MKSAP quiz: Timing of diabetic eye exams
This month's quiz asks readers to determine when a 56-year-old man with recently diagnosed type 2 diabetes should undergo a dilated and comprehensive eye examination.
A 56-year-old man is evaluated for recently diagnosed type 2 diabetes mellitus. He does not have neuropathy, and kidney function evaluation is normal. Medical history is significant for hyperlipidemia and hypertension. Medications are dulaglutide, rosuvastatin, and lisinopril.
Physical examination findings, including vital signs and results of a handheld ophthalmoscopic examination, are normal.
A hemoglobin A1c level is 7.3%.
When should this patient undergo a dilated and comprehensive eye examination?
A. In 1 year
B. In 5 years
C. Now
D. When symptoms or signs develop
MKSAP Answer and Critique
The correct answer is C. Now. This item is available to MKSAP subscribers as item 4 in Extension Set 4 of the Endocrinology and Metabolism section. More information about MKSAP is online.
This patient should be referred for a dilated and comprehensive eye examination now (Option C). Type 2 diabetes mellitus usually presents slowly, with gradual symptom onset. Because of the gradual onset, approximately 25% to 30% of patients have evidence of diabetes complications at the time of diagnosis. Additionally, for some patients, microvascular complications can be found in prediabetes. Diabetes is associated with multiple eye pathologies. Retinopathy, due to microvascular damage to the retina, is one of the most common findings and is the leading cause of preventable blindness in adults who reside in developed countries. A small number of patients have proliferative retinopathy at the time of diagnosis, but the majority of those with retinopathy have the less sight-threatening nonproliferative retinopathy. Additionally, diabetes is associated with premature cataracts and with several forms of glaucoma. For these reasons, the American Diabetes Association advises that all patients with type 2 diabetes have a dilated and comprehensive eye examination when diagnosed.
Although an office-based handheld ophthalmoscope examination was negative, this type of examination is often inadequate to diagnose early retinopathy. Therefore, waiting 1 year to perform a dilated and comprehensive eye examination is inappropriate (Option A).
In contrast to that of type 2 diabetes, the diagnosis of type 1 diabetes in adolescence and young adulthood is often acute and dramatic. These patients do not typically have a long period of undiagnosed disease; therefore, young patients with type 1 diabetes may wait for 5 years after diagnosis before having a comprehensive eye examination (Option B). This patient has type 2 diabetes, and current guidelines recommend that a dilated and comprehensive eye examination occur as soon as the diagnosis is made.
The absence of symptoms, signs, or other complications of diabetes does not eliminate the possibility of retinopathy. Waiting for symptoms or signs to develop before performing a dilated and comprehensive eye examination may result in permanent visual impairment (Option D).
Key Point
- Patients with type 2 diabetes mellitus should have a dilated and comprehensive eye examination at the time of diagnosis.