A 23-year-old male with type 1 diabetes presents to your office with blurry vision in both eyes. He states that he is having problems with reading television captions and things written on the classroom board. He denies any redness, discharge or pain in his eyes. He also complains of increased urination, increased thirst and weight loss. He has had diabetes for the past year, and is presently on a multiple dose injection regimen of NPH and regular insulin. Lately, he has not been compliant with his insulin regimen, and his blood sugars have been ranging from 200-300 mg/dl during the past months. His HBA1c, performed 7 days ago, is 9.0 % (normal 4-6%). Six weeks ago, he was seen by an ophthalmologist who did not note any changes of diabetic retinopathy on fundus examination. What is the next best step in managing this patient's problem?

Question

A 23-year-old male with type 1 diabetes presents to your office with blurry vision in both eyes.  He states that he is having problems with reading television captions and things written on the classroom board.  He denies any redness, discharge or pain in his eyes.  He also complains of increased urination, increased thirst and weight loss.  He has had diabetes for the past year, and is presently on a multiple dose injection regimen of NPH and regular insulin.  Lately, he has not been compliant with his insulin regimen, and his blood sugars have been ranging from 200-300 mg/dl during the past months.  His HBA1c, performed 7 days ago, is 9.0 % (normal 4-6%).  Six weeks ago, he was seen by an ophthalmologist who did not note any changes of diabetic retinopathy on fundus examination.  What is the next best step in managing this patient's problem?

Quizplus · Accepted Answer

Explanation: Patients with diabetes are at risk of a number of eye complications. Macular edema occurs due to the increased vascular permeability of the retinal blood vessels. Usually, patients with macular edema have background diabetic retinopathy (microaneurysms, hard exudates, soft exudates, dot or blot hemorrhages). Blindness can occur as a complication of proliferative diabetic retinopathy, leading to vitreous bleeding, followed by retinal detachment. Blindness can be prevented in majority of these patients with timely detection and treatment using laser photocoagulation. Diabetes is the leading cause of legal blindness in the United States. This patient has poor glycemic control. His blurry vision is most likely due to the swelling in his optical lens secondary to osmotic changes. Improving glycemic control is likely to improve his symptoms. (Choices A and B)Diabetic retinopathy requires some years to develop. The patient described in the vignette has had diabetes for only one year, and is unlikely to have complications for diabetic retinopathy (vitreous hemorrhage, retinal detachment and macular edema). Furthermore, his normal retinal examination six weeks ago almost rules out the possibility of these complications. Referring him for photocoagulation or angiography would not be helpful. (Choice C) A slit-lamp examination will pick up lens swelling, but with this typical history, it is not required. (Choice E)Diuretics are not useful in decreasing lens edema. Occasionally, reversible retinal edema occurs which is reversible with improved glycemic control. Educational Objective: Diabetic retinopathy requires some years to develop. Poor glycemic control and blurry vision can be due to the swelling in the optical lens secondary to osmotic changes. Improving glycemic control is likely to improve the patient's symptoms.

A 23-Year-Old Male with Type 1 Diabetes Presents to Your