DIABETIC

EYE DISEASE

An Illustrated Guide to Diagnosis and Management

WITH THE COMPLIMENTS OF

NOVO LABORATORIES LTD
 Dedication

To our patients
 DIABETIC
EYE DISEASE
An Illustrated Guide to Diagnosis
and Management

ERNA E. KRITZINGER, MSc, FRCS, MRCP

Consultant Ophthalmic Surgeon, Birmingham and Midland Eye

Hospital and Selly Oak Hospital, Birmingham
Consultant Associate, Central Birmingham Health Authority
and
KENNElH G. TAYLOR, Mb, MRCP
Consultant Physician, Dudley Road Hospital, Birmingham
Honorary Consultant Physician, Medical Ophthalmology
Clinic, Birmingham and Midland Eye Hospital

~ .MTP PRESS LI.MITED

~ a member of the KLUWER ACADEMIC PUBLISHERS GROUP
LANCASTER / BOSTON / THE HAGUE / DORDRECHT
*
Acknowledgements
We should like to thank our colleagues, Ron Fletcher and Jayne Kempster, for
their helpful comments, Gwen Taylor who prepared the manuscript and
Heather Beaumont who compiled the index.
Published in the UK and Europe by
MTP Press Limited
Falcon House
Lancaster, England

British Library Cataloguing in Publication Data

Kritzinger, E. E.
Diabetic eye disease.
1. Diabetes-Complications and sequelae
2. Eye--Diseases and defects
I. Title II. Taylor, K. G.
616.4'62 RC660
ISBN-13: 978-94-011-6346-0 e-ISBN-13: 978-94-011-6344-6
DOl: 10.1007/978-94-011-6344-6

Published in the USA by

MTP Press
A division of Kluwer Boston Inc
190 Old Derby Street
Hingham, MA 02043, USA

Copyright © 1984 E. E. Kritzinger and K. G. Taylor

Softcover reprint of the hardcover lst edition 1984
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, without
prior permission from the publishers.

Typeset by Speed lith Photo Litho Ltd., Longford Trading Estate,

Manchester M32 OJT.
 Contents

Introduction 7

1. Examination of the Eye 9

Testing visual acuity 10
Using the ophthalmoscope 14
The normal fundus 17
The abnormal fundus 19
Recording the findings 20
2. Diabetic Eye Disease 21
Diabetic retinopathy 22
Pseudopapilloedema 44
Rubeosis of the iris 46
Cataract 48
Cranial nerve palsy 50
3. Other Ocular Abnormalities Sometimes
Associated with Diabetes 53
Retinal vein occlusion 54
Asteroid hyalosis 56
Cupping of the optic disc (chronic glaucoma) 58
Lipaemia retinalis 60
Xanthelasmata and corneal arcus 62

5
4. Fundus Abnormalities Requiring
Differentiation from Diabetic Retinopathy 65
Myelinated nerve fibres 66
Choroiditis 68
Senile macular degeneration 70
5. Special Techniques Used in Ophthalmology 73
Fundus fluorescein angiography 74
Retinal photocoagulation 76
Vitrectomy 80
6. The Referral Letter 83
Conclusion 85
Index 87

6
 Introduction

The commonest cause of blindness in young and middle-aged

people in the Western world is diabetes mellitus.
Although the mechanism underlying diabetic retinopathy is
still not understood, the technology to reduce its progress
exists, provided treatment is given at the appropriate time.
Doctors caring for patients with diabetes should be familiar
with all aspects of diabetic retinopathy as well as the other
ocular complications of diabetes. They also need a basic
knowledge of the special techniques used in the diagnosis and
treatment of diabetic eye disease (fundus fluorescein
angiography, retinal photocoagulation, vitrectomy) and to
understand how these procedures affect the diabetic patient in
terms of limitation of activities and time off work. To ensure
the most efficient use of ophthalmic services a clear plan of
referral to ophthalmologists is required.
These are the concepts on which this guide is based,
compiled by an ophthalmologist involved in the treatment of
diabetic eye disease and a physician with a special interest in
diabetes. In addition to doctors involved in the management of
diabetic patients, this guide may be of value to ophthalmic
opticians, medical students and nurses as a self-instruction
manual. '

7
 1

Examination of the Eye

Testing visual acuity

Using the ophthalmoscope
The normal fundus
The abnormal fundus
Recording the findings

9
 TESTING VISUAL ACUITY

Method

Test one eye at a time.

Test distant visual acuity.
Correct the refractive error if the visual acuity is worse than
6/6.

Test one eye at a time

Figure 1 Use an occluder in front of each eye in turn.

10
 Test distant visual acuity

Use Snellen's test type charts which should be well illuminated

and placed 6 metres away from the patient.

