Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of known Type 2 Diabetes Mellitus. Reports [stable/worsening] vision, [presence/absence] of floaters, and [presence/absence] of sudden vision loss. History of [duration] years of DM with [poor/fair/good] glycemic control. Current HbA1c: [value]%.
Clinical Examination Findings
Dilated fundus exam reveals: Optic disc: [neovascularization present/absent]. Retina: [presence of neovascularization elsewhere (NVE) or at the disc (NVD)]. Vitreous: [presence of vitreous hemorrhage/fibrous proliferation]. Macula: [presence of clinically significant macular edema]. Intraocular pressure: [value] mmHg.
Treatment Protocol
Plan: 1. Pan-retinal photocoagulation (PRP) laser therapy initiated/continued. 2. Intravitreal anti-VEGF injection [agent name] administered. 3. Consider pars plana vitrectomy if non-clearing vitreous hemorrhage or tractional retinal detachment occurs. 4. Strict glycemic and blood pressure control.