A 28-year-old woman is evaluated during the first trimester of her pregnancy. Medical history is significant for type 1 diabetes mellitus diagnosed at age 14 years. She has no known complications of diabetes. Her last dilated comprehensive eye examination was performed during preconception counseling 7 months ago and was normal. Recent evaluations of kidney function and lipids were normal, as was foot examination. Medications are insulin lispro delivered through continuous subcutaneous insulin infusion and levothyroxine.
The physical examination, including vital signs, is normal.
Laboratory studies show a hemoglobin A1c level of 6.7%, improved from 9% 3 months ago.
When should the next dilated eye examination be performed?
B. Within 6 months postpartum
C. In 1 year and then biannually
D. When symptoms develop
MKSAP Answer and Critique
The correct answer is A. Now. This item is available to MKSAP 18 subscribers as item 9 of extension set 2 in the Endocrinology and Metabolism section. More information about MKSAP 18 is available online.
The next dilated eye examination should be performed now. The 2019 American Diabetes Association Standards of Care recommended that women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk for development and/or progression of diabetic retinopathy. Dilated eye examinations should occur ideally before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum, as indicated by the degree of retinopathy and as recommended by the eye specialist. Additionally, rapid improvement in glycemic control in the setting of retinopathy is associated with temporary worsening of retinopathy. Given tight glycemic targets in pregnancy, this is often a time of intensified glycemic control for women, placing them at greater risk for this complication.
The American Diabetes Association notes that adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. If there is no evidence of retinopathy for one or more annual eye examinations and glycemia is well controlled, then examinations every 1 to 2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually. If retinopathy is progressing or sight-threatening, then examinations will be required more frequently. Waiting for 1 year or until the postpartum period for the next dilated eye examination is inadequate monitoring for diabetic retinopathy during pregnancy when development and progression may be rapid. Waiting for symptoms to develop before performing a dilated examination may result in permanent visual disability.
- In patients with type 1 or type 2 diabetes, dilated eye examinations should occur ideally before pregnancy or in the first trimester, and then every trimester and for 1 year postpartum.