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Figure 2 Different types of Snellen's charts available.

(i) 'E' -chart for use by illiterate patients.
The patient holds a cardboard 'E' in a position
to match that of the 'E' pointed to on the chart
by the examiner.
(ii) Standard 6 metre chart.
(iii) 3 metre chart for use m examination rooms
with limited space.

11
 Correct the refractive error
If the visual acuity is worse than 6/6, correct the refractive
error with the patient's spectacles for distant vision, if worn. It is
important during the test to ensure that the patient does not
confuse reading spectacles with those used for distant vision.
The pinhole test (opposite) can be used to differentiate
between impaired vision due to refractive error and that due to
pathology in the eye. The pinhole test overcomes refractive
errors and improves the visual acuity. Provided the
intervening structures are healthy it is a useful test of macular
function. Worsening of the vision during the pinhole test
suggests maculopathy in the diabetic patient and alerts to the
presence of macular oedema, haemorrhage or exudates.

Action

1. If acuity is abnormal, the fundus should be examined

carefully after dilating the pupil, with special attention to
the macula.
2. Any deterioration in acuity accompanied by abnormalities
of the macula itself or in the area close to it ) Referral
to an ophthalmologist.
3. A two-line deterioration in acuity without any abnormalities
on fundoscopy ) Referral to an ophthalmologist.

12
Figure 3 Pinhole cards are easy to make. Multiple pinholes
help the patient to find one quickly.

Figure 4 The card with pinholes must be held closely against

the eye.

13
 USING THE OPHTHALMOSCOPE

What type of instrument?

A conventional ophthalmoscope with a range of lenses from

+ 12 to -12 dioptres is usually satisfactory. It should have a
bright reliable light. In the severely myopic patient viewing
through the patient's spectacles may make visualisation of the
fundus easier. Alternatively an ophthalmoscope with a wider
range of lenses may be required.

Figure 5 Different types of ophthalmoscope.

Is a dark room necessary?

A darkened room, although desirable, is not essential. It

should be large enough for several doctors to examine patients
at the same time, thus avoiding queueing.

Should the pupils be dilated?

Yes. Diabetic retinopathy may be peripheral and the whole

fundus needs to be examined.

14
 Which mydriatic?

The best mydriatic is probably tropicamide 0.5 % because it

has a short duration of action (3 hours) and does not require
reversing with pilocarpine. Patients with dark brown irises
may need the 1.0 % strength for adequate pupil dilatation.
Patients should be warned about the side-effects of
photophobia and blurred vision. Although close vision is more
affected than distant vision, care must be taken if driving a
vehicle afterwards.

Figure 6 The eye drops should be instilled inside the lower

eyelid. Drops directly on to the cornea are uncomfortable and
will cause blepharospasm.

15
 When is a mydriatic contraindicated?

Provided mydriasis is avoided in patients known to have

glaucoma, the risk of precipitating narrow angle glaucoma is
small. A previous history of eye surgery is also a
contraindication for a mydriatic, in particular cataract
extraction with intraocular lens insertion, as dilatation of the
pupil may lead to dislocation of the intraocular lens. These
patients are best referred to an ophthalmologist for assessment.

Figure 7 An intraocular lens is visible in the pupil.

16
 Fundus examination

Adjust the ophthalmoscope to 0 and view the eye from a

distance of about 50 cm. A red colour - the red reflex - should
be seen through the pupil if the cornea, lens and vitreous body
are healthy. Opacities in these structures will appear dark
against the red reflex.
The examiner now moves very close to the eye selecting a
+ 10 dioptre lens and proceeds to examine the cornea, the
anterior chamber and lens for abnormalities, using suc-
cessively less powerful lenses until the retina is in focus.

Figure 8 The red reflex of the fundus.

17
 THE NORMAL FUNDUS

Figure 9 The normal fundus in a white patient.

Figure 10 The normal fundus in a coloured patient.

18
The fundus should be examined methodically in the following
sequence:
Optic disc
Peripheral retina, divided into quadrants: superior nasal
and temporal, inferior nasal and temporal
Macula - this should be examined last to minimise
photophobia

THE ABNORMAL FUNDUS

The fundus examination should include a search for the
following abnormalities:
Microaneurysms
Intra-retinal haemorrhage
Maculopathy
Exudates - hard
- soft (cotton wool spots)
Venous beading or reduplication
Arteriolar sheathing
New vessels (particularly on the optic disc)
Pre-retinal haemorrhage
Vitreous haemorrhage
Fibrous proliferation
Traction retinal detachment

19
 RECORDING THE FINDINGS

It is most important to provide a record showing:

• date of examination
• visual acuity
• fundoscopy findings

IDate i

R •

- - ----
I
+-~~~-- -~--

L •
i
--~~

Figure 11 A rubber stamp in the notes is useful and should be

large enough to draw in abnormalities.

