Article

MEMORABLE PATIENT ENCOUNTER

Complications of the heart

I thought I knew what to expect when a 77-year-old woman came into my practice in Huebner, Texas, with a fairly standard case of diabetic macular edema (DME). Her care proceeded normally — about 18 anti-VEGF injections over 3 years — however, an unexpected heart attack and full cardiac arrest led me not just to change her treatment but my whole perspective on patient health.

INITIAL SYMPTOMS

She first presented with complaints of blurry vision (20/80 OD and 20/100 OS), and she was unable to see small print or drive at night. Also, she said that she was having problems controlling her blood sugar.

I decided to treat her with bilateral anti-VEGF injections. One injection would last around a month or two, and her vision would improve (20/80 to 20/50 OD and 20/100 to 20/60 OS); however this was short lived, lasting a little more than a month (Figures 1 and 2).

Figure 1: OCT results from the patient, following initial round of anti-VEGF injections.

Figure 2: OCT readings from patient using Ozurdex, following cataract surgery and heart attack.

We began to discuss other options and the possibility of giving Ozurdex (Allergan) to the patient. She initially declined and agreed to strict monthly anti-VEGF injections. She improved under this for a year, but the development of cataracts decreased her OU vision to 20/100.

We discussed the importance of controlling her DME prior to cataract surgery, but given her needs and my schedule I decided against relying on anti-VEGF injections to accomplish this. Instead, I injected Ozurdex OU to help prevent postoperative swelling as well as provide a long enough duration to accommodate the logistics of her medical care.

After cataract surgery, her swelling was controlled for 3 months but then reoccurred. At that time, I considered an anti-VEGF injection followed by a dexamethasone implant (Ozurdex) for a more sustained result. I gave an injection of anti-VEGF and administered the implant 2 weeks later. Two months after the bilateral injections, she was 20/20 OU with an IOP of 16 to 17 mm Hg.

MANAGING DME AROUND OTHER HEALTH CONDITIONS

Three months later, when she had not kept her 4-month appointment, I inquired about her status. I learned she had suffered a heart attack and went into full cardiac arrest. I was unsure if I would ever see her again. Miraculously, she made a full recovery. However, since she missed her strict monthly therapy, her macula edema reoccurred bilaterally and her vision was now 20/60 OU.

I faced a new challenge: bilateral anti-VEGF injections carry significant potential risk due to possible arterial thrombotic event related to her compromised cardiovascular health. I wanted to control her macular edema and improve her vision, though, so we decided to try dexamethasone implant alone in each eye, unsure how long the effect would last. At her most recent appointment 6 months after bilateral injections, her OCT was completely dry and was 20/20 OU with no evidence of increased IOP.

BEYOND CLINICAL BENEFIT

The dexamethasone significantly improved the patient’s quality of life. It decreased her number of doctor visits and let her keep her independence and ability to drive, which she was not certain she would still have. I now see this patient around every 4 to 5 months, and she always leaves in great spirits.

My approach to patients after this experience is to always assess the full picture of their medical background and identify a treatment regime that has the best clinical benefit and takes into account potential effects on other organ systems. In this way, therapy can improve their vision and quality of life while maintaining their systemic health. OM