Treatment Plan

Take a Bloody Picture!

BY LEO SEMES, OD, FAAO

With chronic conditions, it is often frustrating to monitor these patients and encourage compliance, whether it is for regular administration of topical glaucoma drops or for our diabetic patients to be consistent with their treating physician’s regimen.

Regarding the posterior pole complications of diabetic retinopathy, clinically significant macular edema represents the number one cause of vision loss. This fluid accumulation is akin to having a flood in the basement; the longer the water is there, the more damage it can do. Follow-up guidelines for diabetic patients are in the American Optometric Association’s (AOA) Clinical Practice Guideline #3 (AOA, 2014).

What is the significance of documenting the ocular fundus of a diabetic patient? Figure 1 shows changes consistent with diabetic retinopathy. There are hemorrhages and exudates along with cotton-wool spots (CWS) that may be indicative of diabetes, but potentially complicated by systemic hypertension.

Figure 1. Fundus photograph from a patient’s first visit who is treated for systemic hypertension and diabetes.

That is the case with this 55-year-old patient who has been diagnosed with diabetes for more than 20 years. Without visual evidence of these changes, further changes may be overlooked or care may be delayed when clinical presentations are not observed. Reviewing photo documentation, as well as comparing visit-to-visit images, is critical to optimal care.

In this case, the patient has relatively good visual acuity at 20/25 OD. The patient refused both further testing and a consultation with a retina specialist.

Follow-up Findings

When he returned nearly three months later, the most striking change observed was resolution of the CWS superior-temporal to the optic disc. The area of former involvement was replaced by a retinal nerve fiber layer (RNFL) defect. Typically, this is thought to be consistent with a diagnosis of glaucoma. It is clear from the follow-up picture (Figure 2) that there is no optic disc damage, even though the RNFL defect appears to be contiguous with the optic disc. The patient’s visual acuity had improved to 20/20 OD. Such a RNFL defect has been described in the literature recently (Zhang et al, 2012).

Figure 2. Photograph showing a resolved cotton-wool spot with a residual RNFL defect.

It should be noted that the medical history of this patient includes a 25-year history of systemic treatment for hypertension. This helps explain a portion of the fundus picture of a patient who has multiple systemic diseases that have ophthalmic implications. Therefore, taking that photo cannot be overemphasized.

With the emergence of telemedicine, there will be increasing emphasis on accurate photo documentation for diagnosis and treatment. This emphasis represents a worldwide effort (Greenwood et al, 2014; Sabesan et al, 2014; Sieverdes et al, 2013). CLS

For references, please visit www.clspectrum.com/references and click on document #229.

Dr. Semes is a professor of optometry at the UAB School of Optometry. He is a consultant or advisor to Alcon, Allergan, and is a stock shareholder in HPO.