20
 2

Diabetic Eye Disease

Diabetic retinopathy
Pseudopapilloedema
Rubeosis of the iris
Cataract
Cranial nerve palsy

21
 DIABETIC RETINOPATHY

Types Ophthalmoscopic abnormalities

BACKGROUND Retinal vein dilatation
Microaneurysms (dots)
Retinal haemorrhages (blots)
Hard exudates
MACULOPATHY Macular oedema
Diffuse maculopathy
Circinate maculopathy
PRE-PROLIFERATIVE Soft exudates (cotton wool spots)
Venous beading and reduplication
Arteriolar sheathing
PROLIFERA TIVE New vessels
Pre-retinal and vitreous
haemorrhage
ADVANCED Fibrous proliferation
Traction retinal detachment

Questions Commonly Asked About Diabetic

Retinopathy (DR)

Q.l Who is most likely to have diabetic retinopathy?

• Those patients who have had diabetes the longest are most
at risk.
• The prevalence of diabetic retinopathy is related to the age
at onset and to the duration of diabetes.
• 7 ~o of patients aged 0-19 years at diagnosis will have DR
after 10 years.
10 %of patients aged 20-39 years at diagnosis will have DR
after 10 years.
25 %of patients aged 40 + years at diagnosis will have DR
after 10 years.
All patients attending the Diabetic Clinic should have theyearof
diagnosis and their date of birth prominently displayed in the notes.

22
Q.2 Which other patients are at risk of developing
diabetic retinopathy?

• Patients with evidence of microangiopathy elsewhere,

especially renal disease, e.g. patients with proteinuria.
• Patients with hypertension.
• Patients with poor glycaemic control.
• Patients who become pregnant.
• Patients using the contraceptive pill.
• Patients who smoke cigarettes.

Q.3 How often should diabetic patients have their

fundi checked for retinopathy?

• Every patient should have a fundus check at the

time of diagnosis.
• The fundi should also be examined if a patient complains
of visual symptoms such as seeing black 'floaters',
'tadpoles' or 'spiders' webs'.
• Type 1 diabetes (insulin-dependent) :
Diagnosis usually occurs within a few weeks of onset of
diabetes. Retinopathy is seldom found at presentation.
Patients aged less than 19 years at diagnosis should have
their fundi checked at presentation, 5-yearly for 10 years
and then yearly if the fundi are normal.
Patients aged 20 years and over at diagnosis should have
their fundi checked at presentation, after 3 years and then
yearly if the fundi are normal.
• Type 2 diabetes (non-insulin-dependent) :
Patients may have diabetes for several years before
diagnosis and therefore may present with quite advanced
retinopathy.
They should have their fundi checked at presentation,
after 3 years and then yearly if the fundi are normal.
• Patients who have any of the risk factors listed under Q.l
and Q.2 will need more frequent examination of their fundi,
as will those who have the retinal abnormalities described in
the following pages.

23
 Background Retinopathy

Retinal vein dilatation

Microaneurysms (dots)
Retinal haemorrhages (blots)

Action

1. There is no need to refer to an ophthalmologist at this stage,

provided visual acuity is satisfactory. The eyes should be
examined at least annually, but more frequently if 'risk
factors' (pp. 22-23) are present.
2. Although impaired glycaemic control has not been proved
to reverse this situation, evidence is accumulating that it
may slow down its progression. It is therefore reasonable to
Assess control by
• reviewing clinic blood glucose and urine testing results.
• encouraging the patient to monitor the blood glucose
with an appropriate test strip.
• checking glycosylated haemoglobin (HbA 1 ).
Improve control by
• reviewing the diet.
• reviewing compliance to and suitability of therapy.
Patients receiving diet alone may need oral agents.
Patients receiving oral agents may need insulin.
Patients receiving insulin will need injection technique,
sites and timing checked before altering regime.

24
 Background Retinopathy

Figure 12 Retinal vein dilatation - the earliest clinical sign of

diabetic retinopathy,

Figure 13 Microaneurysms (dots), retinal haemorrhages

(blots),

25
 Background Retinopathy

Hard exudates

Action

1. The patient should be referred to an ophthalmologist

• if visual acuity has deteriorated
• if there are more than just a few scattered hard exudates
• if there has been a progression since the previous
examination - emphasising the importance of accurate
charting.
2. If the patient is not referred, the eyes should be re-examined
within 6 months.
3. Attention should be paid to improving glycaemic control
(p 24).

26
 Background Retinopathy

Figure 14 Hard exudates-an early stage.

Figure 15 Extensive hard exudates - a later stage.

