Why you shouldn’t wait a decade between eye exams

Images: (1) OD fundus photo (2) OD OCT (3) OS fundus photo (4) OS B-scan

58M with T2DM x 15 years presents c/o acute vision loss OS x 8 days.

LEE: 10+ years ago

PMH: T2DM, HTN, HLD. Last a1c: 11.0. LBP: 140/87.

POH: None

Meds: Metformin, semaglutide, Novolog, atorvastatin, amlodipine, labetolol

AAOx3, NKDA, social history non-contributory, remaining ROS unremarkable.

Exam findings:

scVA OD: 20/150 PHNI, OS: CF@1’

EOMs full, pupils minimally reactive OU with (-) RAPD

No improvement with refraction.

IOP 20/19mmHg by iCare

Gonioscopy revealed open angles OU flat iris with no PAS or angle neo.

Anterior segment findings remarkable for relatively symmetric NS and PSC OU along with a vitreous hemorrhage in the left eye. Pertinent negatives included (-)NVI and (-) Shafer sign.

Posterior segment in the right eye revealed diffuse retinal hemorrhages, venous beading, cotton wool spots, macular edema, and neovascularization of both the disc and posterior pole. The posterior segment of the left eye was unable to be observed by direct examination due to the dense vitreous hemorrhage, and so a B-Scan was obtained which confirmed the presence of a vitreous hemorrhage and found no evidence of a retinal detachment. The patient was diagnosed with proliferative diabetic retinopathy in both eyes with an accompanying vitreous hemorrhage of the left eye and referred promptly to retina, where he will likely receive avastin injections in both eyes.

Discussion: This is not an uncommon patient presentation — retina clinics across the U.S. are filled with minor variations of this sort of history. If you are a primary care optometrist in the U.S. and have not yet encountered something similar, you almost certainly will at some point in your career. Vitreous hemorrhage from PDR usually results in a profound and acute decrease in visual acuity and may or may not be accompanied by a tractional retinal detachment. B-scans are useful for detecting RDs if the retina cannot be evaluated by fundoscopy. While the attached B-scan superficially resembles the classic “funnel” shape seen in some RDs, the low A-scan amplitude corresponding to the hyperechoic funnel suggests that it is blood rather than retinal tissue.

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