67-year-old female with a history of HTN and DM complains of gradual, painless vision loss OD. Give your opinion.

A 38 year old patient presented for a routine exam. He has no complaints. He has a medical history significant for diabetes mellitus type 2. On exam, his vision is 20/30 and his intraocular pressure is normotensive. What is your favorite diagnosis and management?

DIABETIC RETINOPATHY. Diabetic retinopathy is a progressive damage to the retina which occurs in diabetics.It is a serious sight- threatening complication of diabetes. Diabetic retinopathy depends on the duration of diabetes and the glycemic control. Here ,the tiny blood vessels leak blood and other fluids. SYMPTOMS. 1.Seeing spots or floaters. 2.Blurred vision. 3.Having a dark or empty spot in the centre of the vision. 4.Difficulty seeing well in the night. Long standing hyperglycemia causes fluid to accumulate in the lens that controls focussing. This changes the curvature of lens leading to blurred vision. STAGES OF DIABETIC RETINOPATHY. STAGE I : Microaneurysms occur. STAGE II : Some blood vessels that nourish the retina are blocked. STAGE III : More blood vessels are blocked, depriving several areas of retina of it's blood supply. STAGE IV : New blood vessels grow (Neo vascularization),but they are abnormal and fragile. They leak blood leading to vision loss and blindness. ANOTHER CLASSIFICATION. 1.NON-PROLIFERATIVE DIABETIC RETINOPATHY Signs of NPDR given in a mnemonic. Microsoft Dot com Rated Internet Very Cool and Definitely Hot. Micro aneurysms. Dot and blot hemorrhages. Retinal edema. Intraretinal micro vascular abnormalities. Venous abnormalities. Cotton-wool spots. Dark blot hemorrhages. Hard exudates. 2.PROLIFERATIVE RETINOPATHY. Neo vascularization of disc. Neo vascularization elsewhere in the retina Fibrovascular proliferation. Vitreous hemorrhage TREATMENT. Treatment of Diabetic retinopathy depends on the stage of disease. THE GOAL OF ANY TREATMENT IS TO SLOW OR STOP THE PROGRESSION OF THE DISEASE. PHARMAVOLOGIC THERAPY. TRIAMCINOLONE: Administered intra vitreously, corticosteroid used in the treatment of Diabetic macular edema. BEVACIZUMAB :Administered intra vitreously, monoclonal antibody that can help to reduce Diabetic macular edema and neo vascularization of disc and retina. RANIBIZUMAB : Administered intra vitreously, monoclonal antibody that can help to reduce Diabetic macular edema and neo vascularization of the disc and retina. GLYCEMIC CONTROL. Intensive glucose control is essential to slow or stop these changes. In the early stages of non-proliferative Diabetic retinopathy, regular monitoring may be the only treatment. Diet,exercise and maintaining normoglycemia helps to control the progression of the disease. In the later stages,leakage of blood through the capillaries can be reduced by LASER TREATMENT OR PHOTO COAGULATION .A laser beam of light creates small burns in the retina with abnormal blood vessels and the leaks are sealed LASER PHOTO COAGULATION IS INDICATED IN THE TREATMENT OF CLINICALLY SIGNIFICANT MACULAR EDEMA IN NDPR. PANRETINAL PHOTO COAGULATION IS USED IN THE TREATMENT OF PDR. VITRECTOMY :This is used in PDR in cases of long standing vitreous hemorrhage. CRYOTHERAPY : When laser photo coagulation in PDR is precluded in the presence of an opaque media, such as in cases of cataract or vitreous hemorrhage, cryotheapy may be applied. DIAGNOSIS. LABORATORY STUDIES OF HbA1C LEVELS ARE IMPORTANT IN THE LONG TERM FOLLOW UP CARE OF PATIENTS WITH DIABETES AND DIABETIC RETINOPATHY. FLOTESCEIN ANGIOGRAPHY. OPTICAL COHERENCE TOMOGRAPHY SCANNING B- SCAN ULTRASONOGRAPHY. PATIENT EDUCATION. THE MAINSTAY OF DIAGNOSING DIABETIC RETINOPATHY IS A COMPLETE OPHTHALMIC EXAMINATION AND DILATED RETINAL EXAMINATION BY AN OPHTHALMOLOGIST. EXCELLENT GLUCOSE CONTROL IS BENEFICIAL IN ANY STAGE OF RETINOPATHY. IT DELAYS THE ONSET AND SLOWS DOWN THE PROGRESSION OF OF THE DIABETIC COMPLICATIONS IN THE EYE. SYSTEMATIC PROBLEMS LIKE HYPERTENSION, RENAL DISEASE AND HYPERLIPIDEMIA MAY CONTRIBUTE TO DISEASE PROGRESSION. SMOKING MAY COMPROMISE OXYGEN DELIVERY TO THE RETINA. THEREFORE, ALL EFFORTS SHOULD BE MADE IN THE REDUCTION, IF NOT OUTRIGHT CESSATION OF SMOKING. VISUAL SYMPTOMS LIKE VISION CHANGES, FLOATERS,DISTORTION, REDNESS AND PAIN COULD BE MANIFESTATIONS OF DISEASE PROGRESSION AND SHOULD BE REPORTED IMMEDIATELY.

1st pic Normal ratina 2nd pic Diabetic retinopathy 28 f Type 1 DM with HbA1C 14

SPOT DIAGNOSIS The patient had diabetes mellitus for years