27
 Diabetic Maculopathy

Macular oedema
Visual acuity will be impaired and the pinhole test (p. 12) will
make the vision worse (a useful clinical clue).

Action

1. Early referral to an ophthalmologist.

2. Attention to glycaemic control (p. 24).

28
 Diabetic Maculopathy

Figure 16 Macular oedema - perhaps the most difficult

abnormality to identify because the fundus may appear normal
to the inexperienced observer.

Figure 17 Fluorescein angiography (p. 74) confirms the

presence of macular oedema. Dye leaking from abnormal
retinal vessels accumulates in the oedematous retina.

29
 Diabetic Maculopathy

Diffuse maculopathy

Action

1. Early referral to an ophthalmologist, within a few weeks.

2. Attention to glycaemic control (p. 24).

30
 Diabetic Maculopathy

Figure 18 Diffuse maculopathy with exudates and haemor-

rhages scattered around the fovea (centre of the macula).
Visual acuity will be impaired.

Figure 19 Diffuse maculopathy with hard exudates accu-

mulating in the fovea. Visual acuity will be impaired.

31
 Diabetic Maculopathy

Circinate maculopathy

Action

1. Early referral to an ophthalmologist, within a few weeks.

2. Attention to glycaemic control (p. 24).

32
 Diabetic Maculopathy

Figure 20 Circinate maculopathy. The hard exudates are

arranged in rings in the macular area. Visual acuity may be
normal at this stage.

Figure 21 When exudates have extended into the centre

(fovea) of the macula retinal photocoagulation will not improve
visual acuity.

33
 Pre-proliferative Diabetic Retinopathy

Soft exudates (cotton wool spots), venous beading, venous

reduplication and arteriolar sheathing are features of pre-
proliferative diabetic retinopathy. Other signs of increasing
retinal ischaemia (capillary closure and intraretinal abnorma-
lities) are best seen on fundus fluorescein angiography (p. 74).
There is a 50/0 risk of progression to proliferation within two
years if three or more of these features are present.

Action

1. Early referral to an ophthalmologist, within a few weeks.

2. Attention to glycaemic control (p. 24).

34
 Pre-proliferative Diabetic Retinopathy

Figure 22 Cotton wool spots and venous beading.

Figure 23 Venous reduplication.

35
 Proliferative Diabetic Retinopathy

This is a very serious stage of the disease: retinal and vitreous

haemorrhage invariably follow. Depending on the amount of
new vessel formation, the patient has a 10-25 %risk of severe
visual loss within two years. New vessels on the optic disc
reflect severe retinal ischaemia and are particularly prone to
haemorrhage.
The patient may be asymptomatic until the time that
haemorrhage occurs - emphasising the importance of regular
fundus examination of patients at risk.

Action

The patient needs urgent referral to an ophthalmologist, i.e.

within 14 days.
Retinal photocoagulation, although not immediately
effective, reduces the risk of eventual severe visual loss by more
than 50~~.

36
 Proliferative Diabetic Retinopathy

Figure 24 New vessels extending from the optic disc form

irregular networks above and below the disc.

Figure 25 Extensive new vessel formation affecting the optic

disc and retina.

37
 Proliferative Diabetic Retinopathy

Haemorrhage from new vessels may impair visual acuity. The

patient typically complains of 'black floaters', 'spiders' webs'
or 'tadpoles' in the vision.

Action

These patients need very urgent referral (by telephone) to an

ophthalmologist.
Delay of a few days may result in complete vitreous
haemorrhage, when retinal photocoagulation may be
impossible.

38
 Proliferative Diabetic Retinopathy

Figure 26 Pre-retinal haemorrhage from new vessels

obscures the underlying retinal vessels.

Figure 27 Haemorrhage from new vessels on the optic disc.

39
 Proliferative Diabetic Retinopathy

Vitreous haemorrhage from new vessels will obscure the

fundus details on examination. The haemorrhage may impair
visual acuity for several months. Recurrent haemorrhages
frequently occur.

Action

These patients need very urgent referral (by telephone) to an

ophthalmologist. It may be possible to give retinal photo-
coagulation treatment despite the hazy fundus view.
The other eye also requires thorough examination and may
need prophylactic treatment.

40
 Proliferative Diabetic Retinopathy

Figure 28 Early vitreous haemorrhage obscuring the inferior

half of the retina.

Figure 29 Complete vitreous haemorrhage resulting in a hazy

fundus view.

41
 Advanced Diabetic Retinopathy

In this advanced stage of diabetic retinopathy retinal

photocoagulation is not indicated as it may increase the
traction on the retina. However it may be possible to cut the
fibrous bands and flatten the retina during vitrectomy surgery
(p. 80).

