Is a patient with type 2 diabetes mellitus, diabetic retinopathy, hyperglycemia (A1C 7 %), uncontrolled hypertension (home readings ≈152 mm Hg with left‑arm > right‑arm), stage II chronic kidney disease (estimated glomerular filtration rate 73 mL/min/1.73 m², microalbuminuria), recent fall with chest discomfort, and normal sinus rhythm cleared for left‑eye retinal surgery?

Preoperative Clearance for Retinal Surgery

This patient should NOT be cleared for elective retinal surgery until the recent chest pain is fully evaluated and uncontrolled hypertension is addressed. The combination of recent chest pain (even if attributed to muscle strain), uncontrolled hypertension with asymmetric arm readings, diabetic nephropathy with proteinuria, and multiple cardiovascular risk factors creates an unacceptable perioperative cardiac risk that must be resolved before proceeding with surgery 1, 2.

Critical Red Flags Requiring Immediate Attention

Chest Pain Evaluation is Mandatory

• The recent chest pain occurring 2 days ago with a fall requires cardiac evaluation regardless of the patient's attribution to "muscle strain" 1.
• Diabetic patients frequently experience silent myocardial ischemia (SMI), with 30-50% of asymptomatic type 2 diabetics with cardiovascular risk factors having undetected SMI 1.
• The presence of proteinuria (microalbumin 35) significantly increases cardiovascular risk in both type 1 and type 2 diabetes and is associated with higher rates of coronary disease 1, 3.
• While the ECG shows normal sinus rhythm, this does NOT exclude acute coronary syndrome or myocardial injury 1.
• Obtain serial troponin measurements immediately to detect perioperative myocardial damage, as this allows initiation of appropriate cardiovascular treatment 1.

Uncontrolled Hypertension Must Be Addressed

• Blood pressure readings of 152 mmHg with asymmetric readings (left arm consistently higher than right) is a concerning finding that may indicate subclavian stenosis or other vascular pathology 1.
• Target blood pressure should be <140/85-90 mmHg before elective surgery 1, 2, 4.
• The patient is already on amlodipine 10 mg and lisinopril 20 mg, yet remains uncontrolled—this requires medication adjustment or addition of another agent 1, 4.
• The asymmetric arm blood pressure readings warrant vascular evaluation to rule out significant arterial disease 1.

Cardiovascular Risk Stratification Required

Assessment for Silent Myocardial Ischemia

• This patient has multiple high-risk features warranting cardiac ischemia testing before surgery 1, 2:

  • Proteinuria (microalbuminuria) which significantly increases cardiovascular risk 1
  • Stage II chronic kidney disease (eGFR 73) 1
  • Uncontrolled hypertension 1
  • Recent chest pain 1
  • Diabetic retinopathy indicating advanced microvascular disease 1

• Consider coronary calcium score by CT scan—if >400 Agatston units, this indicates high cardiovascular risk and should prompt ischemia testing 1, 2.

• If ischemia testing is pursued, options include exercise tolerance test, myocardial scintigraphy, stress echocardiography, or stress MRI 1.

Cardiac Autonomic Neuropathy Screening

• Screen for cardiac autonomic neuropathy (CAN), which is common in diabetic nephropathy patients and significantly increases perioperative risk 2.
• Look for: permanent tachycardia, QTc >440 ms on ECG, orthostatic hypotension (check lying and standing blood pressures), or history of unexplained hypoglycemia 2.
• The normal sinus rhythm on today's ECG should be reviewed for QTc interval 2.

Once Cardiac Issues Are Resolved

Glycemic Control Optimization

• A1C of 7% is at target (<7%) for optimal perioperative outcomes 1, 4.
• Hold metformin on the morning of surgery 1, 2.
• Continue basal insulin if the patient were on insulin therapy—never stop completely due to ketoacidosis risk 1, 2.
• Rapid A1C reduction should be avoided as it can worsen retinopathy 1.

Blood Pressure Management Before Surgery

• Intensify antihypertensive therapy to achieve BP <140/85-90 mmHg 1, 2, 4.
• The patient is appropriately on lisinopril (ACE inhibitor), which is recommended for diabetic nephropathy with microalbuminuria 1, 4.
• Consider adding or increasing diuretic therapy or adding another antihypertensive class 1, 4.

Renal Protection Strategies

• Current eGFR of 73 mL/min/1.73m² indicates Stage II CKD 1, 4.
• Microalbuminuria (35 mg) warrants ACE inhibitor therapy, which the patient is receiving 1, 4.
• Avoid all nephrotoxic agents perioperatively 1, 2, 4.
• Plan for mean arterial pressure maintenance of 60-70 mmHg during surgery (or >70 mmHg given baseline hypertension) to maintain renal perfusion 1, 2.

Retinopathy Considerations

• The presence of diabetic retinopathy requiring surgery indicates advanced disease 1.
• Optimize blood pressure and lipid control to reduce retinopathy progression 1.
• Current lipid panel is normal and patient is on atorvastatin 10 mg—continue this 1.

Common Pitfalls to Avoid

• Do not dismiss chest pain in diabetic patients as musculoskeletal without cardiac workup—myocardial infarction is frequently silent in diabetes 1.
• Do not proceed with elective surgery in the setting of uncontrolled hypertension—this increases perioperative cardiac and renal complications 1.
• Do not ignore asymmetric arm blood pressure readings—this may indicate significant vascular disease 1.
• The presence of microalbuminuria in this patient indicates NOT just kidney disease but significantly elevated cardiovascular risk 1, 3.
• While retinal surgery itself is low-risk, the patient's multiple comorbidities and recent concerning symptoms create substantial perioperative risk 1, 2.

Recommended Action Plan

1. Obtain serial troponin measurements and cardiology consultation for chest pain evaluation 1, 2
2. Investigate asymmetric blood pressure readings with vascular assessment 1
3. Intensify antihypertensive therapy to achieve target BP <140/85-90 mmHg 1, 2, 4
4. Consider cardiac ischemia testing given multiple high-risk features 1, 2
5. Once cardiac evaluation is complete and blood pressure controlled, reassess for surgical clearance 1, 2