A CASE OF DIABETIC

RETINOPATHY
Objectives:

1. Utilize and understand the different opthalmologic assessment tools

2. Discuss the outcomes of assessments using actual patient cues
3. Provide an initial impression from varied assessments and differentials
4. Discuss the illness based on patient’s case via schematic diagram
5. Come up with a set of management that would fit the patient’s case
DEMOGRAPHIC DATA
Name: F. M.
Age and gender: 45/F
DOB: 10/19/72
Race: Asian-Filipino
Rel.: Adventist
Living arrangements: Living with husband’s relatives
Occupation status: House-help
Allergy: no known allergies
Dominance: Right Handed
CHIEF COMPLAINT

 Patient came in due to sudden blurring of vision of both eyes that

persisted since October 2017.
HISTORY OF PRESENT ILLNESS

6 mos. PTC the patient was watching television when she

noticed her sight blurred on her right eye describing a
cloud-like appearance that also manifested in her left eye
after a few minutes. The blurriness had no exacerbation
and resolve. However she verbalized one instance she had
suffered orbital discomfort (sand like sensations) with
tearing aside from the blurred vision, the pain was relieved
after she took a nap.
CONTD.
May 2, 2018- patient sought consultation at UERMMC OPD and was
assessed ; Fluorescein Angiography OU and Macula Optical Coherence
Tomography was prescribed

June 21 2018- Patient returned for follow-up with

laboratory and diagnostic results ,she had undergone further
reassessments
 PAST MEDICAL HISTORY

 The patient is a known diabetic (DM II) since 2015 currently taking
metformin 500 mg/ tab TID

 Also the patient has Cholelithiasis diagnosed on 2017 and being

managed by rowachol 1 capsules BID

 March 13, 2018 the patient was admitted for asthma in Medicare
Polilo, Quezon 4days
 CONTD.
 April 14, 2018 the patient was admitted for ameobiasis in
Medicare Polilo, Quezon 4days.

 The patient is currently taking other medications such as

Amlodipine 5 mg OD, Losartan 50 mg OD, and Atorvastatin 40
mg OD prescribed from her May 2nd consultations
FAMILY HEALTH HISTORY

 Father side : HTN, DM, TB

 Mother : Pleural Effusion

 3rd sibling: Nephrolithiais

 4th sibling : Toxic goiter

PSYCHOSOCIAL HISTORY

 F.M. is married with three children two were able to finish college and
one is grade 12 . She currently resides with her husband’s cousin here
in manila and works as a house-help. She expressed that she and her
husband’s relatives are close and they help her with her health
consultations as needed, she is also allowed to go home to her family
from time to time. Her husband worked in construction sites in Quezon
and he takes care of her children when she is not with them. Her
children are able to visit her and they took care of her in her
hospitalizations.

 The patient denied smoking and drinking alcoholic beverages or other

vices
 REVIEW OF SYSTEMS

GENERAL: The patient is conscious, she denied any discomfort, and weakness; (-)
sudden behavioral change

SKIN: The patient denied itchiness or presence of rashes but verbalized she had
attained abrasion on her Left hand due to washing clothes by hand four days prior
to consultation

Head
Face: patient had complete and symmetrical features
Eyes: The patient verbalized her vision is blurred not accompanied by other
symptoms;
Ears, Nose, Mouth and Throat: The patient denied hearing loss or experiencing
any ear discomfort; post-nasal drip , nasal congestion were denied as well as
difficulty in swallowing
REVIEW OF SYSTEMS
Cardiovascular: Patient denied any chest pain or heaviness, palpitations but stated
she suffers from hypertensive episodes.

