GOVOceania.com, Sydney NSW
The role of the optometrist in diagnosis, monitoring and referral of patients with diabetes is vitally important. As this case study shows, it is equally vital to build a frank, professional relationship with your local GP and ophthalmologist.
In 2008, a 45-year-old type 1 diabetic patient with hypertension presented to my practice. She was in her mid-40s and came from a lower socio-economic background. It was difficult to communicate with her; her ability to follow instructions was poor and she seemed to lack motivation to look after herself.
She reported good blood pressure and sugar control. Her spot checks were 6-8 mmol/L, which seemed pretty good. As Figure 1 (RE) and Figure 2 (LE) show, the fundus appeared relatively good, with no bleeding or signs of retinopathy. Visual acuity was still 6/6 in each eye.
|Figure 1. Initial presentation RE
||Figure 2. Initial presentation LE
The patient returned for a routine check-up but now spot checks were sometimes up to 11 mmol/L. Her fundus had begun to show minor changes. We referred her back to her GP with a report asking the GP to review her sugar levels and advising of the damage we were seeing (image not sent with report).
Six months later, the patient returned. We learned that her GP had been so worried about her condition that he had sent her to a dietician to help her with her diet and lifestyle, which were exacerbating her condition. As the GP explained, sometimes there is no point in increasing the medication if the patient has not altered their lifestyle. At this visit, we noticed that her retinopathy was slightly worse.
By the next visit, things were much worse. Her A1C* test was now eight per cent, which meant her risk of blindness had doubled. As well, her blood pressure reading was 160/100. The combination of high blood pressure and high sugar levels can result in a synergy causing more damage than just the sum of both.
As Figure 3 (RE) and Figure 4 (LE) show, there were scattered haemorrhages around the fundus, which had not been present before. The white area over the haemorrhage on the right eye is a cotton wool patch (CWP) where the ‘sick’ nerve fibres have lost their natural clarity and become cloudy. It was determined that the patient’s condition was progressing and becoming a concern, so we referred her to Dr Michael Chilov, a retina subspecialist at the Retina Associates ophthalmic centre in Sydney.
|Figure 3. 2012 presentation RE
||Figure 4. 2012 presentation LE
Due to the patient’s financial hardship, at our request Dr Chilov bulk-billed the consultations.
In his report, Dr Chilov found that the patient’s retinopathy, while concerning, was probably resolving itself. The patient had reported an improvement in her sugar levels before seeing him. Dr Chilov noted the presence of some hard exudate, which often begins to form after the fluid reabsorbs as the retinopathy eases. The patient’s A1C score had dropped to 7.5 per cent and blood pressure was 130/76.
The patient’s condition was reviewed later in 2012; the bleeding was spreading but not progressing, as shown in Figure 5 (RE) and Figure 6 (LE). The patient continued to see Dr Chilov, who had performed OCT scans to check for retinal oedema. He has not yet needed to perform laser treatment, although the patient has not attended my practice for further visits and may have been lost to follow-up.
|Figure 5. Late 2012 presentation RE
||Figure 6. Late 2013 presentation LE
* The A1C test is a blood test that provides information about a person’s average levels of blood glucose, also called blood sugar, over the past three months. The A1C test is sometimes called the haemoglobin A1c, HbA1c, or glycohaemoglobin test. The A1C test is the primary test used for diabetes management and diabetes research.