Definition
A.Retinopathy is damage of retinal blood vessels most commonly due to pathology secondary to hyperglycemia (diabetic retinopathy). There are two major categories of retinopathy: nonproliferative and proliferative. Retinopathy is further classified into nonproliferative stages—mild, moderate, severe, and very severe—and proliferative stages—early, high risk, and severe. Symptoms do not present until late in the disease process. Retinopathy is a risk marker for higher rates of morbidity and mortality from cardiovascular disease.
Incidence
A.Diabetic retinopathy is the leading cause of blindness of adults between the ages of 25 and 74 years.
Pathogenesis
A.Nonproliferative retinopathy is due to nerve fiber damage, retinal hemorrhages, microaneurysms, or tortuous/dilated retinal vessels.
B.Proliferative retinopathy is due to neovascularization vessel growth that produces harmful changes in the retinal bed, including preretinal or vitreous hemorrhages, fibrosis, and retinal detachment.
C.Macular edema may occur during any stage of retinopathy.
Predisposing Factors
A.Diabetes, including gestational diabetes.
B.Uncontrolled hypertension (HTN).
C.Smoking.
D.Chronic kidney disease.
E.Dyslipidemia.
Common Complaints
A.Visual impairments are not common until pathologic changes are well established.
B.Curtain falling
or floaters may be mentioned in vitreous hemorrhage.
Potential Complications
A.Loss of independence due to visual impairments.
B.Loss of employment.
C.Motor vehicle accidents.
D.Isolation due to fear of leaving familiar environment.
E.Depression.
Subjective Data
A.Review the onset, duration, and course of symptoms.
B.Was the change in vision sudden or gradual?
C.Discuss home glucose monitoring and results.
D.Review history of eye disorders and previous eye surgeries or treatments.
E.Review date of last eye exam, including dilation.
F.Review past medical history, including current medications and year of onset of diabetes or HTN.
G.Determine if patient has used over-the-counter (OTC) corrective lenses for self-treatment and determine duration of use.
H.Determine the level of change in activities of daily living (ADLs) due to visual impairment.
Physical Examination
A.Vital signs, including blood pressure.
B.Inspect:
1.Symmetry of eyes and obvious deformities.
2.Pupil symmetry and response to light and accommodation.
3.Assess fields of vision and extraocular movements.
4.Funduscopic assessment.
5.Snellen and Rosenbaum screening.
Diagnostics
A.Funduscopic exam, dilated.
B.Fluorescein angiography (performed by optometrist or ophthalmologist).
C.Hemoglobin A1c.
Differential Diagnosis
A.Diabetic retinopathy.
B.Hypertensive retinopathy.
Plan
A.General interventions:
1.Identify the possible diagnosis of retinopathy and refer to an eye specialist for formal diagnosis.
2.Panretinal laser photocoagulation for proliferative retinopathy (ophthalmology).
3.Vitreous surgery (ophthalmology).
4.Patients diagnosed with diabetes are encouraged to improve glucose levels.
B.Patient teaching:
1.Advise the patient on the importance of routine eye exams.
2.Discuss the importance of good control of blood sugar if diabetic and blood pressure if hypertensive.
C.Pharmaceutical therapy:
1.None. Patient is followed by ophthalmologist.
Consultation/Referral
A.Referral is required for accurate diagnosis following initial funduscopic screening.
Individual Considerations
A.Adults:
1.Retinopathy is the leading cause of blindness between the ages of 25 and 74. Patients should receive an annual ophthalmic exam.
2.Retinopathy can be slowed based on the stage of progression. Early diagnosis is key to sight-saving intervention.
Geriatrics
A.Highest risk factors for older adult retinopathy are uncontrolled diabetes, uncontrolled HTN, and smoking.
B.Vascular endothelial growth factor (VEGF) inhibitors are becoming first-line treatment for retinopathy. These medications (Avastin, Lucentis, and Macugen) can cause macular edema (swelling of the central part of the eye) that is associated with retinopathy (ischemia and vitreous hemorrhage).
C.Manage glycemic levels specifically related to comorbidities and the patient’s life expectancy. (Hospice patients have less stringent glycemic control.) Keep patient’s blood pressure ≤140/80.