A 60 yr old man has both HTN and DM for 10 yrs. There is reduced vision in one eye. On fundus examination there is a central bleed and the fellow eye is normal. The diagnosis is
Diabetic retinopathy Extensively discussed with 2 Ophthalmologists Central bleed implies bleed in macula. This is what is leading to reduced vision in the involved eye. Diabetic retinopathy is the obvious choice due to following reasons: Diabetic retinopathy Among the given options macular bleed can be seen in DR only. Though DR is usually bilateral, but can be unilateral or assymetrical. Microaneurysms are the first ophthalmoscopically detectable change in diabetic retinopathy, seen as small red dots in the middle retinal layers. When these microaneurysms rupture it may give rise to an intraretinal haemorrhages. Optic neuritis Optic neuritis can be ruled out as - Vision loss is usually abrupt - Mild periorbital pain (exacerbated by eye movement) is present in about 90% cases. - Usually seen in young patients - Fundus picture is not matching. Retinal haemorrhages are uncommon. Macular bleed is never seen. Fundus examination is normal in retrobulabar type of optic neuritis (which is the much more common type of optic neuritis). In the less common papillitis type of optic neuritis, optic disc swelling is present. Funduscopic features of optic disc swelling include elevation of the optic nerve head, disk hyperemia, blurring of the disc margins, and edema of the nerve fibre layer. Optic disc hemorrhages are uncommon. Retinal tear Retinal tear are usually peripheral and typically occur in the equatorial and ora serrata regions of the retina. Peripheral retinal breaks alone do not cause loss of vision, but the associated conditions of vitreous hemorrhage and rhegmatogenous retinal detachment can result in severe visual loss. Even if retinal tear is central, will not cause macular bleed. Retinal tear can be of 2 types: traumatic and non-traumatic. Non traumatic can occur because of lattice degeneration or due to vitreous traction. Vitreous traction will lead to symptoms of flashes and associated haemorrhages would cause floaters. Hypeensive retinopathy Hypeensive retinopathy can be of 2 types- Chronic hypeensive retinopathty and Malignant acute hypeensive retinopathy. Chronic hypeensive retinopathy is usually asymptomatic. Fundus picture is - focal constriction and dilatation of the retinal aerioles, touosity of the retinal aerioles, an increase in the aeriolar light reflex, and loss of transparency of the intra-aerial blood column, aeriovenous nicking (aeriovenous nicking is a highly specific .finding and the hallmark of chronic hypeensive retinopathy), retinal hemorrhages, macular edema, and cotton-wool spots. Malignant hypeensive retinopathy is due to acutely elevated blood pressure in a patient with relatively young aerioles undefended by sclerosis. Vision loss is acute and severe. The fundus picture is dominated by edema. The entire retina may be clouded by a generalized edema which may be paicularly accentuated at the disc, resulting in a marked degree of disc edema with multiple cotton wool patches, hard exudates and retinal haemorrhages. Diabetic retinopathy and age: Diabetic retinopathy affects both young and old, as it is the diabetic age and not the chronological age that is impoant. The best predictor of diabetic retinopathy is the duration of the disease. First 5 yrs of type 1 diabetes - very low risk 5-10 yrs of type 1 diahete - 27% develop diabetic retinopathy > 10 yrs - 71 to 90 % develop diabetic retinopathy > 20-30 yrs - 95% develop DR. (In type II diabetes, the time of onset and therefore the duration of disease are difficult to determine precisely)
Retinal tear
Optic neuritis
Diabetic retinopathy
Hypeensive retinopathy