I am 28 and have been diabetic for 24 years. Over the last 18 months, I have reduced my A1cs from 8 to 9% to now 6.8%. My blood pressure has never gone above 120/80 and is often quite a bit lower (lately 95/65). I am not overweight and my lipid levels are not high. I have no renal problems.

In June, my ophthalmologist told me I had pre-proliferative retinopathy, I presume speeded up by the drop in A1c, but there were no changes in my vision. In July, I became pregnant. Now, I am at 17 weeks. My vision has deteriorated and this week I had the four month check up with the ophthalmologist who says that I have macular edema and that it is swollen. They did a fluorescin angiogram and I’m not sure what that showed, but apparently there are no new vessels. The reading that I have done suggests to me that the drop in A1c and the pregnancy would both have compounded this and that the advised treatment is to continue to lower A1c and blood pressure and begin laser treatment immediately.

The articles on Pregnancy and Retinopathy give me hope that the laser treatment would slow this down and, though I may lose some sight, I will still at least be able to see. However, my ophthalmologist said that the swelling may reduce by itself and that I am not to have treatment, but to return in a month to see what happens. She said that lasering wouldn’t be a good option anyway and that she did not recommend it. I was quite upset and could not get her to give me a formal diagnosis or any idea on outcome if it doesn’t improve by itself, but simply a wait and see.

Given that I can’t reduce my blood pressure and A1c a lot more, what can I do? Should I be getting a second opinion? Is a month too late if lasering might help now? The ophthalmologist didn’t seem to think it is connected to the pregnancy, but is that just because I might think of termination? Would that make a difference anyway? What is the likely outcome if I have no laser treatment?

It is quite possible that your dramatic improvement in your A1c caused the acceleration of your diabetic retinopathy. This is often termed the “diabetic re-entry phenomenon” because when mean blood glucose re-enters a more normal range, diabetic small blood vessel complications, particularly retinopathy, often develop or get worse. It is also very probable that your pregnancy worsened your pre-existing retinopathy, as pregnancy is a well established risk factor for worsening retinopathy. As for laser treatment, the current standard of care is to defer such treatment in type 1 diabetic patients until the development of either (1) proliferative retinopathy or (2) “clinically significant” macular edema (aka CSME). This begs the question “is your macular edema ‘clinically significant’?” Laser treatment of CSME has been shown to reduce the risk of substantial worsening of vision by 50%. The diagnosis of CSME hinges on very specific criteria, including the exact location and size of your macular edema. I would recommend that you ask your ophthalmologist this question directly (presumably and hopefully, she is a retinal specialist). Explain to her your concerns and, hopefully, she will communicate more effectively.

Undoubtedly, you psyche and body are under considerable stress and it is in your best interest to have the situation better clarified. I suspect waiting a month will not physically harm you or your eyes, but I would suggest that you contact your doctor for further explanation ASAP; trust your gut instinct and if you are not comfortable with her answers, seek a second opinion. In the meantime, keep your blood glucose and blood pressure as well controlled as possible.

PC
Additional comments from Dr. Bill Jones:

Pregnancy can be associated with progression of retinopathy. It usually occurs in women who have had long standing diabetes and already have some degree of retinopathy. Thus, your condition could worsen. Close surveillance is imperative. I have never read that termination is recommended in severe cases and am not aware of any data suggest that this would improve the condition of the retina. A second opinion is always worthwhile. Since I am not an ophthalmologist, I cannot give you a recommendation on laser therapy. You should rely on your ophthalmologist’s expertise for this therapy.

OWJ