Optometric Management Supplements

June 2015

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10 • INTEGRATED CROSS-DISCIPLINARY APPROACHES TO THE MANAGEMENT OF DIABETIC EYE DISEASES A 38-year-old African American male presents at his optometrist's offce, reporting gradual onset of blurry vision in each eye for 3 months. He was diagnosed with type 2 diabetes 10 years ago, and has hyperten- sion, dyslipidemia and obstructive sleep apnea. He takes atorvastatin (Lipitor, Pfzer) 20 mg daily, fosinopril (Monopril, Bristol-Myers Squibb) 40 mg daily and met- formin 1000 mg twice daily. He's been using continuous positive airway pressure therapy for 2 years. The patient's BMI is 35.9, and hemoglobin A1c is 8.8. His blood pressure is 143/100 mm Hg, and pulse rate is regular at 84 beats/min. Visual acuities are 20/30 OD and 20/40 OS with grade 1 lens opacities OU. A dilated fundus examination 2 years ago revealed mild nonproliferative diabetic retinopathy without macular edema in each eye (Figure 1). Today's exami- nation reveals increased retinopathy (Figure 2). OCT shows diffuse macular edema with center involvement in both eyes (Figure 3). DISCUSSION OF CASE DR. PIZZIMENTI: Dr. Goldberg, how would you manage this patient? DR. GOLDBERG: This patient has uncontrolled hyper- glycemia and hypertension and severe obesity. I would check his lipids and renal function and refocus on lifestyle. He will likely require at least two more antihy- perglycemic agents (A1c goal <7), possible insulin and adjunctive antihypertensive therapy (blood pressure goal <140/90). High intensity statin therapy, e.g., atorv- astatin, 80 mg daily, is warranted. DR. PIZZIMENTI: Dr. Dunbar, what's the role of the optometrist going forward with this patient? DR. DUNBAR: The adage that a picture is worth a thousand words is never truer than in this case, where the fundus photo can really tell the story. The patient may not have fully appreciated his condition at his pre- vious visits, but the rapid progression underscores the potential consequences of his disease. I would again stress the need for him to control his blood glucose and follow up with a diabetologist. After informing the patient of the DME diagnosis, I would refer him to a retina specialist. I would explain that treatment may involve a series of intravitreal injections. CASE STUDY: A REAL-WORLD CLINICAL CHALLENGE This case underscores the ocular consequences of uncontrolled diabetes. Figure 1. Dilated fundus examination 2 years prior revealed mild nonproliferative diabetic retinopathy without macular edema. Figure 2. Current dilated fundus exam reveals signifcant progression of the retinopathy.

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