Western Visayas Medical Center

Department of Ophthalmology

PATIENT CASE PRESENTATION

Presented by
Jessa Mae F. Pangandian

October 15, 2018

GENERAL NS
DATA 61 Male/Married
• Retired
maintenance
worker
• Jaro, Iloilo
CHIEF
COMPLAINT

BLURRING OF VISION
HISTORY OF • 2 years PTC, patient had increasing
PRESENT blurring of vision on both eyes
(OS>OD)
ILLNESS • 7 months PTC, patient undergone
health checkup and was diagnosed
with diabetes mellitus- non-insulin
requiring. He was then advised for
ophthalmologic consult thus consult

(+) blurring of vision

(-) eye pain, pruritus, redness and
discharge
(-) dizziness
(-) headache
PAST
MEDICAL • No previous hospitalization
HISTORY • (+) Diabetes mellitus (NIR)
• (-) Hypertension, Asthma,
Tuberculosis
• No known food or drug
allergies
• Maintenance medications
(good compliance)
• Diamicron
• Metformin 500 mg BID
FAMILY
HISTORY
(+) Diabetes Mellitus
(-) Hypertension,
Tuberculosis, Asthma,
Cancer
PERSONAL
SOCIAL • Non-smoker
HISTORY • Occasional alcoholic
drinker
• Retired maintenance
worker
VITAL SIGNS & ANTHROPOMETRICS

• Blood pressure : 120/80 mmHg (normal)

• Pulse Rate : 82 beats per minute (normal)
• Respiratory Rate : 20 cycles per minute (normal)
• Temperature : 37.0°C (normal)
PHYSICAL EXAM
Organs Findings
Face The face has symmetrical features and expression. Facial muscles do not show any
weakness, paralysis or uncoordinated movement. Patient able to open his mouth and
move his jaw.
Eyes The eyes are symmetrical. The pupils were round and equal, and reactive to light. The
patient has pinkish conjunctiva and dirty sclerae.
Ears No excessive cerumen at both ears. Canal walls pink, smooth and without nodules.

Nose and sinuses No nasal discharge

Mouth, throat and Tonsils Oral moist lips and mucosa

Neck Trachea in midline. No lymphadenopathies.

Chest and lungs Symmetrical chest expansion.
Clear breath sounds. No crackles or wheezing noted.

Heart and blood vessels heart beat is regular in rate and rhythm.
No murmurs, no abnormal heart soundsThe
Capillary Refill Time <2 .
Abdomen Umbilicus at the midline, no lesions. Normoactive bowel sounds with 10 cycles/ minute,
No abdominal bruits. No masses palpated. No direct and rebound tenderness.
Musculoskeletal, Spine No clubbing or cyanosis noted.
and extremities Peripheral pulses are equal with grading of 2+.
Capillary refill <2 seconds.
8 PART EYE
EXAMINATION
DISTANCE
VISUAL
ACUITY
Without Pinhole
Correction

OD 20/20 20/20
OS 20/100 20/80
EXTERNAL Unremarkable
EYE EXAM No lesions, growth,
inflammation an
No ptosis
PUPILLARY
EXAM

OD OS

2-3 mm 2-3 mm
BRTL BRTL
MOTILITY
EXAM

OD OS

Full EOM
VISUAL
FIELD TEST

OD OS

Normal
TONOMETRY

OD OS

12 cm H2O 12 cm H20
Normal Normal
OPHTHALMOSCOPY

OD OS
(+) dot and blot hemorrhage (+) dot and blot hemorrhage
(+) flame hemorrhages
(+) exudates
OPTICAL COHERENCE TOMOGRAPHY

OD OS
Central subfield thickness 315 345
Cube Volume 10.8 10.2

Cube average thickness 299 302

FINDINGS MACULAR EDEMA, OU
DIFFERENTIAL
DIAGNOSES
Main Impression:
Diabetic Retinopathy

Differentials:
1. Ocular Ischemic Syndrome
2. Radiation Retinopathy
3. Retinal Vessel occlusion
4. Hypertensive Retinopathy
OCULAR
ISCHEMIC
SYNDROME Differentiating
Differentiating Tests
Signs/Symptoms
Commonly presents with
amaurosis fugax and
gradual or sudden visual
loss.

