Diabetic Retinopathy: a case study David Garland NP

Transcription

1 Diabetic Retinopathy: a case study David Garland NP

2 Financial disclosure With 3 daughters I don t have any finances

3 The patient Joe 45 year old Polynesian man with hx of diabetic retinopathy Routine f/up medical retinal clinic

4 PMHx DM2 10 years initial poor compliance Severe bilateral non-proliferative DR with bilateral non-centre involving maculopathy HTN Dyslipidaemia

5 Social Lives with wife and 2 school-age children Works as a draughtsman Limited exercise Non-smoker, alcohol on weekends Diet - 2 takeaway meals per week, acknowledges he needs have more vegetables and fruit in his diet. Also has sweetened drinks 2-3 times per week. Often misses breakfast and then snacks on high processed foods (chips, chocolate bar) mid-morning.

6 Medications Gliclazide 160mg bd Metformin 1500mg bd Cilazapril 2.5mg once daily *** Atorvastation 20mg once daily

7 Laboratory results HbA1c 77 mmol/mol (**<41**) (Jan 2016) HbA1c 80 mmol/mol (Mar 2015) HbA1c 116 mmol/mol (Feb 2014) Creatinine 142 umol/l (45-90) (Jan 2016) egfr 51 ml/min/1.73m2 (>90) (Jan 2016) Alb/Creat ratio 20.0 mg/mmol (<2.5) (Mar 2015) Tot cholesterol 4.6 mmol/l (<4.0) (Jan 2016) LDL cholesterol 2.3 mmol/l (<2.0) (Jan 2016) HDL cholesterol 0.9 mmol/l (>1.0) (Jan 2016) Triglyceride 3.0 mmol/l (<1.7) (Jan 2016)

8

9

10 Review of Systems HEENT: No vision loss, no headache, no lightheadness, no insomnia, no nightmares Cardiorespiratory: no chronic cough, no palpations, no shortness of breath, no dizziness/lightheadness from /lying sitting to standing Gastrointestinal: no bloating, flatulence, nausea/vomiting, no abdominal pain, no diarrheoa/constipation, no reflux, no weight loss, no loss of appetitie Genitourinary: no balanitis, no pain passing urine, no malodour, no sexual dysfunction, no nocturia

11 Review of Systems Neurological: no recent episodes of confusion or syncope/loss of consciousness; no memory loss Musculoskeletal: no difficulty with mobilisation, no myalgia, no redness, swelling in feet, no claudication, no foot/leg pain at night Integumentary: no cuts, sores, ulcers, skin rashes, no hair loss Psychiatric: no depression or low mood, no behavioural changes

12

13 Physical examination Vital Signs: o BMI 28 kg/m2; o BP 160/100 mmhg o HR 76 beats/min; o RR 14 breaths/min Cardiovascular: o S1/S2 heart sounds, o no adventitious sounds, o no bounding radial pulse, o pedal and posterior tibial pulses present both feet

14 Physical examination FINALLY THE EYES!!! RVA 6/9 ua LVA 6/9 ua Pupils equal & reactive to light and accommodation, no relative afferent pupil defect Free range of extraocular movement White bulbar conjunctiva/ Pink palpebral conjunctiva both eyes Cornea clear Both eyes Anterior chamber deep and quiet Both eyes No iris neovascularisation Both eyes Lens: bilateral early PSCO

15

16

17

18

19 The problem Bilateral diabetic maculopathy / Bilateral severe non-proliferative diabetic retinopathy

20

21 The problem Glycaemic control sub-optimal on two oral antidiabetic medications High cardiovascular risk factors elevated BP, elevated lipids, stage 3 chronic kidney disease

22 The plan Bilateral diabetic maculopathy o L eye treat with focal macular laser within 6 weeks; o R eye watch closely, follow up 4 months. Bilateral severe non-proliferative diabetic retinopathy o no ocular treatment watch closely, follow up 4-6 months o Education and lifestyle advice. o Systemic changes improve HbA1c, hypertension and lipids

23 Risk factors for diabetic retinopathy Hyperglycaemia o 1% decrease in glycated haemoglobin (HbA1c) roughly equates to a decreased risk of retinopathy by 40%, progression to vision-threatening retinopathy by 25%, need for laser therapy by 25%, and blindness by 15% Hypertension o 10 mm Hg decreased systolic blood pressure roughly equates to a decreased risk of retinopathy progression by 35%, need for laser therapy by 35%, and visual loss by 50% Dyslipidaemia Diabetes duration Ethnic origin (Hispanic, south Asian) Pregnancy Puberty Cataract surgery (Cheung, N,. Mitchell, P., & Wong, T.Y. (2010). Diabetic retinopathy. Lancet, 376, )

24

25 The plan Glycaemic control sub-optimal o improve lifestyle factors (diet, exercise, alcohol intake, reduce weight). See GP is 2/52 for consideration of insulin therapy High cardiovascular risk factors elevated BP, elevated lipids, stage 3 chronic kidney disease improve lifestyle factors o improve lifestyle factors (diet, exercise, alcohol intake, reduce weight). o See GP 2/52 for recheck of BP if >130/80 consider increase cilazapril to 5mg daily o Discuss with GP need to increase atorvastatin 40mg daily

26