When can DM cause reversible haziness of the lens

Multiple reversible haziness of the lens can occur rarely in patients with Type 1 DM (children or young adults) after severe hyperglycaemia and evolve over days or weeks ('snowflake cataracts'). This condition is gradually reversed with control of diabetes. Similar but less intense episodes can be seen in diabetic patients during periods of poor control of their diabetes. This happens more frequently, is manifested with transient refractive visual abnormalities - mostly myopia - which are primarily associated with electrolyte disturbances through the lens, and is reversible.


A 68 year old woman, with poorly controlled DM of 25 years duration, comes to the diabetes clinic for follow-up. Her fasting blood glucose is around 256 mg/dl (14.2 mmol/L) and her HbA1c is 11.2 percent. The patient complains of pricking pains, burning sensation and numbness in her lower extremities, as well as frequent cramps. Furthermore, she reports deterioration of her vision lately with decrease in her visual acuity and blurred vision. She has a history of operated cataract in the left eye. Physical examination is remarkable only for: BP 170/90 mmHg, a systolic murmur in the apex and abolition of Achilles tendon reflexes bilaterally. Her antidiabetic regimen includes: glibenclamide tablets 5 mg, 1 x 3, and metformin tablets 850 mg, 1 x 3 daily. Fundoscopy reveals diabetic maculopathy bilaterally, without obvious lesions in the rest of the retina. What would you recommend for this patient?

A complete blood count (CBC), urinalysis, biochemistry tests and a lipid profile were done. The patient was asked to monitor her blood glucose levels at home, both fasting as well as two hours postpran-dially. Furthermore, since most likely she has developed secondary failure to the oral antidiabetic medicines due to her long-lasting diabetes, it would be useful to confirm this by measuring fasting C-peptide and insulin levels, as well as six minutes after the intravenous administration of glucagon, which evaluates the maximal secretory capacity of the pancreas. Also, a complete ophthalmologic examination would be necessary for a more precise characterization of the ophthalmic disease and planning of the appropriate therapy by the specialist ophthalmologist.

A week later the patient returned to the clinic with the following diagnosis from the ophthalmologist: Oedematous diabetic maculopathy. Fundoscopy and fundus photography revealed multiple hard exudates, microhaemorrhages, and microaneurysms in the whole area of the macula, with diffuse oedema of the macula, in contrast to the rest of the retina which was unremarkable. Also, there was decolorization from optic disk atrophy (Figure 13.1). Findings were in both eyes, most prominent in the left eye fundus. Fluorescein angiography revealed masking of the normal macular appearance, due to multiple leakages from the capillaries and the microaneurysms of the perimacular vascular net. There was also masking of the optic disk due to atrophy(Figure 13.2). Laser treatments were recommended.

Laboratory evaluation showed the following: Ht = 36.1 percent, Hb = 12.2 g/dl, WBC = 7000/ml, (polymorphonuclears = 55 percent, lymphocytes = 37 percent, monocytes = 6 percent), Platelets = 164,000/ml, ESR = 23 mm/hr, glucose = 285 mg/dl (15.8 mmol/L), creatinine = 0.76mg/dl (67.2 mmol/L), cholesterol = 161 mg/dl (4.16 mmol/L), HDL-cholesterol = 57 mg/dl (1.47 mmol/L), LDL-cholesterol = 87 mg/dl (2.17 mmol/L),

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