Vision may be poor, Fluorescein angiography

intraocular pressure may be shows delayed arterial filling
abnormally high or low, and in affected eyes.
anterior segment
neovascularization is a Doppler imaging may show
common feature. carotid stenosis and
ophthalmic artery flow
Commonly unilateral, reversal.
predominantly hemorrhagic,
and often involves equatorial
and anterior retina rather
than the posterior pole.
image
RADIATION
RETINOPATHY

Differentiating
Differentiating Tests
Signs/Symptoms
Typically occurs in people
with a history of radiation
exposure and without
No differentiating tests;
diabetes.
exposure to radiation can
usually be elicited from the
Signs of an irregular pattern
his
of capillary leakage and
nonperfusion are present.
image
RETINAL
VEIN
OCCLUSION Differentiating
Signs/Symptoms
Differentiating Tests

Typically produces acute

visual loss in one eye, and
retinal signs (i.e.,
hemorrhage, cotton wool
spots, macular edema,
neovascularization) are
limited to the eye and to the
territory of the occlusion. Fluorescein angiography is
effective in characterizing the
Central retinal vein occlusion distinctly localized nature of
typically involves the posterior vascular abnormality in retinal
pole, but if a branch vein is venous occlusion.
occluded, signs are limited to
the segment of retina drained
by the vein, and it is usually
possible to identify the point
of occlusion where an artery
crosses anterior to a vein.
image
HYPERTENSIVE
RETINOPATHY
Differentiating
Differentiating Tests
Signs/Symptoms

Systolic and diastolic

pressures are markedly
elevated.

Associated with acute visual

disturbance, with optic disk
swelling (which is uncommon
Fluorescein angiography
in diabetic retinopathy) and
reveals arteriolar
macular edema often in the
nonperfusion, rather than
form of a macular exudate
capillary nonperfusion as in
star.
diabetic retinopathy.
It may involve the posterior
pole of both eyes, but signs
of axoplasmic holdup (i.e.,
cotton wool spots and optic
disk edema) tend to dominate
the fundus appearance.
CASE
DISCUSSION
Diabetes Mellitus
• Group of common metabolic disorders
• Caused by a complex interaction of genetics and
environmental factors
• Lack of insulin hyperglycemia
• Diagnostic criteria : Fasting plasma glucose > 126 mg/dl
• Type 1 DM – Insulin-dependent diabetes (IDDM) Results from
pancreatic beta-cell destruction, usually leading to absolute
or near total insulin deficiency
• Type 2 DM - Non-insulin-dependent diabetes (NIDDM)
• Variable degrees of insulin resistance and impaired insulin
secretion, resulting in hyperglycemia and other metabolic
derangements due to insufficient insulin action
COMPLICATION
DIABETIC RETINOPATHY
• The most severe of ocular complications of
diabetes
• Caused by damage to blood vessels of the retina,
leads to retinal damage
• Microvaascular complication of longstanding
diabetes mellitus
• Most prevalence cause of legal blindness between
the ages of 20 and 65 years
• Common in DM type 1 > type 2
DIABETIC RETINOPATHY
• Duration of diabetes: most important diagnosed
before age 30 yr 50% DR after 10 yrs 90% DR after
30 yrs
• Poor metabolic control: less important, but
relevant to development and progression of
diabetic retinopathy
• Pregnancy associated with rapid progression of DR
PATHOGENESIS

Microvascular Occlusion Microvascular Leakage

MICROVASCULAR
OCCLUSION
MICROVASCULAR
LEAKAGE
RETINAL EXAMINATION
Non-mydriatic Binocular
retinal indirect
photography ophthalmoscopy

Mydriatic
Slit-lamp
retinal
biomicroscopy
photography

A photographer working with a mobile clinic team takes fundus images in a rural hospital. Photo: Cristóvão Matsinhe. CC BY-NC 2.0 CEHJ
 Normal retina Diabetic retinopathy

Haemorrhages

Macula Central Abnormal

Retinal Vein growth of
Fovea Central blood
Optic Retinal Artery vessels
Disc
Aneurysm
Retinal Hard “Cotton wool”
Arterioles Retinal Exudates spots
Venules

