Non-Perfusion and Venous Beading Severe - Type 1 Diabetic
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20 year old diabetic with poor vision for the past three or four years. He reports he has not noticed any change for the better or worse in the past month or two. He reports no history of ophthalmic surgery, laser, or trauma. He reports his has not had his eyes examined in quite some time.
The Patient has a past medical history of diabetes for sixteen years and hemoglobin A1C of 10.0. His fasting blood sugar is 120 today. He reports he is getting better at his sugar control since moving to this country.
Family history is biologically negative for diabetes, retinal detachment, or blindness of unknown cause.
OPHTHALMIC EXAM: Visual acuity with correction of 20/25 OD, 20/30 OS. IOP: 12 OD, 14 OS.
SLIT LAMP EXAM: Biomicroscopy reveals a quiet anterior segment on both sides with no neovascularization anteriorly. The lenses are clear OU. The vitreous is well-formed and shows no syneresis or vitreous separation. There is no vitreous hemorrhage. C/D ratio is 0.2 OU. Large retinal vasculature shows 2+ venous dilation and diffuse venous beading. The macula appears dry, without significant telangiectatic vessels and intraretinal dot-blot hemorrhages present, with intraretinal microvascular abnormalities present as well. There is no preretinal neovascularization visible and there is no preretinal membrane visible.
EXTENDED OPHTHALMOSCOPY: The retinal periphery is flat and attached with no tears, breaks, or detachments. There is no vitreous hemorrhage and there is no peripheral traction or peripheral proliferation noted. There is moderate-to-severe intraretinal hemorrhage diffusely.
OCT SCAN: There is compact neurosensory retinal tissue with no subretinal or intraretinal fluid.
FUNDUS PHOTOGRAPHY: Color and red-free photographs correspond to clinical findings and show significant microvascular abnormalities and dot-blot hemorrhages in both eyes.
FLUORESCEIN ANGIOGRAPHY: The right eye is transit. Arm-to-eye time and AV transit time are within normal limits. There is significant drop-out at the retinal microvascular bed and mild enlargement of the foveal avascular zone on the right side. The left side, as seen in the post AV transit phase in early
recirculation, shows similar changes, which is somewhat less extensive than in the right. As the study progresses into the 2- and 5-minute late phases, there is intraretinal leakage from the microvascular bed in both eyes. There is no preretinal leakage and no subretinal leakage.
IMPRESSION:
1. DIABETES MELLITUS WITH PREPROLIFERATIVE DIABETIC RETINOPATHY AND UNCONTROLLED BLOOD GLUCOSE
2. MACULAR ISCHEMIA RIGHT MORE SO THAN LEFT EYE ON ANGIOGRAPHY
3. INTRARETINAL LEAKAGE WITHOUT MACULAR EDEMA ON EXAM OR OCT SCAN
DISCUSSION: The Patient, his stepfather, and I discussed his diabetic eyes. I explained that he has near certainty of losing vision unless his diabetes is better controlled. I explained there is a life-threatening systemic risk of diabetes as well, including diabetic nephropathy, cardiomyopathy, and central nervous system changes.
The Patient understands and accepts that he needs to improve his blood glucose or he will certainly lose vision. He is going to work with his primary care doctor and endocrinologist to perhaps start an insulin pump or administered insulin with better control and regularity.
The Patient is going to return to you for spectacle refraction after three to four months of well controlled blood sugar, in addition to any other follow-ups you recommended.
I am going to have The Patient come back and see me in three months for follow-up, and I explained to him that even with good sugar control, he has a good chance of progression over the short term.
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years612 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS. 
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years432 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years458 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years385 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years455 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years453 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years411 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years441 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years555 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years630 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years723 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years980 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years1341 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years1261 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years606 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years494 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years513 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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Capillary Non-Perfusion - Severe Non-Proliferative (Background) Diabetic Retinopathy - Type I - 20 Year Old Man Diabetic 16 years571 views20 year old diabetic with poor vision for the past three or four years. He has been diabetic for sixteen years and hemoglobin A1C of 10.0. 20/25 OD, 20/30 OS.
(0 votes)
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20 year old diabetic with poor vision for the past three or four years. He reports he has not noticed any change for the better or worse in the past month or two. He reports no history of ophthalmic surgery, laser, or trauma. He reports his has not had his eyes examined in quite some time.
The Patient has a past medical history of diabetes for sixteen years and hemoglobin A1C of 10.0. His fasting blood sugar is 120 today. He reports he is getting better at his sugar control since moving to this country.
Family history is biologically negative for diabetes, retinal detachment, or blindness of unknown cause.
OPHTHALMIC EXAM: Visual acuity with correction of 20/25 OD, 20/30 OS. IOP: 12 OD, 14 OS.
SLIT LAMP EXAM: Biomicroscopy reveals a quiet anterior segment on both sides with no neovascularization anteriorly. The lenses are clear OU. The vitreous is well-formed and shows no syneresis or vitreous separation. There is no vitreous hemorrhage. C/D ratio is 0.2 OU. Large retinal vasculature shows 2+ venous dilation and diffuse venous beading. The macula appears dry, without significant telangiectatic vessels and intraretinal dot-blot hemorrhages present, with intraretinal microvascular abnormalities present as well. There is no preretinal neovascularization visible and there is no preretinal membrane visible.
EXTENDED OPHTHALMOSCOPY: The retinal periphery is flat and attached with no tears, breaks, or detachments. There is no vitreous hemorrhage and there is no peripheral traction or peripheral proliferation noted. There is moderate-to-severe intraretinal hemorrhage diffusely.
OCT SCAN: There is compact neurosensory retinal tissue with no subretinal or intraretinal fluid.
FUNDUS PHOTOGRAPHY: Color and red-free photographs correspond to clinical findings and show significant microvascular abnormalities and dot-blot hemorrhages in both eyes.
FLUORESCEIN ANGIOGRAPHY: The right eye is transit. Arm-to-eye time and AV transit time are within normal limits. There is significant drop-out at the retinal microvascular bed and mild enlargement of the foveal avascular zone on the right side. The left side, as seen in the post AV transit phase in early
recirculation, shows similar changes, which is somewhat less extensive than in the right. As the study progresses into the 2- and 5-minute late phases, there is intraretinal leakage from the microvascular bed in both eyes. There is no preretinal leakage and no subretinal leakage.
IMPRESSION:
1. DIABETES MELLITUS WITH PREPROLIFERATIVE DIABETIC RETINOPATHY AND UNCONTROLLED BLOOD GLUCOSE
2. MACULAR ISCHEMIA RIGHT MORE SO THAN LEFT EYE ON ANGIOGRAPHY
3. INTRARETINAL LEAKAGE WITHOUT MACULAR EDEMA ON EXAM OR OCT SCAN
DISCUSSION: The Patient, his stepfather, and I discussed his diabetic eyes. I explained that he has near certainty of losing vision unless his diabetes is better controlled. I explained there is a life-threatening systemic risk of diabetes as well, including diabetic nephropathy, cardiomyopathy, and central nervous system changes.
The Patient understands and accepts that he needs to improve his blood glucose or he will certainly lose vision. He is going to work with his primary care doctor and endocrinologist to perhaps start an insulin pump or administered insulin with better control and regularity.
The Patient is going to return to you for spectacle refraction after three to four months of well controlled blood sugar, in addition to any other follow-ups you recommended.
I am going to have The Patient come back and see me in three months for follow-up, and I explained to him that even with good sugar control, he has a good chance of progression over the short term.
