A 45-year-old woman with type 2 diabetes mellitus presents for her routine eye screening appointment. She is on metformin monotherapy and her last HbA1c was 44. She is a current smoker. On examination, she has a body mass index (BMI) of 30. Retinal photography reveals dot and blot haemorrhages and hard exudates. There is no evidence of microvascular growth. The optic discs are vertically oval in shape with a central depression, which has a ratio compared with the disc of 0.3.

What is the most appropriate management for this patient?

Options:
explanation: This is the treatment for preproliferative/proliferative diabetic retinopathy. Photocoagulation is also done for maculopathy but more locally. Alternatives include intravitreal antivascular endothelial growth factor treatment. This patient has only got background changes on her retinal imaging. The treatment for this is good glycaemic control and maintaining a healthy and active lifestyle. This patient should be advised to stop smoking.
name: Panretinal photocoagulation
label: b
answer: no
explanation: This is a patient with type 2 diabetes with background changes (also known as mild preproliferative retinopathy) on her retinal photography (dot/blot/flame haemorrhages, microaneurysms, hard exudates.) There is no evidence of preproliferative change (soft exudates, also known as cotton wool spots, or venous changes) or proliferative changes (new vessels and frank haemorrhage). There are no changes at the macula or within one optic disc space of the macula, which would indicate a diagnosis of maculopathy. The optic disc is normally vertically oval in shape and the central depression is otherwise known as the optic cup. The normal cup:disc ratio is 0.3. For background changes, the mainstay of treatment is lifestyle modifications, such as weight loss, smoking cessation and healthy diet. Glycaemic control is good in this case and it is important to note that rapid tightening of glycaemic control can make retinopathy acutely worse; long-term, gradual control is important for improving long-term outcomes.
name: Lifestyle modifications
label: a
answer: yes
explanation: This is one of the first-line pharmacological treatments for acute angle closure glaucoma (AACG). Diabetic patients have a higher risk of AACG; however, this patient has no symptoms consistent with this, such as pain, loss of vision or vomiting. The patient also has normal optic discs; in glaucoma there is a raised cup:disc ratio. The retinal findings are consistent with background diabetic retinopathy; therefore, first-line treatment is lifestyle advice and good glycaemic control.
name: Acetazolamide
label: c
answer: no
explanation: This is the definitive management for AACG. This patient has no features of glaucoma on clinical presentation or on her retinal photographs. The retinal photography findings describe the normal appearance of the optic discs and of background diabetic retinopathy, the first-line treatment for which is lifestyle advice.
name: Peripheral iridotomy
label: d
answer: no
explanation: The retinal image findings are consistent with background diabetic retinopathy; therefore, the first-line treatment is lifestyle advice and good glycaemic control. This patient continues to smoke and has a high BMI. Advice to lose weight and quit smoking can improve her long-term outcomes, both in terms of microvascular disease but also macrovascular disease.
name: No treatment required
label: e
answer: no

Correct answer: a


Learning point: Lifestyle modifications, including weight loss and smoking cessation, are crucial for managing background diabetic retinopathy in type 2 diabetes patients.