A 61-year old male farmer presented with gradually worsening vision in both eyes over the past 2 months. He has a 15-year history of uncontrolled diabetes. Examination found cataracts and signs of proliferative diabetic retinopathy in both eyes, including laser scar marks, dot and blot hemorrhages, and tortuous blood vessels. The patient was previously treated with laser photocoagulation in both eyes for diabetic retinopathy. The provisional diagnosis was proliferative diabetic retinopathy in both eyes status post pan retinal photocoagulation, along with nuclear sclerosis cataracts.

1. Case Presentation
Moderator : Dr. Sohan Lohiya Sir
Presenter : Dr. Aakanksha Bele
Jawaharlal Nehru Medical College, Sawangi (M), Wardha

2. General Information
• Name : Mr. Dilip Gawande
• Age : 61 yrs
• Sex : Male
• Religion : Hindu
• Occupation : Farmer
• Date of admission : 21/09/2021 (Patient is admitted in medicine ward i/v/o
uncontrolled blood sugar levels)

3. Chief Complaints
• C/o Diminution of vision in Right Eye since 2 months
• C/o Diminution of vision in Left Eye since 1 month

4. History of presenting illness
• A 61 years old farmer presented in eye OPD with complain of painless
diminution of vision in right eye since 2 months which was insidious in
onset & gradually progressive in nature. Followed by painless diminution of
vision in left eye since 1 month which was insidious in onset & gradually
progressive in nature. He also has difficulty in reading newspaper for last 2
months.

5. Negative History
• He does not wear any glasses.
• He denies any history of flashes or floaters, eye discomfort, redness, pain,
night blindness, metamorphopsia
• No history of prior eye surgeries.
• No history of eye trauma

6. Past Ophthalmic history
• Patients gives history of Laser procedure done in both the eyes 1 year ago
at Kasturba health society hospital, Sewagram, Wardha.
• Although patient does not have any documents for the same.
• Patient denies getting any injections in either eye
• At present patient is not on any ocular medications

7. Systemic History
• He is a known case of non
insulin dependent diabetes
mellitus since 15 yrs on
regular treatment.
• Currently he is on T. Gepride
M2 (Glimepride 2 mg &
Metformin 2 mg) two times a
day
• & T. Voglibose 0.3 mg two
times a day

8. Systemic History
• No history of hypertension/ bronchial asthma/ tuberculosis/ seizure
disorder/ hypercholesterolemia
• No history of allergy
• Patient denies any other systemic symptoms

9. Family History
• Negative for glaucoma/ diabetic retinopathy/ hypertensive retinopathy or
blindness
• Negative for diabetes mellitus/ systemic hypertension

10. Personal History
• Bowel & Bladder habits appears to be normal
• Sleep patterns – normal
• No history suggestive of stress or depression
• 20 pack year smoking history & occasional consumption of alcohol

11. Examination

12. General Physical Examination
• Patient is conscious, co-operative & well oriented to time, place & person.
• He is mesomorphic in built
• Height – 175 cms
• Weight – 76 kgs
• BMI – 24.8
• He is Afebrile to touch
• Pulse – 84 beats/ min
• Respiratory Rate – 16 breaths/ min
• Blood Pressure – 130/90 mmHg
• No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy or pedal edema

13. Systemic Examination
• Cardiovascular system – S1S2 normal, No Murmurs
• Respiratory system – Air entry equal on both sides, no adventitious sound
heard
• Per Abdomen – no guarding, rigidity, distention or tenderness in any
quadrants of abdomen
• Central nervous system – No abnormally detected

14. Ocular Examination
• Patient sat in erect position, looking straight without any turn, tilt,
elevation or depression of chin or abnormal movement of head.
• Face appears to be symmetrical
• Hirshberg test – Orthophoric
• Forehead – Normal
• Eyebrows - Normal

