Diabetic Retinopathy and Its Management

Neil M. Bressler

Case Vignette

A 70-year-old man notes progressive problems with reading the newspaper and seeing signs while driving over the past year. His most recent examination with a comprehensive ophthalmologist was approximately 3 years ago when he was told he had some evidence of ‘‘diabetes’’ in his eyes. He also has a past medical history of diabetes for which he is taking an oral hypoglycemic agent, and a history of hypertension for which he is taking two medications, but he cannot recall what the medications are, and did not bring them to his examination. He is not aware what his hemoglobin A1C level is, but his reply to this question also was that he might have ‘‘a little anemia.’’

On evaluation, his visual acuity was 20/40 in his right eye and 20/50 in his left eye with his glasses. A manifest refraction revealed no change to his current prescription and did not result in any better visual acuity measurement. The pupils reacted normally to light and intraocular pressures were 19 and 18 mmHg in the right and left eyes, respectively. The slitlamp examination showed no iris neovascularization in either eye although there was some nuclear and cortical opacity in the right eye and nuclear opacity in the left eye which did not appear to account for any decrease in visual acuity. Dilated ophthalmoscopic examination of the right eye showed more than 20 dot and blot hemorrhages in one field nasal to the optic nerve and temporal to the macula. There were a few nerve fiber layer infarcts along the supero-temporal arcade, but no evidence of venous beading or intraretinal microvascular abnormalities (IRMA). The distance between the surface of the retina and the retinal pigment epithelium in the center of the macula appeared thickened, with some microaneurysms and lipid within the central macula. Dilated ophthalmoscopic examination of the left eye also showed more than 20 dot and blot hemorrhages in one field temporal to the macula, but no evidence of venous beading or intraretinal microvascular

N.M. Bressler (*)

Department of Ophthalmology, The Methodist Hospital, Houston, Texas