EyeSpyOphthalmic Education

Case 01 - Retina and vascular pathology

The Asymptomatic Fundus Finding

60-year-old obese woman - General malaise - No ocular complaints - Bilateral fundus changes

Illustrated eye for pathology case review
Case 01Non-Proliferative Diabetic Retinopathy

Clinical Presentation

A 60-year-old obese woman complains of general malaise and has no ocular complaints. The fundus photograph illustrates the ophthalmoscopic findings in both eyes.

Learner Questions

  1. Describe the ophthalmoscopic findings.
  2. What are the histopathologic correlates of these findings?
  3. What pertinent questions would you ask while taking the medical history?
  4. What is your diagnosis?

Answer Framework

Findings

Dot-and-blot hemorrhages, hard exudates (yellow-white lipid deposits, sharp borders), and microaneurysms bilaterally. No neovascularization - consistent with NPDR.

Key history

Duration & type of DM, HbA1c, BP, renal function (nephropathy correlates with severity), lipid levels, prior laser, medications, family history of DM complications.

Histopathology

Microaneurysms = pericyte loss -> capillary outpouching (earliest change). Hard exudates = inner BRB breakdown -> lipoproteins in outer plexiform/Henle's layer. Blot hemorrhages = deeper retinal layer capillary rupture.

Diagnosis

Non-Proliferative Diabetic Retinopathy (NPDR). DDx: Hypertensive retinopathy, HIV retinopathy, CRVO. Severity by ETDRS '4-2-1 rule': hemorrhages in 4 quadrants, venous beading >=2 quadrants, or IRMA >=1 quadrant = severe NPDR.

Teaching Pearl

DR is the leading cause of new blindness in working-age adults in the developed world. Tight glycemic control (DCCT/UKPDS) and annual dilated exams are the cornerstones of prevention. Refer to retina when CSME is present - edema within 500 um of the foveal center.

Original answer transcript 
Findings Key history
Dot-and-blot hemorrhages, hard exudates (yellow-white lipid deposits, sharp borders), and Duration & type of DM, HbA1c, BP, renal function (nephropathy correlates with severity),
microaneurysms bilaterally. No neovascularization - consistent with NPDR. lipid levels, prior laser, medications, family history of DM complications.
Histopathology Diagnosis
Microaneurysms = pericyte loss -> capillary outpouching (earliest change). Hard exudates = Non-Proliferative Diabetic Retinopathy (NPDR). DDx: Hypertensive retinopathy, HIV
inner BRB breakdown -> lipoproteins in outer plexiform/Henle's layer. Blot hemorrhages = retinopathy, CRVO. Severity by ETDRS '4-2-1 rule': hemorrhages in 4 quadrants, venous
deeper retinal layer capillary rupture. beading >=2 quadrants, or IRMA >=1 quadrant = severe NPDR.
TEACHING PEARL
DR is the leading cause of new blindness in working-age adults in the developed world. Tight glycemic control (DCCT/UKPDS) and annual dilated exams are the
cornerstones of prevention. Refer to retina when CSME is present - edema within 500 um of the foveal center.