15. Right Eye Left Eye
Visual acuity – unaided 6/24 6/18
Visual acuity – with pinhole 6/9 6/9
Near Vision N12 N12
Best corrected visual acuity +0.00 +1.75 x 170
– 6/9
Near - +3.00
+0.00 +1.25 x 10
– 6/9
Near - +3.00
Color Vision Normal Normal
Contrast Sensitivity Normal Normal

16. Right eye Left eye
Eyelids
• Position Normal Normal
• Lid margin Normal Normal
• Eyelashes Normal Normal
• Skin of eyelids Normal Normal
Conjunctiva
• Bulbar conjunctiva Normal Normal
• Palpebral conjunctiva Normal Normal
• Limbal conjunctiva Normal Normal

17. Right eye Left eye
Cornea
• Size Normal Normal
• Shape Normal Normal
• Surface Regular Regular
• Transparence Clear Clear
• Vascularization Absent Absent
• Pigmentation Absent Absent
• Sensations Present Present
Anterior Chamber
• Depth Normal depth Normal depth
• Contents No abnormal content No abnormal content

18. Right eye Left eye
Iris
• Color Normal Normal
• Pattern Normal Normal
Pupil
• Number Single Single
• Size 2-3 mm 2-3 mm
• Shape Circular Circular
• Position Central Central
• Pupillary margin Normal Normal
• Color Greyish white Greyish white
Pupillary Reaction
• Direct light reflex Present Present
• Consensual light reflex Present Present
• Swinging flashlight test No RAPD No RAPD

19. Right eye Left eye
Lens Immature Senile Cataract Immature Senile Cataract
Intra – Ocular Pressure
(Non-Contact Tonometer)
16 17
Lacrimal apparatus
• Puncta Normal Normal
• Lacrimal sac area Normal Normal
• Regurgitation test Negative Negative
• Lacrimal syringing Patent Patent
• Extraocular Movements
Free & full in all directions
of gaze
Free & full in all directions
of gaze

20. Slit Lamp Biomicroscopy
Right Eye Left Eye
Undilated pupil 2-3 mm pupil
Anterior chamber – normal
Immature senile cataract
2-3 mm pupil
Anterior chamber – normal
Immature senile cataract
Dilated Pupil 8 mm pupil
Nuclear sclerosis grade 1
8 mm pupil
Nuclear sclerosis grade 1

21. Fundus Examination
Right eye Left eye
Media Hazy Hazy
Disc
• Size Normal Normal
• Shape Circular Circular
• Color Pinkish Pinkish
• Margins Well defined Well defined
• Cup : Disc ration 0.3:1 (V & H) 0.3:1 (V & H)
• Peripapillary area Normal Normal
Blood vessels Tortuous blood vessels Tortuous blood vessels
Foveal Reflex Dull Dull

22. Fundus Examination Continued…
Right eye Left eye
Background - Laser scar marks seen beyond
vascular arcade till ora serrata
- Focal laser scar marks present
over macula
- Generalized dot & blot
hemorrhages present in all 4
quadrants
- Laser scar marks seen beyond
vascular arcade till ora serrata
- Focal laser scar marks present at
temporal edge of macula
- Generalized dot & blot
hemorrhages present in all 4
quadrants
- Few hard exudates present over
macula without retinal
thickening

23. Fundus
examination
contd…
• Fundus photograph of
right eye

24. Fundus
examination
contd…
Fundus diagram of right
eye

25. Fundus
examination
contd…
• Fundus photograph of
left eye

26. Fundus
examination
contd…
Fundus diagram of
left eye

28. Blood Sugar Levels
• Fasting – 231 mg/dL
• Pre lunch – 267 mg/dL
• Post lunch – 356 mg/dL
• Pre dinner – 252 mg/dL
• Post dinner – 340 mg/dL

29. Differential diagnosis
• Central retinal vein occlusion
• Retinal vasculitis

30. Provisional
Diagnosis
• Right Eye – Proliferative diabetic retinopathy,
Status post pan retinal photocoagulation with
nuclear sclerosis grade 1cataract
• Left Eye – Proliferative diabetic retinopathy,
status post pan retinal photocoagulation with
nuclear sclerosis grade 1 cataract

31. Thank you