Action

These patients should have early referral, within a few weeks,

to an ophthalmologist. Vitrectomy surgery, before the retina is
totally detached, may restore some visual function.

42
 Advanced Diabetic Retinopathy

Figure 30 Fibrous proliferation with traction retinal

detachment sparing the macula.

Figure 31 Fibrous proliferation with subtotal traction retinal

detachment.

43
 PSEUDOPAPILLOEDEMA

Young diabetics may present with acute swelling of one or both

optic discs, which requires differentiation from papilloedema
due to raised intracranial pressure. The presence of an
associated diabetic retinopathy, which may be mild, can aid the
diagnosis and prevent extensive neurological investigation.
The patient is usually asymptomatic, although enlargement
of the blind spot may occur. If vision is affected, prognosis for
recovery is good, usually within a few weeks. However,
swelling of the optic disc may take up to one year to resolve and
may result in mild optic atrophy.

Action

Referral to an ophthalmologist for fundus fluorescein

angiography which may differentiate between pseudo- and
true papilloedema.

44
 PSEUDOPAPILLOEDEMA

Figure 32 The optic disc is swollen with an ill-defined margin

and cup.

45
 RUBEOSIS OF THE IRIS

New blood vessels on the anterior surface of the iris give it a

pink hue-hence the term 'rubeosis'. The new blood vessels
obstruct the anterior angle of the eye and the outflow of
aqueous fluid causing 'neovascular glaucoma'. Neovasc-
ularisation of the iris, as in the case of the retina, is a response to
ischaemia and therefore is often associated with proliferative
retinopathy.
Early panretinal photocoagulation may result in regression of
new vessels in both the iris and retina.

Action

If new vessels are seen on the iris the patient should have early
referral to an ophthalmologist, ideally within a month.

46
 RUBEOSIS OF THE IRIS

Figure 33 There are new vessels on the anterior surface of the

iris, adjacent to the pupillary margin .

Figure 34 Chronic neovascular glaucoma with new vessels

radiating over the anterior surface ofthe iris. There is a mature
cataract. Associated chronic iritis has resulted in nodular
exudate on the iris and keratic precipitates on the inner surface
of the cornea (best visible in the lower half of the cornea).
47
 CATARACT

Cataracts are common in diabetics, and senile cataract occurs

at an earlier age than in non-diabetics. Three types of lens
opacities occur: true diabetic cataract (juvenile or 'snowflake'
cataract), senile cataract and temporary opacities. In addition
variations in blood glucose levels have osmotic effects on the
lens and vitreous body causing refractive changes and
fluctuations of visual acuity. It is advisable to refrain from
prescribing new spectacles until diabetes is stabilised.

Action

1. Patients with early cataracts should have visual acuity

checked annually and b~ referred to an ophthalmologist
when acuity is significantly impaired.
2. If the fundus details are ill-defined the patient should be
referred to an ophthalmologist within a few months.
Indirect ophthalmoscopy may allow assessment of the
fundus for possible associated retinopathy. If the cataract is
too advanced, extraction will have to be considered.
3. In young diabetics with 'snowflake' cataract accompanying
loss of vision may occur within days or weeks. Urgent
referral should be considered as cataract extraction will be
necessary before the fundus can be examined.

48
 CATARACT

Figure 35 Juvenile or 'snowflake' cataract may present

acutely and may progress rapidly.

Figure 36 Advanced senile cataract obscuring the fundus

view.
(Figures 35 and 36 courtesy Dr Barry E. Wright)

49
 CRANIAL NERVE PALSY

Palsy ofthe third, fourth or sixth cranial nerve may occur with
only mild diabetes. Improvement of ophthalmoplegia and
diplopia usually begins within three weeks although symptoms
may persist for up to three months. It is important to
distinguish diabetic ophthalmoplegia from that due to an
intracranial space-occupying lesion or migraine. When the
third nerve is involved the pupil is usually spared in dIabetes
but dilated in the other two conditions.

Action

Referral to a neurologist may have to be considered to exclude

a cause other than diab~tes.

50
 CRANIAL NERVE PALSY

Figure 37 Sixth nerve palsy with limitation of abduction of

the right eye.

Figure 38 Third nerve palsy with ptosis affecting the left eye.
(Figures 37 and 38 courtesy Orthoptic Department,
Birmingham and Midland Eye Hospital)

51
 3

Other Ocular Abnormalities

Sometimes Associated with Diabetes

Retinal vein occlusion

Asteroid hyalosis
Cupping of the optic disc
due to chronic glaucoma
Lipaemia retinalis
Xanthelasmata and corneal arcus

53
 RETINAL VEIN OCCLUSION

Diabetes mellitus may be associated with retinal vein

occlusion, but other predisposing conditions to be considered
are hypertension, hyperlipidaemia and hyperviscosity of the
blood. Retinal vein occlusion also causes retinal ischaemia
which may lead to new vessel formation and vitreous
haemorrhage. Cases of central retinal vein occlusion run the
additional risk of developing rubeosis of the iris with
neovascular glaucoma (p. 46). Retinal photocoagulation may
prevent all these complications.

