Medical diagnosis: Diabetes mellitus, type II. Dyslipedemy. Diabetic retinopathy.

 

Medical history: Patient is a 69 year old male with no significant family history other than maternal diabetes. He smokes 20 cigarettes a day. Medical records report good appetite and drinking of about ¾ of a litre of wine a day. The patient was admitted to the hospital for cephalalgia (severe headache*) accompanied by temporal absence, and this in a diabetic patient with an abnormal ECG showing irritation signs. All neurological tests yielded negative results except for a right carotidography showing a stenosis (narrowing) of the initial tract of the internal carotid artery (no subsequent medical intervention was documented).

 

In a second hospitalization, the patient was diagnosed with right uveitis (infection of the inner eye), decompensated diabetes mellitus type II, and slight peripheral neuropathy. A further hospitalization was due to an acute anterior uveitis of the right eye and fungal choroiditis. An ultrasound exam of the right eye showed posterior detachment and inflammation of the vitreous body. The patient underwent a phacoemulsification procedure for a complex cataract of the right eye. A month after surgery, a retinal fluorangiography gave the following results: numerous capillary, epicapillary and macular micro aneurysms and dilations in the right eye with some retinal ischemia (blood supply restriction). In the left eye, a widespread vascular tortuousness and a dilation of the perimacular capillary net with macular edema was found and treated with photocoagulation. Hard exudates at the posterior pole with hemorrages of the retina around the macular area were observed. Digital angiography revealed a high myopic maculopathy in the right eye and a laser-treated, non-proliferative diabetic retinopathy in the left eye (cf images). Medical diagnosis describes an advanced senile maculopathy in the right eye with extensive neovascularisation and sub-retinal hemorrages at the posterior pole; a laser-treated pre-proliferative diabetic retinopathy, micro aneurysms, retinal hemorrages and hard essudates at the posterior pole of the left eye. No areas of hypo-afflux are reported (cf images).

 

Diabetic condition showed an improvement of the glycate values (8.4) and the treatment with Glibomet and Glucophage was recommended. Several reports indicate that the patient is having difficulty in maintaining an appropriate diet. In the last check-up, Cholesterol and TGL values were in the normal range. Glycaemia was 182 mg/dl and glycate is 8.7%. Cardiologic and other blood tests were within the normal range. More recent reports are not available.

 

Medical questions referred to Medical Opinion online consultation service: The patient requests an online second opinion on the prognosis and with regard to possible treatments.

 

This medical report is based on a review of the medical summary and fluoresceine angiograms.

 

Ocular History: A 69 year-old-male who suffers from diabetes complicated by neuropathy and retinopathy. He had uveitis and choroiditis in the right eye, which were fungal in origin. He had cataract surgery in the right eye and was reported to have bilateral maculopathy, which was treated with laser photocoagulation in the left eye. Medical reports describe myopic maculopathy and neovascular age related macular degeneration in the right eye, and non-prolific diabetic retinopathy in the left eye.

 

Ancillary Test: Fluoresceine angiography demonstrated areas of blocked fluorescence, staining and transmission defects involving the center of the macula of the right eye.

 

Online Doctor´s Assessment: The patient suffers from diabetic retinopathy and maculopathy in both eyes, as well as maculopathy of another origin in the right eye. The neovascular lesion described in the right eye is not recent, and might be secondary to uveitis, myopia, or age related macular degeneration.

 

No details were provided regarding the visual acuity, recent ophthalmic exam, or recent imaging studies. In the absence of these details, it is difficult to determine the prognosis for the preservation or improvement of visual acuity in either eye. The chronic nature of the lesion in the right eye and the fluoresceine angiography results suggest that chances of improvement of acuity in either eye are probably low.

 

Recommendations by the online medical consultation:

* Some definitions/explanations of terms have been added for the lay reader.