Rishi Singh, MD, Management of AMD/DME - Episode 1

Patient Case #1: 59-Year-Old Male With DME

Dr Rishi Singh reviews the case of a 59-year-old male with diabetic macular edema (DME).

Rishi Singh, MD: Hello. My name is Rishi Singh from the Cleveland Clinic Florida, in Stuart, Florida, and it's my pleasure to present to you this case of a patient with diabetic macular edema [DME].

This is a 59-year-old man who has a history of proliferative diabetic retinopathy in both eyes. He has a history of diabetic macular edema, which was referred to us by an optometrist who made this diagnosis. The panretinal laser was completed 2 months ago in our clinic, where the optician and the optical shop saw him and couldn't improve his visual acuity. He was then referred to an optometrist who saw this change in vision and the pictures and sent him back to us for evaluation and management.

Here is his past medical history: He has type 2 diabetes with a glycated hemoglobin A1C of 7.7. He has a history of treatment noncompliance. This patient has a difficult time maintaining therapy and maintaining appointments for his diabetes. He also has a history of hypertension, hyperlipidemia, and obesity. His history is significant for a primary opening of glaucoma, and he is using timolol eye drops. He is currently a smoker and uses metformin and a number of other hypoglycemic medications as well. There are no allergies to medications and his review systems are noncontributory to this case. Here is his eye examination. You can see in the right eye that he is 20/60, and in the left eye, 20/25. The eye pressures are normal at 16, and there's no afferent pupillary defect present. Here's a slit lamp photograph, which shows he has 1+ nucleus cataracts in both eyes but otherwise is unremarkable. In the right eye, you can see that he has some amount of optic nerve cupping with a 0.75 cup-to-disc ratio in the right eye and a 0.6 cup-to-disc ratio in the left eye. He has an intact rim, but definitely has some retinal nerve fiber layer loss on clinical examination in the right eye. In both eyes, you see blood hemorrhages flame, hemorrhages with the macula cotton wool spots, and exhibits in the macula, all significant for what we would expect to see in a patient with diabetic retinopathy and diabetic macular edema. In addition, he has some cotton wool spots and dot blood hemorrhage present, but significant amounts of panretinal lasers scars present in both eyes. Here's his OCT [optical coherence tomography] for the right eye and the left eye. You can see the right eye shows intraretinal system fluid present. The hyaloid is still intact with the retina and in the left eye; you see also internal system fluid present. Again, there is less edema on the left-eye side and the right, but yet again with those changes in the intraretinal surface scene. The retinal thickness in the right eye was 442 μm; the left eye was 322 μm at this point in time. The question in this patient becomes the management of whether we do anti-VEGF [vascular endothelial growth factor therapy] or observation. We'll discuss this in the next few questions as we address these topics within the study.

Transcript Edited for Clarity