Our patient reported moderate blood sugar control with elevated yet stable blood work. However, the patient’s lengthy duration of disease significantly increased his risk of developing sight-threatening retinopathy. The initial management plan for our patient was to closely monitor his level of retinopathy. The goal was to identify progression from moderate to severe diabetic retinopathy, via the 4-2-1 rule. When proliferative retinopathy is observed, prophylactic PRP is almost always performed in an attempt to reduce the patient’s risk of permanent vision loss. Unfortunately for our patient, he returned to our service presenting with high-risk PDR which was responsible for his vision loss OD.
It is imperative that when retinopathy is observed in patients with a long duration of diabetes (especially poorly controlled disease), they are followed more closely. If a patient’s severity progresses from moderate to severe by meeting the 4-2-1 rule, we must decide to monitor the patient far more closely or refer to ophthalmology for prophylactic treatment.
The 4-2-1 rule is used to classify severe nonproliferative diabetic retinopathy and is defined as severe retinal hemorrhages in all 4 quadrants of the posterior pole, significant venous beading in 2 or more quadrants, and/or moderate intraretinal microvascular abnormalities (IRMA) in 1 or more quadrants. Once patients progress to severe NPDR, we must strongly consider initiating retinal consultation, due to the likelihood of necessary treatment. Approximately half of all patients with severe nonproliferative retinopathy will further progress to proliferative status within 12 months.8,9 The ETDRS study demonstrated a statistically significant reduction in severe vision loss in eyes receiving early laser treatment. PRP is considered standard first-line treatment in the majority of cases for proliferative retinopathy.
Our patient is young, presented with moderate blood sugar control, and had only a history of moderate diabetic retinopathy at his initial exam with us. Yet his extensive duration of disease and poor follow-up compliance resulted in a loss of vision. As thus, the patient’s presenting with high-risk characteristics should be monitored appropriately to reduce the risk of vision loss, especially if extensive duration of disease is present.
It is essential that we educate our diabetic patients on ocular risk and follow-up compliance in an attempt to reduce the risk of vision loss that was seen in this case. The care provided did prevent further vision loss OS, however continued vigilance and blood sugar control is always necessary in managing the diabetic patient (regardless of type 1 vs. type 2).
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