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In Chapter 1, it was pointed out that we all went into ophthalmology because taking care of an entire patient is not our bag, man. If we could get the eye mailed to us—without the attached patient—that would be fine. However, if you see worrisome hemorrhages, it is definitely time to dust off those atrophied clinical skills and check a blood pressure. Right there in the lane. While you are at it, you should also order a CBC, hemoglobin A1c and renal studies if no one has done them lately. These tests will identify significant problems much faster than a referral letter will, and the results will jumpstart the patient's care. Oh yeah, you might also help save their life (which is a nice break from a day full of "better one, better two"). The point is to try to take advantage of all the information the fundus is willing to give you. If you look, but do not see, you will be failing to treat the patient's eye properly (and also be very un-Zen).

Another hemorrhagic nuance occurs in patients who are taking Coumadin. These patients will often have many more hemorrhages in the retina relative to their overall degree of retinopathy (in other words, they have more hemorrhages than you would expect, given the number of microaneurysms and non-hemor-rhagic vascular changes that you see). All these hemorrhages may have varying sizes and unusual shapes. Make sure that your patients that are on this rat poison are really getting their levels checked; you will find occasional patients that are not being monitored properly. A more complete discussion of this drug in terms of diabetic retinopathy is found in Chapter 25.

Cotton wool spots are another fundus finding that can tell you a lot about the patient. These used to be considered very important in terms of predicting future proliferative disease, but this has been disproven (which makes one wonder what other "facts" will be disproved in the future, which, in turn, makes one glad this book is produced with software and not woodcuts). A few scattered cotton wool spots are to be expected, and individual spots may last for several months. However, if there are a lot of cotton wool spots or if crops of new lesions appear rather quickly, it may signal problems with hypertension, renal failure, or hematologic abnormalities. Never forget that patients are also allowed to get completely unrelated problems, and it is always possible that a patient with lots of cotton wool spots may have an additional disease such as AIDS, retinal vasculitis or radiation retinopathy. Given the overall sturm and drang of diabetic retinopathy, it may be difficult to dissect out the presence of these other diseases unless you remember to think of them in the first place. (Check Chapter 26 for the full scoop on this.)

When actively studying hemorrhages and cotton wool spots, the Renaissance Retina Observer also inspects the hard exudate situation. Hard exudates begin to appear as more and more leakage occurs. You can think of them as high-water marks—the serum bathtub rings that outline where the retina is desperately trying to suck the abnormal fluid back into the capillaries and the leftover protein and lipid congeal into little yellow lumps. These lumps may be all over, but often they show up on the border between the healthy and damaged retina. Large amounts of hard exudates should always suggest the possibility of hyperlipi-demia, so be sure to inform their medical doctor. Patients should be trained to consider their lipid profile to be as important as their blood pressure and hemoglobin A1c. Tight lipid control is a little-recognized aspect of total diabetic care, at least in the ophthalmic community, and pointing out to the patient that you can see "all those little fatty deposits" in their retina may be more of a motivator for healthy living than weeks of diabetic education classes.

There is always something a bit mysterious, even to sophisticated patients, about having someone look into one's eye and being told that damage is visible. Sometimes, this can be a very effective tool for encouraging patients to take better care of themselves. Sometimes, however, it can be very depressing for patients to hear this—and you need to be sensitive to this as well. This is a good reason why it really is better that we don't get the eyes mailed to us. Chapter 20 will elaborate on issues like this a bit more.

Figure 2. This kind of extensive hard exudate formation, especially along peripheral vessels, is very suggestive of hyperlipidemia.

Figure 2. This kind of extensive hard exudate formation, especially along peripheral vessels, is very suggestive of hyperlipidemia.

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Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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