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ALERTA, Kathrinna Feliz

13-0146

Identifying Information
D. G. 38 year old female, single, Roman Catholic, residing in Pasig City
Chief Complaint
Vision loss, left eye
History of Present Illness
The patient is a 38 year old female, known case of type 2 diabetes mellitus, coming in for deteriorating
vision of the left eye.
Three year prior, the patient noted floaters in bilateral vision fields, left eye described as having more
floaters than the right. She sought consult with another ophthalmologist, and was diagnosed as case of beginning
retinal detachment, left eye. She was advised surgery, however was lost to follow up.
In the interim, the floaters persisted, but the patient did not perceive any deterioration in vision, or onset
of any other symptoms, like eye pain or eye discharge. The patient did not seek another ophthalmologic consult
until…
One month prior, the patient noted flashing light in her left visual field, promptly followed by blurring of
vision. The patient sought consult with current AP, and only noted the severity of the severity of vision after doing
visual acuity exam, probably to the compensation of the contralateral right eye. Patient was diagnosed as a case of
chronic retinal detachment, and was hence advised surgery.
Review of Systems
General (-) fever, (-) weight loss, (-) weight gain, (-) loss of appetite, (-) weakness, (-) fatigue
HEENT (-) headache, (-) dizziness, (-) blurring of vision, (-) tinnitus, (-) deafness, (-) epistaxis, (-)
frequent colds, (-) hoarseness, (-) dry mouth, (-) gum bleeding
Respiratory (-) dyspnea, (-) hemoptysis, (-) cough, (-) colds, (-) wheezing
Cardiovascular (-) palpitations, (-) chest pains, (-) syncope, (-) orthopnea
Gastrointestinal (-) nausea, (-) vomiting, (-) hypogastric pain, (-) dysphagia, (-) heartburn, (-) constipation,
(-) diarrhea, (-) rectal bleeding, (-) jaundice
Endocrine (-) excessive sweating, (-) heat intolerance, (-) cold intolerance, (-) polyuria, (-) excessive
thirst
Genitourinary (-) dysuria, (-) changes in urine color, (-) sexual dysfunction
Neurological (-) seizures, (-) tremors
Past Medical History
The patient is a known case of diabetes mellitus type 2 since 2002, maintained on Metformin 500 mg
taken twice a day. The patient has no other comorbid conditions, no hypertension, no asthma. The patient is
known to be allergic to penicillin and shellfish. The patient was previously hospitalized for typhoid fever in 1996.
She has had no previous surgeries.
Ocular History
The patient is using corrective lenses, and is a high myope at +7.00 for both eyes, as the patient recalls.
The patient recalls having been diagnosed with retinal detachment 3 years prior, but was unable to have the
condition managed due to changes in the company she was working with. The patient was also already diagnosed
with cataract of the right eye.
Family History
The patient has a family history of diabetes, hypertension and asthma. No other heredofamilial diseases
were noted.
Personal-Social History
The patient is an occasional alcoholic beverage drinker, but denies smoking and illicit drug use. She is a
college graduate who works in a company that requires visits to other countries, hence the delay for treatment of
her previously diagnosed retinal detachment.

Stakeholders Analysis
Stakeholder Stake Stand Intensity of Degree of Remarks
Stand Influence
Patient Concerned for her own Ally High High Basically independent.
health She is the sole decision
maker regarding her
health and will be the
primary financier
Sister Concerned for sister’s Ally High Moderate May be tapped to
health increase health seeking
behavior of patient; will
be helping the patient
while in the hospital
Parents Emotional support Ally High Moderate May be a source of
financial help, if there is
a need
Physical Examination
System Findings
General Survey Awake, conscious, coherent, not in cardiorespiratory distress
Anthropometrics Wt 99 kg Ht 157.4 cm BMI 40 (obese)
Vital Signs BP 130/90 HR 80 RR 20 T 36.4 degC Pain scale 0/10
ENT Pink palpebral conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no
cervicolymphadenopathies
Cardiovascular Adynamic precordium, PMI at 5th ICS left MCL, no murmurs
Chest and Lungs Symmetric chest expansion, clear breath sounds
Breasts Not examined
Abdomen Flabby, no scars, normoactive bowel sounds, soft, non-tender
Rectal Not examined
Extremities <2 s CRT, no cyanosis, full and equal pulses

Ocular Exam
Visual Acuity
SC PH CC PH
Right 20/100 20/80 20/60+1 NIPH
Left HM + fair light - - -
projection
Gross examination

