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Abstract: This is a case of a 65-year-old male patient who presented to the hospital 1 week ago with the onset of bilateral blurred vision, worse in the right eye than in the left eye, unrelieved by rest, a history of previous diabetes mellitus, poor efficacy of oral metformin, a history of hypertension, and no drug therapy. After admission, the patient was diagnosed with diabetic retinopathy (proliferative stage) based on his medical history and examination results. After treatment with medication and laser photocoagulation, the condition was controlled and the vision improved significantly.
Basic information】Male, 65 years old
Disease Type】Diabetic retinopathy (proliferative phase)
Hospital】The First Hospital of Harbin Medical University
Date of consultation】November 2021
Treatment plan】Medication (Novaline N + valsartan) + anti-VEGF intravitreal injection therapy (razumab) + total retinal laser photocoagulation in both eyes
Treatment period】1 month, retinal laser photocoagulation treatment once a week
Treatment effect】The disease has been controlled, and all indicators are good
I. Initial consultation
The patient began to have blurred vision in both eyes 1 week ago, with the right eye being more severe than the left, and she came to the clinic without relief after rest. The patient told me that he found elevated blood sugar 10 years ago and was diagnosed as diabetic, and was treated with oral metformin, but the effect was not good. Fasting blood sugar was about 12 mmol/L, and no postprandial sugar was measured. Blood pressure was generally 150-160mmHg systolic/90-95mmHg diastolic, and was not treated with any antihypertensive medication. Visual acuity showed 0.2 in the right eye and 0.6 in the left eye. fundus examination: retinal hemorrhage and exudation in both eyes and macular edema in the right eye. Fluorescence angiography showed that the retinas of both eyes showed a large number of microangiomas, hemorrhages, large patchy non-perfused areas, and scattered multiple neovascularization. The diagnosis of diabetic retinopathy (proliferative stage) was made based on the clinical findings.
II. Treatment history
In view of the patient’s poor glycemic and blood pressure control. Firstly, the patient was told that the cause of vision loss was diabetes mellitus, and if the blood glucose was not well controlled, the progression of fundus lesions would be accelerated, while hypertension would also aggravate the fundus lesions, so the primary treatment strategy was to control blood pressure and blood glucose well. This will slow down the progression of diabetic retinopathy. The patient decided to be hospitalized in the endocrinology department to readjust blood glucose with Novolin N and control blood pressure with oral antihypertensive drug valsartan. Meanwhile, for diabetic retinopathy, the patient was given the anti-VEGF drug ranibizumab in the right eye, intravitreal injection for macular edema, and whole retinal laser photocoagulation in both eyes.
III. Treatment effect
After 1 month of hospitalization with these measures, the patient’s fasting blood glucose dropped to 6.1 mmol/L and postprandial blood glucose 7.6 mmol/L. Blood pressure values returned to normal, systolic blood pressure 130 mmHg/diastolic blood pressure 90 mmHg, and visual acuity in the right eye returned to 0.6, and the patient himself felt significantly higher visual acuity. On examination, the hemorrhage was absorbed in both eyes, and a large number of laser spots were seen in the retina. The macular edema in the right eye subsided. Fluorescence angiography did not find a large non-perfused area, microangioma disappeared, retinal neovascularization atrophied, and a large number of laser spots were visible. The patient was granted discharge and instructed to undergo retinal laser photocoagulation once a week.
IV. Precautions
After the treatment, the patient’s vision improved, and I am glad to help the patient improve the quality of life, which is also my duty. However, it is recommended that the patient also needs to pay attention to blood pressure, lipid and renal function changes afterwards, all of which can drive the progression of diabetic retinopathy. If blood pressure, lipids, blood glucose, and renal function can be effectively controlled, it can significantly slow down the progression of the lesion. Therefore, it is necessary to control blood pressure, lipids and improve renal function along with blood glucose control. Regular review is also needed to observe the lesions in the fundus of the eye. Pay more attention to eating fresh fruits and vegetables, which can increase eye nutrition and facilitate recovery, and avoid eating spicy and stimulating foods. Keep the bowel movement smooth and avoid constipation and force to prevent elevated intraocular pressure.
V. Personal insight
Due to long-term chronic hyperglycemia in diabetic patients, it can damage the canal cells of retinal capillaries, leading to canal wall dilation, which in turn can cause retinal microangioma, retinal hemorrhage, retinal edema and other changes. In severe cases, it can lead to vitreous hemorrhage, retinal detachment and other blinding lesions. As in this case, the patient’s blood glucose was not well controlled, the effect of taking medication was not good, and the medication was not changed in time, which led to retinopathy, and the condition improved by active treatment. Diabetic retinopathy can be avoided if blood sugar can be actively and effectively controlled. Therefore, it is recommended that diabetic patients should have regular eye examinations for early detection and early treatment to avoid irreversible visual impairment.