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Low Vision Assessment and Rehabilitation

Ophthalmic Assessment


Ophthalmic assessment of the patientDr. Cole was referred to a vitreoretinal specialist for an urgent ophthalmological assessment. His corrected visual acuities were 3/200 right eye (approximately 20/1300) and 20/60-2 left eye. His poor vision was caused by advanced diabetic retinopathy; there were no cataracts and no iris rubeosis.

The appearances of both retinas were similar - there was evidence of

(1) bilateral diffuse macular edema (tissue waterlogging) [image] with leakage of tissue fluid into the central retina from retinal vessels damaged by the diabetes; [ video explaining macular edema ]
(2) widespread small retinal vessel damage. Blood vessels had disappeared leaving many areas of the retina with an impaired blood supply, causing a rather featureless appearance, and
(3) bilateral, early proliferative diabetic retinopathy, [images] as new blood vessels attempt to form, but with the tendency to produce scar tissue and to hemorrhage into the cavity of the eye.

Fundus photographs [ below ] and a fluorescein angiogram [ at bottom of page ] of both retinas were taken to provide more information about the nature and extent of the diabetic retinopathy.

Fundus photo of right eye of patient with diabetic retinopathy Fundus photo of left eye of patient with diabetic retinopathy
The retinas of both eyes above are markedly discolored because of diffuse retinal ischemia. There are many small retinal hemorrhages and collections of yellowish lipid exudates. Both maculas are severely involved.

Photograph of a normal eye:

Normal fundus photograph


Photograph used by permission of Jeffrey W. Berger, MD, Scheie Eye Institute, University of Pennsylvania.

The initial management goals were to stabilize the diabetic retinopathy and limit the visual loss, to minimize the future effects of his severe diabetic retinopathy, and to restore independent visual functioning using a multidisciplinary team of low vision specialists, rehabilitation teachers, orientation and mobility teachers, vocational rehabilitation counselors, diabetic educators, and eye physicians.

Diabetic retinopathy is controlled by various types of out-patient laser treatment using a laser attached to an ophthalmic slit-lamp microscope.

The extent of the microvascular damage can be seen in the first row below in the fluorescein angiogram of the retinal midperiphery, and in the right macula ( in mid-phase of the macular threshold grid laser treatments.)


Fluorescein angiogram of patient's right eye
Right eye
Fluorescein angiogram of patient's left eye
Left eye
Late fluorescein angiography views of both maculas above showing severely attenuated retinal vasculature and diffuse intraretinal leakage.
 
Fluorescein angiogram of patient's right eye
Right eye
Fluorescein angiogram of patient's left eye
Left eye
Early fluorescein angiography views of both maculas 5 months into grid and panretinal photocoagulation treatments. There is residual macular edema. Note severe mid-peripheral retinal ischemia adjacent to optic nerve in the left eye.

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Last Update: Nov 29 2012