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OD Photo
OS Photo
History
This 62 year old bilingual
(English/Spanish) woman presents to the clinic (1) blurry vision at
distance (2) dry eyes (3) floaters and (4) [diabetic retinal exam.
The patient reports that the above symptoms are not acute and did
not occur suddenly. She is using Allergan Liquigel, a viscous
lubricant upon my recommendation but she still has complaints of
dryness.
Her last eye exam was in Feb 2005 with
this provider. Her last PCP visit was on 05/24/06 and her next is
one months hence. She has a medical history of
(1) T2DM x 15 yrs (2) Dyslipidiema (3) suspected CAD (4)
Hypertension. Her Medication list is as follows:
(1) Lantus Insulin; 20 units in the morning; 15 units in the evening
(2) Avandia, 4mg, daily (3) Metformin, 1000mg, BID (4) Lipitor,
80mg, nightly (5) Lisinopril, 40mg, daily (6) Adalat CC, 90mg daily
(7) Levothyroxid, 0.125 mg daily (8) enteric coated aspirin, 81mg,
daily (9) Estradiol, 0.50mg PRN twice a week Hb1ac
was most recently 7.9%
Physical examination
- Entry sc OD 20/50
OS 20/CF 6 ft
- Intraocular pressures (TA, 09:22hrs)
were OD 26 mm Hg and
OS 28 mm Hg.
- The dilated fundus examination revealed
a large chorioretinal scar with a etiology of most likely
toxoplasmosis (which cannot be seen easily on the OS photo.
Question:
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Why does a 15 year T2DM require Insulin?
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What might you think are the predictors
for minimal morbidity (retinopathy) in the face of multiple
management modalities, dyslipidemia, hypertension and chronic
hyperglycemia (7.9%)
Dr Hom's Response
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The patient is under maximum medical
therapy with both Insulin and oral agents. Insulin is the most
effective hypoglycemic agent for glycemic control over a day. Oral
agents may help in moderating the high fluctuations that often
occur in meal times. For patients on insulin monotherapy, insulin
pumps are used to smooth the swings in blood sugar levels that may
occur with boluses of insulin injections.
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Studies have shown that chronic
hyperglycemic over 9.0% will definitely cause retinopathy. At 7.0%
and below, the morbidities are definitely reduce. What is
problematic is the range between the two. It is likely that the
damage is microvascular and invisible and will eventually
transition to visible damage at a future date
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Lastly, the patient's renal function,
hypertensive state and lipid status are all excellent. The ETDRS
papers suggest that severe vision loss (SVL) can result if these
three factors are not accommodated or are untreated.
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