Patient History
HPI:
A 35 year-old convenient store manager with history of non-insulin dependent DM x 5 years presents to the Eye Clinic for his annual visit. He admits to progressive blurring of vision since his last visit one year ago. Reading street signs while driving seems more difficult. He is unsure of which eye seems worse. He does not wear any glasses or contacts with the exception of over-the counter reading glasses. He denies any flashes or floaters, diplopia, eye discomfort or pain.
The patient reports that he has been going through some tough times recently with a difficult divorce about 6 months ago. As a result of all the stress, his blood sugars have not been under good control and he feels he has been making this worse by eating a lot of junk food and not always taking his diabetic medications. His blood sugar has been as high as 400 and he was admitted to the hospital three months ago for diabetic ketoacidosis.
Past Ocular History:
No prior eye surgeries, no hx of eye trauma, amblyopia or strabismus. No prior diabetes findings in the eye.
Ocular Medications:
None
Past Medical History:
Hypercholesterolemia, Obesity, DM Type 2, Hypertension
Surgical History:
None
Past Family Ocular History:
Negative for macular degeneration, glaucoma, diabetic retinopathy or blindness
Social History:
30 pack year smoking history and drinks alcohol socially.
Medications:
Lisinopril, Hydrochlorothiazide, Metformin, Simvastatin
Allergies:
None
ROS:
Denies any other CNS, heart, lungs, GI, skin or joint symptoms
Visual Acuity (cc):
OD: 20/40
OS: 20/40
IOP (tonoapplantation):
OD: 16 mmHg
OS: 15 mmHg
Pupils:
Equal, round and reactive to light. No APD
Extraocular Movements:
Full OU. No nystagmus
Confrontational Visual Fields:
Full to finger counting OU
External:
Normal, both sides
Slit Lamp
Lids and Lashes |
Normal OU |
Conjunctiva/Sclera |
Normal OU |
Cornea |
Clear OU |
Anterior Chamber |
Deep and quiet OU |
Iris |
Normal OU; no neovascularization of the iris OU |
Lens |
Clear OU |
Anterior Vitreous |
Clear OU
|
Dilated Fundus Examination:
OD |
Clear view, CDR 0.35; neovascularization of the disc involving ~ 50% of disc; flat macula with multiple microaneurysms and hard exudates > 500 microns away from the fovea, no clinically significant macular edema; multiple dot-blot hemorrhages in the retina periphery in all 4 quadrants without retinal detachment |
OS |
Clear view, CDR 0.40 with sharp optic disc margins; flat macula with multiple microaneurysms and hard exudates > 500 microns away from the fovea, no clinically significant macular edema; peripheral retina with multiple dot-blot hemorrhages in the periphery in all 4 quadrants
|
Other:
Fluorescein angiography with evidence of abnormal vasculature (microaneurysm with leakage in later frames) and areas of capillary dropout. In the R eye there is hyperfluorescence in the area of the neovascularization of the disc.