No lid swelling, no discharge, no matting, nonhyperemic conjunctiva


EOMs
Full and equal extraocular muscles; no pain or diplopia on movement
Left eye EOMs cannot be assessed due to inability to follow examining finger because of inherent vision loss
Slitlamp Examination

Cornea clear Cornea clear


Anterior chamber formed Anterior chamber formed
No cells and flares No cells and flares
Indirect Fundoscopy (dilated)

Cup-to-disc ratio 0.3 Cup-to-disc ratio 0.3


AVR 2:3 AVR 2:3
Distinct disc borders Distinct disc borders
No exudates, no hemorrhages (+) retinal detachment in the inferior region
(+) hemorrhages
No horseshoe tears
Salient Features
Subjective Objective
38 year old, female Visual acuity of 20/100, PH 20/80, with correction
Unilateral vision loss, left 20/60+1 on right eye, Hand movement and fair light
Known diabetic since 2002 projection on left eye
Known case of retinal detachment, left, lost to follow Grossly normal, both eyes
up No abnormal findings via slitlamp, both eyes
Vision loss not perceived until 1 month prior, when (+) retinal detachment and hemorrhages, left eye via
eye exam was done indirect fundoscopy
No eye pain, eye discharge
High myope at +7.00, both eyes

Primary Impression
Chronic retinal detachment, left eye
Rhegmatogenous retinal detachment, left eye
Diabetes mellitus type 2
Obese type 2
Differential Diagnoses
Diagnosis More Likely Less likely
Cataract Chronic presentation Usually presents as bilateral but may
Painless present with a unilaterally more opaque
lens
Clear lenses were found on slit lamp and
fundoscopy
CRAO Unilateral vision loss Chronic presentation, as CRAO usually
Painless presents acutely; patient should have
perceived the vision loss immediately
instead of having realized it upon eye exam
Vitreous hemorrhage Unilateral vision loss Chronic presentation
Painless Vitreous hemorrhage would have
Perception of floaters in the vision presented more acutely, certainly
The patient is diabetic, and the underlying producing perceptible symptoms faster
pathology of ineffective angiogenesis in than the 3 years it took for the patient to
the eye in diabetic patient, predisposes notice the extent of the visual disturbance
her to vitreous hemorrhages.
Discussion
As the term suggests, retinal detachment is the detachment of the retina from the back of the eye or the
choroid, from where the retina photoreceptors derive their nutrition. Consequently, detachment renders the
photoreceptors without nutrition. And because the “choroidal circulation has the highest blood flow rate per cubic
centimeter of tissue in the human body” (Arroyo, 2018), detachment of the retina essentially “starves” it, thus
impairing vision. The presentation varies depending on the extent of the detachment.
There are 3 main types of retinal detachment: rhegmatogenous, the type which starts from a retinal break
that causes pooling of vitreous fluid between the neurosensory retina, and the retinal pigment epithelium and the
choroid, subsequently filling the space with fluid and effectively detaching the retina; tractional, which is
essentially the increase in tension in the vitreous body, pulling the neurosensory retina away from its attachment;
and exudative, which is the pooling of exudative material between the neurosensory retina, and the retinal
pigment epithelium and the choroid, most probably due to an infectious process.
Tractional retinal detachment is the type that occurs in diabetic patient. In diabetes, the main pathology
involves several areas of ischemia. While the body overcompensates by trying to induce angiogenesis, it fails to
effectively perfuse these areas of ischemia in the eye. As a result, these areas start to develop fibrosis with the
vitreous layer, producing areas of increased tension within the eyeball. While in the parts of the eye where there is
vascular growth, because of ineffective mechanisms, hemorrhages tend to occur, which produce consequent
inflammation, degeneration and eventual fibrosis. These areas of increased tension cause the retina to be pulled
from its area of attachment, detaching it.
Retinal detachment presents as sudden unilateral, painless vision loss. Partial retinal detachment may
present with partial field loss. Flashes and floaters may be perceived before vision loss is noted. In the case of the
patient who allegedly didn’t notice until much later that her left eye already had bad vision, detachment of the
retina inferiorly can sometimes present insidiously.
Patients who are predisposed to retinal detachment are those with myopic refractive error, with prior
intraocular surgery, a family history of RD, and those with retinal detachment in the contralateral eye. Another risk
factor, due primarily to the changes in the eye brought about by the disease process, is a history of diabetes
mellitus. Other risk factors, as identified by Jalali (2003), are as follows:

1. Axial myopia

2. Post cataract surgery (aphakia/pseudophakia) especially if the posterior capsule is


ruptured during surgery and/or there is vitreous loss.

