Ophthalmology - Systemic Diseases and the Eye

Question 1

A 42yo male with T1DM since age 8 presents with gradual mildly decreased vision in both eyes. Name 5 signs of diabetic retinopathy you might find on fundoscopy.

Answer 1

1. hard exudates (lipoprotein precipitates): hyperglycaemia causes endothelial dysfunction and thus increased vascular permeability
2. dot/blot haemorrhages: hyperglycaemia causes pericyte dysfunction and thus formation of microaneurysms which can leak

Microvascular occlusion causes retinal ischaemia and thus growth factor production:

3. cotton wool spots: build up of axonal debris due to poor axonal metabolism at margins of ischaemic infarcts
4. AV shunts
5. neovascularisation

Question 2

A 42yo male with T1DM and known diabetic retinopathy attends eye screening. Fundoscopy reveals hard exudates and 2 dot haemorrhages. Which grade of diabetic retinopathy does this represent and how would you f/u?

Answer 2

R1: Mild background DR: 1-3 dot haemorrhages or microaneurysm ± hard exudates

Rescreen in 12mths

Question 3

A 42yo male with T1DM and known diabetic retinopathy attends eye screening. Fundoscopy reveals hard exudates, dot haemorrhages and neovascularisation on the disc. Which grade of diabetic retinopathy does this represent and how would you f/u?

Answer 3

R4: Proliferative retinopathy: NVD, NVE, vitreous haemorrhage, retinal detachment.

Refer to ophthalmology

Question 4

A 42yo male with T1DM and known diabetic retinopathy attends eye screening. Fundoscopy reveals hard exudates, 6 dot haemorrhages in the right hemifield and 2 on the left. Which grade of diabetic retinopathy does this represent and how would you f/u?

Answer 4

R2: Moderate background DR: 4+ blot haemorrhages in 1 hemifield.

Rescreen in 6mths.

Question 5

A 42yo male with T1DM and known diabetic retinopathy attends eye screening. Fundoscopy reveals hard exudates, 4 dot haemorrhages in the right hemifield and 4 on the left. AV shunts and venous beeding are also present. Which grade of diabetic retinopathy does this represent and how would you f/u?

Answer 5

R3: Severe non-proliferative or pre-proliferative DR: 4 blot haemorrhages in both hemifields, intra-retinal microvascular anomalies, venous beeding.

Refer to ophthalmology.

Question 6

A 42yo male with T1DM and proliferative retinopathy presents with decreased vision. What are his treatment options?

Answer 6

1. Laser therapy
   - focal laser treatment: for macula oedema
   - panretinal photocoagulation: for severe pre-proliferative or proliferative retinopathy. Aim to decrease retinal O2 demand and thus stimulus for neovascularisation. Halves risk of severe visual loss.
2. Medications
   - intravitreal triamcinolone acetonide (long-acting steroid)
   - intravitreal anti-VEGF
3. Surgery
   - vitrectomy: for significant vitreal haemorrhages