Action

Urgent referral to an ophthalmologist.

54
 RETINAL VEIN OCCLUSION

Figure 39 Central retinal vein occlusion with dark, dilated,

tortuous veins and numerous scattered haemorrhages.

Figure 40 Branch retinal vein occlusion.

55
 ASTEROID HY ALOSIS

In this condition numerous small yellow opacities composed of

calcium phosphate and lipid occur in the vitreous gel. It is
more common in diabetics than in the general population, but
it is not necessarily associated with diabetic retinopathy. It is
harmless and has no effect on vision. However it may be
confused with the hard exudates of diabetic retinopathy.

Action

Referral to an ophthalmologist for thorough fundus

examination.

56
 ASTEROID HYALOSIS

Figure 41 Asteroid hyalosis in an otherwise normal fundus.

Figure 42 The opacities typically overlie the retinal vessels on

fundoscopy. There is underlying diabetic retinopathy.

57
 CUPPING OF THE OPTIC DISC (Chronic glaucoma)

Chronic glaucoma is reported to occur more frequently in

diabetics than in the general population. The elevated intra-
ocular pressure results in cupping of the optic disc and visual
loss in the peripheral field. The patient is usually
asymptomatic until the final stages when 'tunnel' vision
occurs.

Action

Urgent referral to an ophthalmologist for assessment of intra-

ocular pressure and visual field.

58
CUPPING OF THE OPTIC DISC (Chronic glaucoma)

Figure 43 Normal cupping of the optic disc.

Figure 44 Glaucomatous cupping of the optic disc.

59
 LIPAEMIA RETINALIS

This condition occurs with marked hypertriglyceridaemia

which may be a feature of severely uncontrolled diabetes. The
hypertriglyceridaemia and the fundus abnormalities are
reversible usually with control of the diabetes.

Action

A careful dietary assessment should be made. Alcohol abuse

may be present. Control of the diabetes may be achieved by
diet with or without oral agents, but insulin may be required.

60
 LIPAEMIA RETINALIS

Figure 45 The blood vessels in the fundus appear milky due

to hypertriglyceridaemia.
(Figure 45 courtesy Dr Barry E. Wright)

61
 XANTHELASMATA AND CORNEAL ARCUS
Xanthelasmata may be associated with hyperlipidaemia and lor
diabetes. When hyperlipidaemia is present it is usually
hypercholesterolaemia.
Corneal arcus is commonly seen in older patients and
probably signifies underlying atherosclerosis. In patients aged
under 40 years it suggests premature atherosclerosis and an
underlying cause should be sought.
Both xanthelasmata and corneal arcus may occur in patients
without diabetes or an apparent lipid abnormality.

Action

1. Examine the patient carefully for xanthomata of the skin and

tendons.
2. Obtain a blood sample after a 12-hour fast and determine
serum cholesterol and triglyceride levels.
3. The diagnosis of hyperlipidaemia should rest on two fasting
blood samples. If confirmed, thyroid, renal and hepatic
function should also be assessed.
Significant hyperlipidaemia should be treated initially
with diet and then drug therapy if necessary.
4. Cosm~tically disfiguring xanthelasmata can be removed by
a simple plastic surgery procedure.

62
 XANTHELASMATA AND CORNEAL ARCUS

Figure 46 Bilateral xanthelasmata and corneal arcus.

Characteristically there is a clear zone of cornea peripheral to
the arcus - a feature distinguishing it from calcific band
keratopathy.

63
 4

Fundus Abnormalities Requiring

Differentiation from Diabetic
Retinopathy

Myelinated nerve fibres

Choroiditis
Senile macular degeneration

65
 MYELINATED NERVE FIBRES

Myelinated retinal nerve fibres appear as shiny white patches

with feathery margins. They typically extend from the margin
of the optic disc but may also be situated in other areas of the
retina. The retinal vessels are characteristically partially
obscured. This is a harmless congenital abnormality.

Action

Nil, other than to distinguish them from hard or soft exudates

(pp. 27, 31, 33, 35).

66
 MYELINATED NERVE FIBRES

Figure 47 Myelinated nerve fibres typically extend from the

optic disc.

Figure 48 Myelinated nerve fibres partially obscuring the

retinal vessels.

67
 CHOROIDITIS

Inflammation of the choroid may be caused by infections such

as Toxoplasma, Toxocara, syphilis, tuberculosis or by
granulomatous disorders, for example sarcoidosis. To the
inexperienced observer the scars of choroiditis may resemble
the changes found after retinal photocoagulation.