3. Yag laser capsulotomy.

4. Lattice degeneration of the retina.

5. Symptomatic (flashes/floaters) retinal tears.


6. Ocular trauma.

7. RD in one eye.

8. Family history of RD.

9. Certain genetic disorders such as Marfan's syndrome, Stickler's syndrome.

10. Pre-existing retinal diseases like coloboma choroid, retinoschisis.

11. Following acute retinal infections as in acute retinal necrosis syndrome (ARN) or CMV
retinitis.

Diagnostics

According to Jalali (2003), the best way to diagnose retinal detachment is by indirect ophthalmoscopy
with scleral indentation. This was already done for the patient, as indirect ophthalmoscopy is already part of the
routine eye exam for all patients. In
While a proper ocular exam should be enough to diagnose retinal detachment, a few other diagnostic
tests were ordered for the patient in order to confirm diagnosis and the be able to help in surgical planning.

Diagnostic Results Interpretation


Fluorescence Right Edema can be seen in the fuzzy
angiography inferior borders of the retina of the
left eye, owing to secondary changes
due to the presumed retinal
detachment

Left
Optical Right The right eye shows normal structure
coherence and layers of the retina
tomography

The left eye shows a clear space in


between what is presumably the
neurosensory retina, and the retinal
pigment epithelium and the rest of
the back of the eye. The space should
not be there, and shows the
detachment of the structures
mentioned.

Left
Surgical Management
Medical management has no role in the management of retinal detachment, much less when the
detachment has already presented for as long as it has in the patient. Surgical management is the only option for
possible improvement of vision, and even then, prognostication should be done and clear expectation
management should be discussed with the patient.
The principle behind surgical management is that reattaching the retina to the back of the eye should
improve vision, in the converse way that the detachment has deteriorated the vision. The following procedures
done
The plan for the patient was to do vitrectomy to remove vitreous material from where it has pooled
between the retina and the eyeball due to the detachment. The vitreous fluid within the eye itself is also removed,
because the fibrotic vitreous body attachment to the retina is the main pathophysiology of the tractional retinal
detachment. C3F8 gas bubble tamponade was done to push the detached retina towards the eye wall. Silicone oil
was then infused to replace the vitreous fluid. And then focal endolaser photocoagulation was done in order to
create a strong chorioretinal adhesion between the detached part of the retina and the back of the eye.
The third of the procedures mentioned, photocoagulation, acquires maximal strength after 7 days.
Some complications that may be noted post-surgery are the following (Lihteh Wu, 2015):
 Post-operative glaucoma – due to the decreased anterior angle caused by the detachment
 Choroidal detachments – from vortex vein obstruction
 Cystoid macular edema – due to the inflammatory response after surgical trauma
 Strabismus – usually presents after scleral buckling, which was not done to the patient
 Macular pucker
 Proliferative vitreoretinopathy – most common cause for surgical failure; condition wherein cells
of the retinal pigment epithelium, glia and fibrocytes proliferate, as the name suggests, creating
layers on the surface of the retina and the vitreous cavity, effectively obscuring vision. Some risk
factors that have been identified are number and size of retinal breaks, number of previous
operations, and the degree of breakdown of the blood-ocular barrier. None of these, as per the
information provided by the patient and the examination of the physicians involved, are present
in the patient.
 Persistent subclinical subfoveal fluid
Post-operatively, the patient was given the following medications:
Moxifloxacin (Vigamox) eye drops 1 drop to L eye As antiinfective
every 2 hours
Prednisolone acetate (PredForte) eye drops 1 As anti-inflammatory
drop L eye every 2 hours

Preventive. For patients unlike D.G., who may be found to have had retinal tears prior to actual
detachment of the retina, laser retinopexy or cryretinopexy can be done in order to reinforce the area around the
retinal tear to prevent detachment from happening. Laser photocoagulation may also be done, especially if the
areas of the tear are in the very periphery, and photocoagulation will not be impairing the vision of the patient
significantly. (Arroyo, 2018)
Visual prognosis. It should be discussed with the patient that vision loss that has presented as insidiously
as it had, and has lasted for as long as it did in the patient, will not improve to a vision of 20/20 with surgery.
Expectation setting must be done prior to the surgery.

Sources
Jalali, S. 2003. Retinal Detachment. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705859/
UpToDate – Arroyo, J. G. 2018. Retinal Detachment.
McMeel, W. 1987. Diabetic Retinopathy: Fibrotic proliferation and retinal detachment. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1310429/pdf/taos00030-0453.pdf