Venous
beading
Optic Disc
Macula Hard
Exudates

Haemorrhages “Cotton wool”

spots

Normal retina Severe non-proliferative diabetic retinopathy

with severe diabetic macular edema

Source: Singapore Eye Research Institute

 Grading of Diabetic Retinopathy (DR)
No apparent DR No abnormalities
Mild non-proliferative DR • Microaneurysms only

Moderate non-proliferative DR • More than just microaneurysms,

less than severe non-proliferative DR
• No signs of proliferative DR

Severe non-proliferative DR Any:

• Intraretinal haemorrhages
• Venous beading
• Intra-retinal microvascular abnormalities

Proliferative DR Any:
• Intraretinal haemorrhages
• Venous beading
• Intraretinal microvascular abnormalities
One or more:
• Neovascularisation
• Vitreous/pre-retinal haemorrhage
Criteria for diagnosis of clinically significant macular edema
•Thickening of the retina at or within 500 micrometers of the fovea
•Hard lipid exudates at or within 500 micrometers of the fovea if associated with
retinal thickening
•A zone of retinal thickening one disk area or larger, any part of which is within one
disk diameter of fovea
NON-PROLIFERATIVE
DIABETIC
RETINOPATHY OU,
MACULAR EDEMA
MAIN IMPRESSION
 TREATMENT OPTIONS

• Laser photocoagulation
• Intravitreal anti VEGF
• Intravitreal steroids
• Vitrectomy

Ophthalmic staff preparing to see patients, Ethiopia. Photo: Lance Bellers/Sight Savers. CC BY-NC 2.0 CEHJ
TREATMENT
TREATMENT
Prevalence of Diabetes in Adults
(20-79 years), 2015

415 million adults with diabetes worldwide, or 1 in 11 adults

• 35.8% of cases are undiagnosed in high-income countries,
50% in low / middle income countries.

• 87-91% of cases are type 2 diabetes

• Type 2 diabetes factors: Lifestyle, culture,

industrialisation, urbanisation, availability & affordability
of processed foods, genetics.
 Impacts of Vision Loss on the Poor
• Less access to health support
services

• Loss of earning capacity

• Loss of dependence and

dignity

• Need for greater social support

• Women and girls suffer most

 Effects of Vision Loss on a Person
Fear of total blindness, Psychological Daily necessities:
feeling isolated and well-being preparing meals, shopping,
helpless, depression recognizing faces

More difficult to
IMPACT OF Work &
care for self, Physical
increased risk of
social
well-being VISION LOSS
injury due to falls Integration

Forced to rely on Work:

caregivers, guilt Lost going to work, continued
independence employment in current job

Mitchell J, Bradley C. Health Qual Life Outcomes 2006

Wysong A et al. Arch Ophthalmol 2009
 Health Related Quality of Life
Complication Mean
Mild stroke 0.70

Diabetic neuropathy 0.66

Angina 0.64

Diabetic nephropathy 0.64

Amputation 0.55

Diabetic retinopathy 0.53

Blindness 0.38

End-stage renal disease 0.35

Major stroke 0.31

Huang S et al. Diabetes Care 2007 0 = death, 1 = life in perfect health

 Timing of Eye Screening
Type 1 Diabetes Type 2 Diabetes Gestational Diabetes

Initial Five years As soon as possible As soon as possible

after diagnosis after diagnosis after diagnosis
of diabetes of diabetes of diabetes

Ongoing Every one Every one If diabetes resolves

to two years to two years after pregnancy,
no further
screening needed
 Eye Examination
• Ideally all people with
diabetes should have at
least an initial
comprehensive eye
examination by an eye
care professional

• If this is not possible,

then eye screening
should be performed
consisting of visual
acuity test and retinal
examination

Screening and photo grading services, Indonesia. Photo: Dwi Ananta, HKI. CC BY-NC 2.0 CEHJ
 Ophthalmic Assessment of
Diabetic Eye Disease
• Record of medical history

• Assessment of visual acuity

• Slit-lamp biomicroscopy

• Measurement of intraocular pressure

• Gonioscopy (in certain cases)

• Fundus examination
 Managing Diabetes
• Social support • Medication
• Nutritional support • Medical examinations and
treatment
 Managing Diabetes to Manage
Eye Health
• Communicate need for ongoing eye screening

• Encourage lifestyle modification

• Develop individual plans

• Provide support for ongoing self-management

• Ensure regular contact with health professionals

• Ensure access to education programmes,

including education on eye health