Melissa Valdellon

Patient case for June 13, 2023

A 62 year old Hispanic female came in for her annual DM eye exam and was complaining of blurred vision after losing her glasses in Mexico a few months ago.

Medically, she is taking medications for mixed hyperlipidemia, osteoarthritis, type 2 DM, gastroesophageal reflux disease, and POAG with reported good compliance for everything. Her latest HbA1C was 7.4 and she did not check her blood sugar the day of her exam.

Incoming uncorrected visual acuity was 20/100 and 20/300 with pinhole to 20/30 and 20/50. Pupils and EOMs were normal.

Refraction results showed:
OD -22.5 DS  2025
OS -3.00 -0.50 x 170  20/40

Anterior segment showed meibomian gland dysfunction, nasal and temporal pterygium, 2-3+ NS, and vitreous syneresis, all in both eyes, though the cataract may have been slightly more hazy in the left than the right. IOP today was 14/14.

Posterior segment showed thin superior and inferior rims of both optic nerves with C/Ds of 0.65. There had been a hemorrhage on the inferior rim of the left optic nerve back in 2021. That has since resolved but there is now a corresponding mild nerve fiber layer defect. Otherwise, posterior segment was clear and without evidence of diabetic retinopathy.

For more background, this patient has been monitored for her nerve appearance since 2018. Pachymetry is 538/550. Gonioscopy is open in both eyes with no angle recession.

The patient has done multiple visual fields and for the right eye, there is a possible inferior nasal step that “comes and goes”, showing up in some fields but not all. The left eye also shows an inconsistent superior nasal step defect.

OCTs of the nerves show superior thinning that had been stable since 2018, but progressive inferior temporal thinning in the left eye more than the right since 2018.

Treatment of Latanoprost QHS was initiated in 2021 when the optic nerve hemorrhage was first seen. Prior to treatment, IOPs ranged from 19-22 OU. After treatment, her IOPs have fluctuated from 14-22, achieving IOPs of 15 or lower in half the visits since treatment was initiated.

Sorry for the lack of imaging to go along with the case but hopefully you were able to follow along. What would you prescribe for this patient for their refractive error or how would you counsel them in regards to their vision? What would you tell the patient and their doctor about their diabetes management? And what would you like to do about this patient’s glaucoma?

I look forward to hearing your thoughts.

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