A 35-year-old convenience store manager with a history of non- insulin-dependent DM for 5 years presents to the Eye Clinic for his annual visit. He admits to a progressive blurring of vision since his last visit a 1 year ago. Reading street signs while driving seems more difficult. He is unsure of which eye seems worse. He does not wear contacts and uses over-the-counter reading glasses. He denies any flashes or floaters, diplopia, eye discomfort, or pain. The patient reports that he has been going through some tough times recently, with a difficult divorce approximately 6 months earlier. As a result of all the stress, his blood sugars have not been under good control and he feels he has been making this worse by eating a lot of junk food and not always taking his diabetic medications. His blood sugar has been as high as 400 and he was admitted to the hospital 3 months back for diabetic ketoacidosis. Past ocular history: No prior eye surgeries, no history of eye trauma, amblyopia, or strabismus. No prior diabetes findings in the eye. Ocular medications: None. Medical history: Hypercholesterolemia, obesity, DM Type 2, and hypertension. Surgical history: None. Family ocular history: Negative for macular degeneration, glaucoma, diabetic retinopathy, or blindness. Social history: 30 pack-year smoking history and drinks alcohol socially. Medications: Lisinopril, hydrochlorothiazide, metformin, and simvastatin. Allergies: None. Other systems: Normal. Ocular examination: Visual acuity: OD: 20/40, OS: 20/40. Intraocular pressure: OD: 16 mmHg; OS: 15 mmHg. Pupils: Equal, round, and reactive to light. No APD. Extraocular movements: Full OU. No nystagmus. Confrontational visual fields: Full to finger counting OU. External: Normal, both sides. Slit lamp examination: Normal. Dilated fundus examination: OD: Clear view, CDR 0.35; neovascularization of the disc involving ~50% of the disc; flat macula with multiple microaneurysms and hard exudates >500 microns away from the fovea, no clinically significant macular edema; multiple dot-blot hemorrhages in the retinal periphery in all four quadrants without retinal detachment. OS: Clear view, CDR 0.40 with sharp optic disc margins; flat macula with multiple microaneurysms and hard exudates >500 microns away from the fovea; no clinically significant macular edema; peripheral retina with multiple dot-blot hemorrhages in the periphery in all four quadrants.

Objectives: at the end of PBL sessions, all students will be able to:

1. Define diabetic retinopathy (DR)

2. Identify the pathogenesis, CP, classification, risk factors, and management of DR

3. Perform visual rehabilitation of patients with advanced DR.

Abbreviations: APD, afferent pupillary defect; CDR, cup disc ratio; CP, clinical picture; DM, diabetes mellitus; OD, right eye; OS, left eye; OU, both eyes; PBL, problem-based learning; Premed, premedical.