What is the treatment for Diabetic Ketoacidosis (DKA) with symptoms of blurry vision?

Blurry Vision in DKA: Immediate Treatment Protocol

Blurry vision in diabetic ketoacidosis requires immediate emergency treatment of the underlying DKA with intravenous insulin, aggressive fluid resuscitation, and electrolyte monitoring—the visual symptoms will resolve completely once the severe acidosis and metabolic derangements are corrected. 1

Understanding the Visual Manifestation

• Blurry vision or even complete blindness can occur as a presenting symptom of severe DKA, though this is rare, and is directly tied to the severity of acidosis (low serum pH). 1
• The visual disturbance is completely reversible with correction of the metabolic acidosis—dramatic improvement occurs as pH normalizes with insulin and bicarbonate treatment. 1
• This visual complication is intimately linked to the patient's serum pH level, making timely correction of severe acidosis critical to preventing permanent vision loss. 1

Immediate DKA Management Protocol

Initial Assessment and Stabilization

• Check blood or urine ketones immediately when a patient presents with hyperglycemia and visual symptoms, as this combination may indicate life-threatening DKA requiring urgent intervention. 2
• Admit the patient to an intensive care unit or medical unit for close monitoring, as DKA is a life-threatening emergency requiring continuous observation. 2, 3
• Monitor vital signs hourly along with neurologic status and capillary glucose. 2
• Obtain laboratory studies every 2-4 hours including electrolytes, blood glucose, and blood gases to guide ongoing management. 2, 3

Fluid Resuscitation

• Initiate intravenous fluid resuscitation immediately to restore circulatory volume and tissue perfusion—this is a cornerstone of DKA management. 4, 5
• Administer fluids cautiously with gradual correction of osmolality to prevent cerebral edema, particularly in younger patients. 3

Insulin Therapy

• Start continuous intravenous insulin infusion at 0.1 units/kg/hour—this is the standard of care for critically ill patients with DKA. 4, 2, 3
• Continue insulin therapy until the anion gap normalizes and bicarbonate levels correct, not just until glucose normalizes. 6
• Administer basal subcutaneous insulin 2-4 hours prior to stopping the intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia. 4

Electrolyte Management

• Monitor potassium levels closely and replace as soon as urine output is established, as hypokalemia is a life-threatening complication. 2, 3
• Assess renal function with blood urea nitrogen and creatinine to guide fluid and electrolyte management. 2

Glucose Administration for Severe Acidosis

• Once blood glucose begins to decline, add dextrose (10% or 20% solutions) to intravenous fluids to facilitate continued high-dose insulin administration needed to correct severe acidosis. 6
• The large amounts of insulin required to normalize pH and anion gap necessitate concomitant glucose administration to prevent hypoglycemia. 6

Critical Monitoring for Visual Recovery

• The visual symptoms will reverse as the metabolic acidosis corrects—monitor both pH normalization and visual improvement as markers of treatment success. 1
• Timely correction of severe acidosis is instrumental in preventing permanent vision loss, making aggressive DKA treatment the definitive therapy for the visual manifestation. 1

Special Considerations

• Be aware that approximately 10% of DKA cases present with euglycemic DKA (glucose <200 mg/dL), particularly in patients taking SGLT2 inhibitors, pregnant patients, or those with reduced food intake. 7, 6
• If the patient is on SGLT2 inhibitors, stop these medications immediately as they significantly increase the risk of euglycemic DKA. 2
• Pregnant individuals may present with euglycemic DKA and mixed acid-base disturbances, complicating diagnosis. 4, 7

Common Pitfalls to Avoid

• Do not delay treatment waiting for extremely high glucose levels—severe acidosis with visual symptoms demands immediate intervention regardless of glucose level. 1
• Do not stop insulin infusion once glucose normalizes—continue until acidosis fully resolves (normal pH, bicarbonate, and anion gap). 6
• Do not overlook the need for dextrose once glucose drops below 250 mg/dL—this allows continued insulin therapy to clear ketones and correct acidosis. 6
• Do not assume visual symptoms indicate a primary ophthalmologic emergency—in the context of DKA, these are metabolic manifestations requiring DKA treatment, not ophthalmologic intervention. 1