PDR – October 2016

Case presentation

A 41 year-old female was referred to Illinois Retina Associates for blurry vision in both eyes of long duration. She was referred for bilateral retinal hemorrhages.

Further history

The patient is known for poorly controlled diabetes and hypertension. She had not had regular dilated eye examinations since the diabetes diagnosis.

Posterior segment exam

On anterior segment examination, visual acuity was 20/40 in both eyes. In the posterior pole, there were scattered retinal hemorrhages, vitreous and pre-retinal hemorrhages, venous beading, and diffuse pre-retinal neovascularization (Figures 1 & 2).

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Figure 1

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Figure 2

Diagnostic testing

Fluorescein angiography of both eyes demonstrated peripheral nonperfusion, venous beading, and extensive leakage from the pre-retinal neovascularization (Figures 3 & 4).

OCT imaging revealed traction from a thickened posterior vitreous in the right eye and the lack of macular edema in both eyes (Figure 5 & 6).

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Figure 3

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Figure 4

Figure 5

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Figure 6

Differential diagnosis

Given the history of poorly controlled diabetes, the most likely cause of the extensive ischemia and neovascularization was proliferative diabetic retinopathy. Other potential causes to be considered include: bilateral central retinal vein occlusions, bilateral ocular ischemic syndrome, familial exudative retinopathy, sickle cell retinopathy.

Treatment and follow-up

The main problem that had to be addressed was the extensive pre-retinal neovascularization in both eyes. The patient underwent panretinal photocoagulation laser therapy in both eyes.

Other treatment options to be considered could include vitrectomy surgery, which would allow removal of the vitreous hemorrhage and release of the traction on the macula (in the right eye), along with laser to the peripheral retina.

The patient will need to be followed closely for worsening vitreous hemorrhage, recurrence of neovascularization, macular edema, and tractional macular detachment.

Discussion

Diabetic retinopathy afflicts a large number of patients with diabetes, and the prevalence increases with time since diabetes diagnosis and poor glycemic control. Non-proliferative diabetic retinopathy is characterized by retinal hemorrhages, intraretinal lipid, ischemia, venous beading. The more advanced stage of the disease, proliferative diabetic retinopathy, can present all of the above findings, in addition to pre-retinal neovascularization, vitreous hemorrhage, tractional retinal detachments, and/or anterior segment (iris and angle) neovascularization.

If not treated promptly, proliferative diabetic retinopathy can lead to severe loss of vision from vitreous hemorrhage and/or tractional retinal detachment. Urgent referral for treatment is essential to prevent loss of vision. The gold standard for treatment of proliferative diabetic retinopathy is peripheral laser therapy, which leads to regression of neovascularization. In cases with non-improving vitreous hemorrhage or tractional retinal detachments, vitrectomy may be necessary.

In addition to the peripheral retinal findings above, diabetic patients may present with decreased vision from macular edema at any stage of the disease. The treatment for diabetic macular edema is anti-VEGF or steroid intravitreal injections or laser.

In fact, it is recommended that patients with type 2 diabetes undergo regular dilated eye examinations to screen for the development of diabetic retinopathy starting at the time of diabetes diagnosis.

References

Berrocal MH, Acaba LA, Acaba A. Surgery for Diabetic Eye Complications. Curr Diab Rep. 2016 Oct;16(10):99.

Leasher JL, Bourne RR, Flaxman SR et al. Global Estimates on the Number of People Blind or Visually Impaired by Diabetic Retinopathy: A Meta-analysis From 1990 to 2010. Diabetes Care. 2016 Sep;39(9):1643-9.

Scuta GL, Cantor LB, Cioffi GA. Basic and Clinical Science Course. Singapore: American Academy of Ophthalmology, 2013: 89-112

Stewart MW. Treatment of diabetic retinopathy: Recent advances and unresolved challenges. World J Diabetes. 2016 Aug 25;7(16):333-41.

 

 

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