Action

Referral to an ophthalmologist to determine whether the

choroiditis is active.

68
 CHOROIDITIS

Figure 49 Choroiditis.

Figure 50 Photocoagulation scars in the retina.

69
 SENILE MACULAR DEGENERATION

This disorder is the commonest cause of blindness in old

people and typically affects reading vision before distant
vision.
All the stages illustrated will impair central vision to some
extent. The pinhole test (p. 12) will make vision worse. To the
inexperienced observer these abnormalities may resemble
those found in diabetic maculopathy.

Action

Early referral to an ophthalmologist is essential as laser

photocoagulation of subretinal new vessels may retain useful
vision in selected cases.

Figure 51 Dry pigmentary macular change.

70
SENILE MACULAR DEGENERATION

Figure 52 Macular drusen.

Figure 53 Disciform macular scar.

71
 5

Special Techniques Used in

Ophthalmology

Fundus fluorescein angiography

Retinal photocoagulation
Vitrectomy

73
 FUNDUS FLUORESCEIN ANGIOGRAPHY

Fundus fluorescein angiography is used to demonstrate

abnormalities in the vascular architecture of the fundus before
retinal photocoagulation is performed. A sodium fluorescein
solution is injected intravenously and its circulation through
the fundus recorded with a fundus camera. Normal retinal
blood vessel walls are impermeable to sodium fluorescein and
retain the dye within the vessels. In diabetic retinopathy the
new vessels leak dye through their walls due to breakdown of
the blood-retinal barrier. In addition retinal ischaemia due to
capillary closure shows up as dark underperfused areas on the
angiogram.

Information to the Patient

1. This is an out-patient procedure requiring no anaesthetic.

2. The fluorescein dye stains other tissues in the body: the skin
will appear yellow for a few hours afterwards and the urine
yellow for a few days. The latter may interfere with urine
tests for glucose.
3. For clear fundus views the pupils will be dilated widely with
eye drops. This will result in some blurring Qf vision and
photophobia for several hours. Reading vision is more
affected than distant vision.

74
 FUNDUS FLUORESCEIN ANGIOGRAPHY

Figure 54 Normal fundus fluorescein angiogram.

Figure 55 Diabetic retinopathy showing microaneurysms

(M), areas of capillary closure (C) and leakage (L) from new
vessels.

75
 RETINAL PHOTOCOAGULATION

Although the mechanism underlying neovascularisation is not

known, it is thought that retinal ischaemia plays a major role.
The rationale for panretinal photocoagulation for proliferative
diabetic retinopathy is to ablate areas of retinal ischaemia. In
severe cases new vessels may be treated directly. Focal retinal
photocoagulation is used to seal leaking microaneurysms and
so decrease the formation of exudates.
Two types of retinal photocoagulation are currently in use:
Xenon-arc photocoagulation (white light)
This form of treatment is usually uncomfortable for the patient
and may require retrobulbar anaesthesia. It is also the
technique used under general anaesthesia if the patient IS
unable to co-operate for treatment.
Laser beam photocoagulation (monochromatic light)
This form of treatment is not painful. The only anaesthetic
administered is eye drops so that a contact lens can be placed on
the eye and the laser beam brought to a focus on the retina. It is
always an out-patient procedure.

Information to the Patient

1. Both these forms of treatment may be given as out-patient

procedures. However if a general anaesthetic were given for
xenon-arc photocoagulation an overnight stay is usually
required.
2. Return to work is usually possible the following day (out-
patient) or within a few days (after general anaesthesia), but
strenuous physical activity may have to be avoided for
several weeks.
3. Several attendances may be required to complete the course
of treatment for each eye.
4. At each attendance the pupils will be widely dilated to allow
thorough fundus examination. This will result in some
blurring of vision and photophobia for several hours.
Reading vision is more affected than distant vision.

76
 RETINAL PHOTOCOAGULATION

Figure 56 Retrobulbar anaesthesia for xenon-arc photo-

coagulation.

Figure 57 Laser photocoagulation in progress.

77
 Effects of Retinal Photocoagulation

Macular Exudates

Figure 58 Before treatment.

Figure 59 After treatment, showing partial resolution of the

exudates.

78
 Effects of Retinal Photocoagulation
New Vessels

Figure 60 Before treatment.

Figure 61 After treatment. The new vessels on the optic disc

and retina have regressed.

79
 VITRECTOMY

In vitrectomy surgery micro-instruments are introduced into

the eye through the sclera. The fundus is viewed with an
operating microscope through the patient's cornea and
vitreous haemorrhage aspirated, new vessels coagulated or
fibrous bands cut. The vitreous fluid is replaced with a
balanced salt solution.
This procedure is used in advanced diabetic retinopathy. It
is difficult, requires a general anaesthetic and is available only
in specialist centres.

