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. Team- ViewerTM 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.