Station - Instructions for candidate
You are a junior doctor working in the diabetes outpatient clinic of a metropolitan hospital.
Despina/Yiannis Georgiou, a 61-year-old musician with type 2 diabetes for 14 years, has been sent to the clinic by the GP for review of poor glycaemic control and six months of gradually blurred vision, worse in the right eye. Fundus photographs were taken by the clinic's retinal camera today and are described for you below, together with the visual acuities and recent results. The patient is sitting with you and would like to know what the pictures show.
| Observations | BP 152/90 mmHg, HR 82 /min, BMI 33 kg/m2, fingerprick glucose 13.4 mmol/L |
|---|---|
| Current medicines | Metformin 1 g twice daily, gliclazide MR 60 mg daily, amlodipine 5 mg daily. Smokes 10 cigarettes a day. No allergies. |
Results provided:
Fundus photographs (non-mydriatic retinal camera) and visual acuity
| Item | Value | Reference range |
|---|---|---|
| Visual acuity, right eye | 6/12, no improvement with pinhole | 6/6 |
| Visual acuity, left eye | 6/9, improving to 6/6 with pinhole | 6/6 |
| Right eye: red reflex | Clear | Clear |
| Right eye: disc | Normal colour and margins; a lacy tuft of fine, irregular vessels lies on the surface of the disc and extends over its inferior edge | Vessels do not cross the disc surface |
| Right eye: vessels | Venules show segments of irregular calibre like a string of sausages along the superotemporal arcade | Smooth calibre |
| Right eye: macula | A ring of waxy yellow deposits temporal to the fovea, its inner edge within one disc diameter of the fovea; the foveal reflex is dull | No deposits; bright foveal reflex |
| Right eye: periphery | Scattered blot-shaped dark red haemorrhages in all four quadrants; four fluffy white patches with feathery edges along the superior arcade | None |
| Left eye: red reflex | Clear | Clear |
| Left eye: disc | Normal colour, margins and cup; no abnormal vessels | Normal |
| Left eye: vessels | Normal calibre; no beading | Normal |
| Left eye: macula | Normal foveal reflex; no deposits within two disc diameters of the fovea | Normal |
| Left eye: periphery | About a dozen tiny red dots and small dot haemorrhages, mostly nasal to the disc; two small clusters of waxy yellow deposits in the far periphery; no fluffy white patches | None |
Recent bloods (GP, 2 weeks ago): HbA1c 9.5% (80 mmol/mol); eGFR 62 mL/min/1.73m2; urine albumin-creatinine ratio 8 mg/mmol; total cholesterol 5.6, LDL 3.4, HDL 1.0, triglycerides 2.8 mmol/L.
fundoscopy - read aloud by the examiner
Two colour fundus photographs. Right eye: a normal-looking disc carries a fine lacy network of thin irregular vessels on its surface spilling over its lower edge; the veins along the upper temporal arcade vary in width like beads; dark red blot-shaped haemorrhages are scattered across all four quadrants; four soft white fluffy patches sit along the superior arcade; and to the temporal side of the fovea a ring of hard waxy yellow spots encircles a slightly dull central area. Left eye: a normal disc and normal vessels; a dozen or so pinpoint red dots and small round haemorrhages mostly to the nasal side; two small clusters of waxy yellow spots far out in the periphery; the macula looks normal with a bright central reflex.
Look up an example image: Radiopaedia proliferative diabetic retinopathy fundus photograph neovascularisation of the disc
Your tasks are to:
- Interpret the fundus photographs and visual acuities, describing the findings in each eye systematically to the examiner.
- State your diagnosis for each eye, with a grade of severity, and your differential diagnoses.
- Outline your management plan to the examiner, including referral, systemic treatment and follow-up.
- The examiner will ask you two questions at the end of the station.
- You do NOT need to take a history or examine the patient; the relevant information is provided.
- You are not required to explain the findings to the patient in this station, but you may speak to them if you wish.
- State drug names and doses where you propose systemic treatment.
This is a 10-minute station, with 2 minutes of reading time.