Information to the Patient

1. This procedure requires a general anaesthetic and an in-

patient stay of about 7 days.
2. Strenuous physical activity will have to be avoided for
several months post-operatively.
3. Return to work may not be possible for several weeks or even
months after surgery.

80
 VITRECTOMY

Operating microscope

Aspiration cutter

Lens Cornea

Vitreous haemorrhage

Traction retinal detachment

Figure 62 Vitrectomy technique.

81
 6

The Referral Letter

The referral letter to an ophthalmologist should contain the

following information, enabling a degree of priority to be
readily decided:
Age and sex of patient.
Type and duration of diabetes.
Form of treatment.
Other factors: pregnancy, hypertension, nephropathy.
Visual acuity (corrected).
Presence of lens opacities.
Fundus abnormality.

83
 Conclusion

Retinopathy is common in diabetic patients and is usually

asymptomatic. Examining for its presence and preventing its
progress must be principal aims. If those involved in diabetic
care are familiar with the spectrum of eye disorders and the
priorities for management, they can utilise available facilities
to the best advantage.

85
 Index

anaesthetic, retrobulbar 76-7 exudates

arteriolar sheathing 22, 34 hard 22,26-7,31,33,78
asteroid hyalosis 56-7 in mtls 47
atherosclerosis 62 soft 22, 34-5
see also asteroid hyalosis
eye drops: administration of 15
blood, hyperviscosity of 54
blood-retinal barrier 29, 74-6 fluorescein angiography 29, 34,
44, 74-5
fovea 31,33
cataract 47, 48-9 fundus
choroiditis 68-9 abnormalities 19
cornea 17, 47 examination and screening
corneal arcus 62-3 17-20,23
cotton wool spots 22, 34-5 normal 18
cranial nerve palsy 50-1 red reflex 17

glaucoma 16
diabetes chronic 58-9
glycaemic control 24 neovascular 46-7, 54
types 1 and 2 23 glycaemic control 24
diabetic retinopathy 22
advanced 42-3, 80 haemorrhage
background 24-7 macular 12,31
pre-proliferative 34-5 retinal 22, 25, 36, 38-9, 55
prevalence and risk factors 22-3 vitreous and pre-retinal 22, 36,
proliferative 36-41,46,75-6 38-41,54
screening 23 hypercholesterolaemia 62
symptoms 23, 38 hyperlipidaemia 54, 62
see also maculopathy hypertension 54
diplopia 50 hypertriglyceridaemia 60-1

87
intraocular pressure
in chronic glaucoma 58
iris, rubeosis of 46-7, 54
iritis 47
ischaemia see iris, retina
keratic precipitates 47
laser see photocoagulation
lens
intraocular 16
opacities 17, 48
see also cataract
lipaemia retinalis 60-1
macula, senile degeneration of
disciform scar 71
drusen 71
dry pigmentary change 70
maculopathy, diabetic 12, 22,
28-33
circinate 32-3
diffuse 30-1
oedema 12, 28-9
use of photocoagulation 78
visual acuity in 12, 28
microaneurysms 22, 25, 75, 76
mydriatic 15-16, 74, 76
neovascularisation 22
of iris 46-7
of retina 36-9, 54, 76
use of photocoagulation 79
nerve fibre myelination (retinal)
66-7
new vessels see neovascularisation
ophthalmoplegia 50-1
ophthalmoscopy 14, 17
optic disc
cupping 58-9
neovascularisation and haemor-
rhage 36-7, 39, 79
swelling 44-5
88
photocoagulation 36, 46, 54, 69,
70, 76-9
pinhole test 12-13, 28, 70
pseudopapilloedema 44-5
ptosis 51
pupillary dilation
abnormal 50
by mydriatic 14-16, 74, 76
referral letter 83
refractive error correction 10, 12
retina
detachment 22, 42-3
ischaemia 34, 36, 54, 74-6
neovascularisation and haemor-
rhage 22, 36-9, 54, 76, 79
scarring 69
see also under diabetic retino-
pathy, fundus, maculopathy
retinal vein occlusion 54-5
Snellen's charts 11
spectacles
prescription of and glycaemic
control 48
use of in visual testing 12, 14
venous beading and reduplication
22,34-5
venous dilatation 22, 25
visual acuity: testing 10-13
vitrectomy 42, 80-1
vitreous
fibrous proliferation in 22,
42-3,80
haemorrhage 40-1, 54, 80
opacltles in 17, 56
replacement of 80
xanthelasmata 62- 3
xenon-arc photocoagulation 76