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    What we can learn from managing diabetic patients

    Patient education just as important as a careful ocular exam

    Many diabetics neglect their eyecare due to not knowing and/or misunderstanding the effects of diabetes to the eyes and visual system. Much of the inadequacies in patient education can be attributed to the absence or insufficient communication among healthcare providers, including optometrists, and our patients.

    One misconception is our patients’ assessment of the possibility of having any significant eye disease—patients’ “meter stick” is usually their visual acuity and the absence of pain. Several years ago, I asked a diabetic patient with significant retinopathy if he was suffering any diabetic-related kidney disease. He replied by saying that his kidneys functioned perfectly. I then asked if this was conveyed to him by his physician through any kidney function testing. He replied no, but went on to say that he knew his kidneys were perfect because he urinated without any difficulty.

    It became clear to me at that time that our patients make the same assumptions about their eyes. If they see fine or have no eye pain, then they can’t be suffering from any eye disease. It is this conclusion that leads patients not to seek adequate eye care as well as their poor compliance with follow-up care even in the midst of treatment. 

    More from Dr. Rafieetary: A clinical perspective of neovascular glaucoma

    Case 1: “I was doing great until I wasn’t”

    A 42-year-old African-American male was referred for possible retinal detachment OD. He had noticed floaters and some vision loss in his right eye for four days and claims no symptoms or problems in his left eye. He has been diagnosed with type 2 diabetes for less than a year and indicates good glucose control. His best corrected visual acuities were OD 20/60, OS 20/30. His fundus exam and optical coherence tomography (OCT) (Figure 1) is remarkable for proliferative diabetic retinopathy and macular edema in both eyes, plus he has a large subhyaloid hemorrhage and extramacular tractional retinal detachment. His initial treatment (Figure 2) consisted of intravitreal anti-vascular endothelial growth factor (VEGF) injection followed by vitrectomy, repair of traction retinal detachment and endo-photocoagulation in the right eye, and panretinal photocoagulation in the left eye. Subsequently the patient underwent a number of additional procedures for persistent neovascularization and macular edema seen on OCT and fluorescein angiography (Figure 3).

    A number of lessons can learned from this case. First, many type 2 diabetics suffer from the disease for periods longer than their actual diagnosis date.1 Therefore, there may not be a “grace period” between the time of diagnosis and presence of end-organ damage. These patients require close follow-up care initially until a level of stability in their findings is established.

    Related: Diabetes nation—addressing an epidemic

    Second, we must stress the fact that although the patient’s symptoms have sudden onset, the disease has been evolving for some time; therefore, there are no quick solutions and the patient should expect chronicity of care.

    Lastly, a lesson for us practitioners to bear in mind: every drastic presentation like the one encountered here has begun by a single microaneurysm. It is incumbent upon us to make a lasting impression on our patients when we capture the disease in its initial stages. By not pacifying the situation, the patient must be educated that potential devastation can be avoided by the proper care of the underlying condition and compliance with follow-up care. The result of neglect is blindness.

    Next: "Why do I need to come back?"

    Mohammad Rafieetary, OD, FAAO
    Dr. Mohammad Rafieetary is a consultative optometric physician at the Charles Retina Institute in Memphis. He is a fellow of the ...


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