Type 1 Diabetic and Hypertensive Retinopathy: Case Presentation and Review of Literature

Abstract

Background: Type 1 Diabetes (T1D) Mellitus is a complex, chronic illness that affects half a million children under the age of 15 years. Complications associated with diabetic retinopathy can be prevented with continued self-management of Blood Glucose (BG) and Blood Pressure (BP) into adulthood. In this case, we present a 20-year-old man with a 15 year history of T1D who loses control of his BG and BP for 2 years. Methods: Blood pressure, visual acuity and intraocular pressures were measured at the time of visit. Non-mydriatic retinal imaging was performed using a Canon CR-2 Plus AF with a resolution of 18 megapixel. A Spectral Domain (SD)-OCT provided a 5 micron resolution of the posterior pole including the macula/fovea. Optical Coherence Tomography Angiography (OCTA) (Optovue, Inc., Fremont, CA, USA) captured 6*6 mm angiograms centered on macula. TeamViewer TM was used to perform remote tele-presence tele-ophthalmology. Results: Color Fundus Photo (CFP) of the subject in 2013 showed few hemorrhages with virtually no signs of retinopathy although his BP, last Glycated hemoglobin (HbA1c) and BG were uncontrolled (130/91 mm Hg, 13+, 421 mg/dL, respectively). Two years later, after 15 years of diabetes, his BP, last HbA1c, and BG are still uncontrolled (142/62 mm Hg, 13.5%, and 319 mg/dL, respectively). CFP and tele-consultation confirms severe Non-proliferative diabetic retinopathy (NPDR), after 131 days since last annual eye examination, with 259 retinal hemorrhages and 12 Intraretinal microvascular abnormalities (IRMAs) in his left eye. OCT was normal, but OCTA identified areas of retinal telangiectasia and micro-aneurysm formation. 21 days following NPDR diagnosis, he reduced BP to 122/78 mm Hg, HbA1c to 10%, and BG to 115 mg/dL. CFP showed 80 fewer hemorrhages and 10 IRMAs. 57 days following NPDR diagnosis, subject had BP of 107/72 mm Hg and BG of 124 mg/dL. CFP showed 180 fewer hemorrhages and 13 IRMAs. Conclusions: As BG and BP were decreased and maintained within normal levels, the subject benefited from reduction in retinopathy findings. This case identifies the role non-mydriatic retinal imaging, OCT, and OCTA may play in the assessment and follow-up of patients with long duration type 1 diabetes. Tele-ophthalmology can be an important tool in the follow-up and second opinion of screened patients. An emphasis on BP monitoring can play an important role in the better management of patients with type I diabetes. Close monitoring and maintenance of BP below 130/80, fasting BG under 120 mg/dL, and HbA1c<10% can help reduce NPDR microvascular complications and save vision.

Ocular Health Screening in a Type 1 Diabetes Mellitus Population

“…Average Body Mass Index (BMI) for this cohort was 21 that is considered healthy in the USA. The mean duration of T1DM was ten (10) years. With the introduction of the insulin pump, 8 daily control in T1DM became easier allowing children to interact with non T1DM more seamlessly (average number of years using the IP was 7-years with 71% male and 79% female).…”

“…Consensus for these groups is for T1DM to undergo an ocular screening at 5-years post diagnosis or at the age of 15 years old. 10 Of the 216 participants (432 eyes), our retinal color digital Table 2). In our 10-year experience with screening this group of T1DM shows that a more sensitive diagnostic instruments such as fundus autofluorescence images (FAF) 10 optical coherence tomography (OCT) and OCT-A (angiography) can reveal earlier posterior pole changes that can benefit from early intervention such as tighter blood glucose levels, limiting daily very high followed by very low blood glucose levels as well as good control of blood pressure.…”

Advances in Type 1 Diabetes Ocular Remote Tele-Health Screening

“…Retinal changes were severe with a total of 440 dot-blot and flame hemorrhages in the right and left eye primarily localized within the posterior pole consistent with diabetic retinopathy (Figure 3A and 3B). 7 The OCT-A images showed signs of retinal telangiectasia and micro-aneurysms. The subject had developed non-proliferative diabetic retinopathy, but his OCT-A findings indicating an avascular foveal pit impacted the direction of management therapy to favor more behavioral changes rather than ocular clinical treat- …”

“…During his screening in 2012, blood glucose was 184 mg/dL, blood pressure was 128/78, and no indications of retinopathy were noted. 7 He had adequate control for 13 years.…”

Type 1 Diabetes Update at Children With Diabetes Community

“…1 Suddenly, he decided (at 19 years old) to no longer follow a good control regimen for his T1D. We did not see him at CWD that year and the following year he reluctantly returned (parental pressure) and underwent a screening.…”