Ophthalmology/Eye Institute

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 Department of Ophthalmology Case Studies

 

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Discussion:

This case describes a patient with proliferative diabetic retinopathy (PDR) in both eyes as seen by the NVD OD and NVE OS. Proliferative retinopathy is defined by the development of abnormal blood vessel (a process called neovascularization ) on the surface of the retina (neovascularization elsewhere – NVE) or optic disc (neovascularization of the disk – NVD).

Nonproliferative diabetic retinopathy (NPDR) is an initial, less severe stage of diabetic ocular disease. Retinal findings of NPDR include dot-blot hemorrhages, hard exudates and macular microaneurysms . NPDR can range from mild to severe, and roughly 40% of patients with the severe form will develop PDR within one year.

Patients with diabetes can also develop diabetic macular edema (DME), seen as fluid in the layers of the retina in the macula of the eye. DME can develop with either NPDR or PDR. DME can result in significant vision loss. It is characterized by fluid (known as edema) leaking from damaged blood vessels called microaneurysms. Sometimes exudates (small accumulations of debris left behind from edema) are also present. When certain criteria is met, the DME is considered clinically significant. Clinically significant macular edema (CSME) treated with focal laser is associated with a better long term visual outcome. Pharmacologic agents also can be use to treat CSME.

The leading cause of blindness in working age individuals in the United States is diabetic retinopathy. It is very important that individuals with diabetes have a dilated fundus exam at least yearly to monitor for diabetic retinopathy. An important factor in the development and progression of diabetic retinopathy is blood sugar control. Tight control is associated with reduced likelihood of vision loss from diabetic retinopathy. PDR is responsible for the majority of vision loss from diabetes. Severe complications of PDR include vitreous hemorrhage and traction retinal detachment. Retinal detachment is a result of the contraction of fibrous tissue which accompanies the new vessel formation.

Proliferative diabetic retinopathy can be diagnosed based on the funduscopic examination. Fluorescein Angiogram (FA) can also aid in diagnosis because abnormal neovascularization is hyperfluorescent. An important aspect of treatment includes good control of blood sugar. According to The Diabetic Retinopathy Study, panretinal laser treatment decreases vision loss in patients who have PDR with “high risk characteristics.” These high risk characteristics include neovascularization of more than one third of the optic disc surface, neovascularization of the disc with preretinal or vitreous hemorrhage, and any neovascularization away from the disk with preretinal or vitreous hemorrhage. Performing laser photocoagulation reduces the metabolic oxygen demand of the retina, helping the neovascularization to regress. Once complications such as a non-clearing vitreous hemorrhage or traction retinal detachment have occurred, laser treatment may no longer be effective and an intraocular surgery called a pars plana vitrectomy could be necessary.
 

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