diabetic retinopathy (PDR) is the more advanced form of the disease
- At this stage, circulation problems deprive the retina of oxygen. As a result new, fragile blood vessels can begin to grow in the retina and into the vitreous. The new blood vessels may leak blood into the vitreous, clouding vision
- Fundoscopic exam (abnormal growth of vessels) neovascularization
Treatment includes control of blood glucose and BP
- Ocular treatments included retinal laser photocoagulation, intravitreal injection of antivascular endothelial growth factor drugs (eg, ranibizumab, bevacizumab), intraocular corticosteroids, vitrectomy, or a combination
- If diabetic get yearly dilated ophthalmoscopic examination
Diabetic retinopathy is caused by damage to the blood vessels in the tissue at the back of the eye (retina). Poorly controlled blood sugar is a risk factor. Early symptoms include floaters, blurriness, dark areas of vision, and difficulty perceiving colors. Blindness can occur. Mild cases may be treated with careful diabetes management. Advanced cases may require laser treatment or surgery
Question 1 |
Hypertension | |
Diabetes mellitus | |
Macular degeneration Hint: See B for explanation. | |
Retinal artery occlusion Hint: See B for explanation. |
Question 2 |
maternal rubella infection Hint: While maternal rubella infection is a risk factor for ocular disease in the newborn, it is not a specific risk for retinopathy of prematurity. | |
maternal alcohol abuse Hint: Maternal alcohol abuse is associated with the development of fetal alcohol syndrome, which includes craniofacial abnormalities, but does not include increased risk for retinopathy of prematurity. | |
perinatal oxygen therapy | |
family history of retinal detachment Hint: If retinopathy of prematurity is not treated, retinal detachment may occur causing blindness. A family history of retinal detachment is not considered a risk factor for the development of retinopathy of prematurity. |
Question 3 |
Panretinal laser photocoagulation | |
Iridectomy Hint: Iridectomy is of no value in preserving the retina and iridectomy is harmful in this situation due to the trauma it causes to the eye. | |
Radial keratotomy Hint: Radial keratotomy is indicated to correct myopia. This surgery destroys normal eye architecture and has no benefit in diabetic retinopathy. | |
Vitrectomy Hint: Vitrectomy is indicated for treatment of retinal tears and not to preserve an intact retina. |
Question 4 |
Drusen Hint: Drusen are tiny to small yellowish round spots with hard or soft edges that are often seen in age-related macular degeneration. | |
Cotton-wool patches | |
Hard exudates Hint: Hard exudates are yellowish bright lesions with well-defined borders. They are often small and round. | |
Preretinal hemorrhages Hint: Preretinal hemorrhages obscure the underlying retinal vessels and are seen as a horizontal line of demarcation with plasma above and cells below. |
Question 5 |
Cytomegalovirus retinitis Hint: See C for explanation. | |
Diabetic retinopathy Hint: See C for explanation. | |
Hypertensive retinopathy | |
Sickle cell retinopathy Hint: See C for explanation. |
Question 6 |
He can wait until next year when he goes to get his refraction Hint: In type 2 diabetes, retinopathy is present in up to 20% of patients at diagnosis and may be the presenting feature. Eye examination for vision usually does not require a dilated eye exam, and refraction is not calculated with ophthalmoscope or direct visualization but by refractometer which does not examine the retina where retinopathy occurs. | |
He does not need to see an ophthalmologist if his Hemoglobin A1C is < 6.0 Hint: See C for explanation. | |
Retinopathy is present in 20% of patient with type 2 Diabetes Mellitus at time of diagnosis | |
Your non-dilated exam can substitute for this referral Hint: See C for the explanation. |
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