Diabetic retinopathy (DR), a microvascular complication of diabetes, is the most common cause of vision loss in adults ages 20 to 74 years in many countries. Initial screening for DR should occur within 5 years of a type 1 diabetes diagnosis and at the time of a type 2 diabetes diagnosis. Slowing of DR progression involves optimization of glycemic control, blood pressure management, control of diet and lipid levels, and lifestyle modification. Panretinal photocoagulation (PRP) can prevent progression of proliferative DR with minimal risk of damaging the macula. Ranibizumab, an anti-vascular endothelial growth factor (VEGF) drug, can be an effective alternative to PRP. Age-related macular degeneration (AMD) is a leading cause of visual impairment and vision loss in developed countries. AMD leads to progressive loss of central vision and distortion of images. Smoking is the strongest modifiable risk factor. Hypertension and hyperlipidemia also have been associated with AMD. The initial patient evaluation should include a comprehensive eye examination, visual acuity measurement, assessment with the Amsler grid, and fundus photography. Smoking cessation should be recommended for patients with AMD who smoke. For patients with wet, or neovascular, AMD, first-line therapy is an intravitreal anti-VEGF drug (ie, ranibizumab, bevacizumab, aflibercept [Eylea]).

Case 3. MB is a 72-year-old woman with osteoarthritis of the lumbar spine, hypertension, type 2 diabetes, and hyperlipidemia. She comes to your office requesting referral to an ophthalmologist. She says that over the past year she has noticed increased blurriness throughout her visual field. She says it has become challenging for her to read books and recognize faces. She also says that she requires additional light to adequately see her surroundings.