(Kiosk 4) Critical Illness Polyneuromyopathy and Retinal Detachment: A Case Report

Case Diagnosis: Traction retinal detachment secondary to proliferative diabetic retinopathy

Case Description or Program Description: A 43-year-old patient with history of uncontrolled diabetes mellitus type 2 was admitted to acute inpatient rehabilitation (IPR) two months after hospital admission for septic shock and pyelonephritis requiring ICU-level care and leading to critical illness polyneuromyopathy. Initial HbA1c during admission was 13.2%. Patient reported subjective worsening of her vision during hospitalization. Initial rehabilitation exam was notable for anisocoria, limited vision, proximal muscle weakness, atrophy, sensation loss, and loss of deep tendon reflexes. Medical Research Council sum score was 42.

Setting: Inpatient Rehabilitation Hospital

Assessment/Results: Bedside ophthalmologic investigation noted visual acuity as limited to only counting fingers at 1 inch OD and OS, tonopen pressure at 20 OD and 50 OS, and ocular motility was full. These findings were concerning for retinal detachment, open versus closed angle glaucoma, and cataracts.

Discussion (relevance): Critical illness in the setting of diabetes mellitus and infection increases production of endogenous glucose production. It is unknown when the patient developed vision loss. Due to the limitations of inpatient visual evaluation, her ophthalmologic evaluation performed at outpatient visit which revealed bilateral retinal detachment. Diabetic retinopathy worsened during acute illness increases the likelihood that such an event may occur. Low vision complicates a patient’s rehabilitation course and overall level of function. Occupational and physical therapists employ a variety of strategies to help patients with low vision attain independence. Strategies such as lighting and contrast help patients visualize corners and other potential obstacles. Therapists teach patients to scan for hazards before ambulating and identify changes in floor surface texture and height with other senses. Visual rehabilitation is more prevalent in outpatient settings. Treatments used to spare further eyesight loss include anti-vascular endothelial growth factor therapy, cyclophotocoagulation, and intraocular pressure reducing ophthalmic drops. These treatments are also primarily done as outpatient.

Conclusions: The patient was discharged from IPR and achieved a functional level of supervision with ADLs and mobility with assistance of roller walker. She returned home with assistance of home health therapies. This case highlights IPR shortcomings for visually impaired patients, and is reason to consider increasing visual rehabilitation services for IPR facilities.