Respiratory: patient had demonstrated eased breathing, chest equally expands;

she denied any discomfort in breathing

Gastrointestinal: patient stated that she was diagnosed with Cholelithiasis and
would have episodes of RUQ pain; she had no recent episodes of diarrhea and
vomiting

Genitourinary: The patient had stated increasing urinary urge with scanty output ,
she stated she has regular bowel movement

Musculoskeletal: patient had full ROM , she expressed feelings of pins and
needles with her extremities
PHYSICAL EXAMINATION
Vitals:
Bp: 140/100 mmHg
HR: 102 bpm
RR: 19cpm O2 sat: 97%
Temp: 36.0 C
Ht: 5’1
Wt: 60.7 kg

General: conscious, alert, conversant, coherent and not in distress,

Skin: Good turgor, warm, dry; with edematous excoriations on her Left
hand 3rd, 4th, and 5th digits; 3cm grade 2 edematous ulceration on her
Right ankle (-) generalized edema
CONTD.
Head: symmetrical facial features able; can raise eyebrows and shut eyes
tight; nose is midline; symmetrical smile; (-) scars, swelling, discharges

Eyes: VA OD: 5/200 sc OS: 20/125 NIPH 20/25 cc

J OD: J+16 OS J16
no edema, ptosis or matting of eyelids, anicteric scleral; clear cornea,
pink conjuctiva; OU pupils 2-3cm, SRTL (+) RAPD; Brown Irises; Digital
Tonometry =Firm; Full EOMs; no apparent visual field loss; Deep anterior
chamber, clear lens; (+) ROR , increase in vasculature with exudates more
on OD; IOP OD 12 OS 14

Ears, Nose, Mouth : Unremarkable

Neck: not enlarge, (+) gag reflex , trachea is midline; thyroid is

symmetrical, jugular veins not distended
CONTD.
Chest: symmetrical expansion: clear breath sounds in all lung fields ;
regular heart rhythm distinct S1 and S2, no murmurs, good equal
pulses

Abdomen: unremarkable, (-) discomfort

Genito-urinary: (+) urinary straining, polyuria

Musculoskeletal: Full ROM muscle grading 5, (-) deformity, has

edematous excoriation of 3rd, 4th and 5th digit of Left hand;
Edematous ulceration grade 2 on Right ankle; (-) Rombergs; tingling
sensation on 4 extremities
DIFFERENTIALS

 Creatinine 107 44-106

 Sodium 135 135-155
 Potassoium 4.0 3.5-5.3
 HBA1C 11% 4.27-6.07

 Urine : Yellow, turbid, acidic

 Direct and Indirect Opthalmoscopy : Deep AC, clear lens

clear lens; (+) ROR , increase in vasculature with
exudates more on OD; IOP OD 12 OS 14
THE EYE
INDIRECT OPTHALMOSCOPY

Normal retina Diabetic Retinopathy

NORMAL FLUORESCEIN ANGIOGRAPHY
ACTUAL FLUORESCEIN ANGIOGRAPHY
OPTICAL COHERENCE TOMOGRAPHY

Normal Actual
MACULAR CUBE SCAN
IMPRESSION:

 Proliferative Diabetic Retinopathy

- late stage of DR; blood vessels leak making the retinal
swell and leaving exudates causing ischemia to the
macula and retina; compensated thru production of new
tiny vessels that will eventually leak and cause retinal
tear
Predisposing factors:

Family health hx DM,

HTN

Hypertension
Constant
High glucose
in circulation
Metabolic
Dysfunction:
Impaired
blood glucose
transport

Weakened
capillary walls Macular
: Increased edema
permeability
Precipitating factors:

45 y/o Female
DM2 uncontrolled, HTN,
 Damages Ischemic
and changes Release Neovasculari-
reduction in the of VEG-F zation leak
of retinal retina
pericytes

Macular
edema

Capillary
leak of Retinal edema
CHON and
lipids Hard
exudates
on the
retina
PDR
TREATMENT

 Photocoagulation
 Panretinal Photocoagulation

 Anti-VEGF medication
CASE MANAGEMENT
Physical :
 Control the patient’s diabetes and hypertension by modifying her diet to Low
salt ,Low carbs, High fiber ;
 Encouraging exercise of moderate intensity like brisk walking 30 mins per
day ;
 Explain the medications being prescribed
 Provide patient with medication schedule to avoid missed doses.
 Instruct patient to begin monitoring her blood sugar BID before meals
 Instruct patient to use appropriate lighting when at work
 Instruct patient to have her yearly eye examination
CASE MANAGEMENT
Psychosocial
 Encouraged the current support system to help the patient keep on track of
her disease management;

 Inform patient and Support system how they can be helped by their
barangay and city hall for their medical consultations;

 Involve the patient with community health group teachings in their barangay
pertaining to DM2