Optometrist Seeing Red
Written by: Juanne Lee Pui Xin
It is not just a matter of getting spectacles done. Your vision may be good, but is your eye health in tip-top condition?
A 46-year-old Asian lady presented with an emergent complaint of sudden onset of constant blurry vision in her right eye for the last week. She felt that her vision with her current spectacles has deteriorated and wished to update her 2-year-old prescription. She was diagnosed with hyperglycaemia on her last medical check 2 years ago, and her doctor advised her to control her diet albeit no medications given. Her father had hypertension but she was uncertain of its duration and treatment. Otherwise, there was no family history of diabetes or other diseases. Her past ocular history was unremarkable.
Visual acuities at presentation were OD hand movement at 1m and OS counting fingers at 1m which were not improvable with pinhole test. Pupillary assessment showed equal, round pupils but OD weak direct light reflex and OS strong direct light reflex. On top of that, there was absence of red reflex in the right eye. No relative afferent pupillary defect was seen.
Refraction was not attempted in view of a potential emergency and priority given to rule out underlying pathology. Anterior ocular health examination with slit lamp biomicroscopy revealed OS nasal pterygium 2mm encroaching from limbus. OU Van Herick test of 100%, deep and quiet anterior chambers. There were no rubeosis iridis seen in either eye.
Posterior ocular health examination with indirect ophthalmoscopy through an undilated 90D Volk lens revealed OD no view of fundus which raised suspicion of a diffuse vitreous haemorrhage. The left eye showed a pink disc with cup disc ratio of 0.2 with distinct margin. There were venous beading, vitreous haemorrhage and neovascularization elsewhere in the superotemporal quadrant accompanied with traction membranes. Few scattered hard exudates and dot blot haemorrhages were seen at mid periphery of the retina. There was restricted view of the macula due to pupil miosis.
Figure 1. Colour fundus photo of OS. Note the vitreous haemorrhage and traction membranes at the superotemporal quadrant of the retina.
Based on the bilaterality of the condition and a history of hyperglycaemia, we tentatively diagnosed the patient with proliferative diabetic retinopathy. In this case, it was imperative to refer the patient urgently to an ophthalmologist for dilated fundus examination and to rule out possibility of retinal detachment in view of vitreous haemorrhage. Patient was then seen by a retinal specialist on the same day, who confirmed the diagnosis of bilateral proliferative diabetic retinopathy.
Ophthalmologists will have to perform laser panretinal photocoagulation to destroy the ischemic retina in order to reduce the overall oxygen demand. This will in turn reduce the release of angiogenic molecules, called vascular epithelial growth factor (VEGF). Reducing the production of VEGF will reduce the formation of neovascularization. In cases of vitreous haemorrhage, ophthalmologists will monitor patients for a couple of weeks for the haemorrhage to settle and clear. If there is still no clearance of vitreous haemorrhage, a vitrectomy would be considered.
Approximately a week later after her first visit to the retinal specialist, she was treated with OS laser panretinal photocoagulation. No treatment was given yet to the right eye as there was tendency of vitreous haemorrhage clearance.
Management as a Primary Eye Care Optometrist
Besides referring patients promptly to an ophthalmologist, it is our responsibility to advise patient to go for a systemic workup on their current health status. For this patient, her systemic report showed that she had uncontrolled diabetes, hypertension and hyperlipidemia. She is currently on medication to control her systemic diseases. Thus, we advised patient to be compliant with her medication and her regular reviews to her general practitioner for blood glucose level and HbA1c tests. On questioning, patient confessed she had not been on diet control since diagnosed with hyperglycaemia 2 years ago. She was thus encouraged strongly to exercise and have a healthy diet. She was also advised to stop smoking and be compliant with her visits to ophthalmologist.
One month later, patient came for review and to update her spectacles. Her subjective refraction showed plano/-0.75×75 with best corrected visual acuity of 20/25 in her right eye and plano (no improvement with pinhole) with best vision of counting fingers at 1m in her left eye. OU near addition was prescribed as +1.50DS. Posterior ocular health examination showed foggy view of OD pink optic disc with cup disc ratio of 0.4. There was restricted view of OD macula due to pupil miosis. In her left eye, vitreous haemorrhage in the superotemporal quadrant had subsided a fair bit. There was also moderate residual fibrosis.
With regards to this patient’s visual prognosis, the ophthalmologist mentioned that there may or may not be improvement of vision in the left eye. A follow up visit to the ophthalmologist was made in a month’s time.
Compliance to their diet, medication and regular visits to their practitioners are of utmost importance in diabetic patients. One should note that the longer the duration, the higher the chance of developing some forms of diabetic retinopathy. A fundus photo should be taken at least once every year to note any progression. Good vision does not exclude ocular pathology. Stay committed to a comprehensive eye examination for your patients.
Figure 2. Taken on patient’s second visit. Colour fundus photo of OU. Note that there is considerable clearance of vitreous haemorrhage in OD with decent view of fundus as of current. Vitreous haemorrhage had also subsided in OS, leaving remnants of scar tissues.
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- Kanski J J (2007). Clinical Ophthalmology: A Systematic Approach. 6th ed. Edinburgh: Elsevier Butterworth-Heinemann. 1-931.