Special Senses Patient A

The following is a description of a 55 year old patient that was presented in the Journal of the American Medical Association 2011;365:1520-1526.

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A 55-year-old man with a 20-year history of type 2 diabetes mellitus was referred to a retina specialist after noticing a few black floaters in his left eye for the preceding week. His glycated hemoglobin level was 8.2%.

He had no history of laser treatment for proliferative diabetic retinopathy in either eye. Ophthalmoscopic examination of the right eye showed venous beading, intraretinal microvascular abnormalities, and no macular edema.

Ophthalmoscopic examination of the left eye showed extensive neovascularization of the optic disk, consisting of new vessels extending beyond the optic disk in all directions.

Patient A: Tests and Diagnosis

The retina specialist diagnosed severe nonproliferative diabetic retinopathy in the right eye and high-risk proliferative diabetic retinopathy in the left eye, with no macular edema in either eye.

The patient who is described in the vignette has proliferative diabetic retinopathy in the left eye with four high-risk features, including the presence of neovascularization, severe neovascularization, and neovascularization at the optic disk. A small amount of vitreous hemorrhage, not seen in the fundus photograph, caused the apparent floaters and is the fourth risk factor.

Patient A: Treatment

Observe photographs of the retina in Figure 1, which shows the effects of the laser treatment (URL = http://www.nejm.org/doi/full/10.1056/NEJMct0908432).

Prompt initiation of panretinal photocoagulation in the left eye is recommended to reduce the risk of severe loss of visual acuity. Because the patient has no macular edema, it is unlikely that vision loss from macular edema that is caused by the treatment will develop. ("Pan" means the treatment is given across the entire retina.)

The consent process should include a discussion regarding the risks of permanent loss of peripheral and night vision, as well as discomfort or pain during the procedure and within 24 hours after the procedure. The patient should be advised that whether the treatment is completed in one or more sittings, it is important to complete panretinal photocoagulation as soon as possible before severe vitreous hemorrhage occurs.

The patient will need to return for follow-up approximately a month after panretinal photocoagulation is completed. Also, the right eye needs to be monitored approximately every 4 months for progression to proliferative diabetic retinopathy, because of the presence of severe nonproliferative diabetic retinopathy in that eye. Some ophthalmologists might initiate treatment in the right eye at this point, because with long-term follow-up, virtually all such eyes eventually need treatment.

Finally, the patient should be reminded to work with his primary care provider to try to optimize both diabetes management and general medical care, because control of diabetes and blood pressure can influence the progression of retinopathy.

QUESTION: What does proliferative in this context mean?


QUESTION: This patient does not have macular edema. Is that expected?


QUESTION: What other treatments are used for proliferative diabetic retinopathy?