Retinopathy

Diabetic retinopathy is the leading cause in new cases of blindness in patients aged 25 to 74 in the United States. Patients with this complication are 29 times more likely to become blind than those without retinopathy. Glaucoma and cataracts, also more common in diabetics, can contribute to new cases of blindness in diabetic patients. Blindness due to diabetes is estimated to account for more than 500 million dollars in lost income and public expense annually. An estimated 97 percent of diabetics taking insulin (types 1 and 2), and 80 percent of diabetics who do not take insulin (type 2 only) who have had their diabetes for 15 years or longer have some diabetic retinopathy. Among those with this complication, 40 percent of insulin-using and 5 percent of non-insulin-using diabetics have the most severe form—proliferative retinopathy—that frequently leads to blindness. 18 In the DCCT, type 1 patients who had no retinopathy at baseline had their risk of developing sustained retinopathy lowered by 76 percent over patients who did not practice intensive glucose control. In those patients with mild retinopathy at the start of the study, intensive therapy reduced their risk for sustained retinopathy by 54 percent, the progression to proliferative retinopathy by 47 percent, and the need for laser photocoagulation treatment by 56 percent.13

Obtain a history of any visual changes from diabetic patients. On examination, low visual acuity and the presence of visual field defects should arouse suspicion for retinopathy. Dilated funduscopy is often not practical in the emergency department, but a nondilated retinal exam can frequently reveal "cotton wool" exudates, microaneurysms, and vascular proliferation consistent with diabetic retinopathy ( Table... .2.0.9-6.). A red and/or painful eye in association with headache or simply unexplained headache in diabetics should prompt measurement of intracocular pressures to rule out acute glaucoma. The presence of these findings should prompt a referral to an ophthalmologist for further examination and therapy.

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