Sight savers real case studies: part 1

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1 Sight savers real case studies: part 1 44 Shamina Asif, BSc (Hons), MCOptom The role of the optometrist goes beyond refraction and vision correction with optical devices. The importance of disease detection has never been more critical and no doubt will become increasingly significant as the population ages, patients become more aware of their own health status, and demand for higher standards of care increases. It can be easy for practitioners to become accustomed to practice life and the detection of common ocular problems. However, as this series of articles will demonstrate, you never know when the next potentially sinister problem might present to you, making it increasingly important for all practitioners to have the right skills and knowledge to deal with such cases. This article begins by looking at the ocular effects of systemic problems. Course code C Deadline: February 22, 2013 (Group 6, ) Be able to understand which signs/symptoms could relate to a neurological condition and understand the significance and relative importance of the findings (Group 6, ) Be able to recognise an adverse reaction to medication (systemic or topical) and describe the reporting scheme About the author Shamina Asif is a resident optometrist in the West Midlands. She is chair of Dudley LOC and is a council member representing the West Midlands for the College of Optometrists. She graduated from Aston University in 2004 with a 1st class honours degree and has a keen interest in the effect of nutrition on AMD and the ocular effects of systemic disease. She has previously written an article on drusen resolution following supplementation and presented at Cambridge University. She has also written articles in the Daily Mail on The 17 eye test that could save your life and The health foods that doctors say don t work. Visit for all the information about Enhanced CET requirements

2 Subtle optic disc swelling A 55-year-old man presented for a routine eye examination, being asymptomatic other than noticing a slight and gradual deterioration in his near vision for reading. His general health was fine as far as he was aware, and he was not taking any medication. His previous eye examination was two years ago, at the same practice. The best-corrected VA was 6/6 (Snellen) and N5 at 40cm in both eyes. A small change in refractive error was present (RE: +1.75/-0.25x125, LE: +1.75/-0.50x50, +1.75DS near add R+L) and the patient was advised to update his near spectacles. The IOP (by non-contact method) was 12.0mmHg in the right eye and 16.0mmHg in the left eye. Pupil reactions were normal with no RAPD, and visual fields were full (Henson central 25 field test, threshold 36dB in the right eye and 35db in the left eye). Fundus examination revealed slightly blurred margins of the right optic nerve head, most notably superior-nasally and nasally (Figure 1, left). The left optic nerve head appeared flat, with well-defined margins. Fundus examination was otherwise unremarkable in both eyes apart from a small druse nasal to the fovea of the right eye, which was of no consequence. The patient was asked if he had noted anything unusual about his vision in the right eye, and whether he had any symptoms such as headaches and eye pain, particularly on eye movements, to which he replied that he hadn t. Further examination revealed normal colour vision on Ishihara plates, tested monocularly in each eye. Having contacted the local hospital eye service (HES) by telephone, suspecting early optic Figure 1 Subtle optic disc swelling. The image on the left displays slightly raised (superior-nasal and nasal margin) appearance of the optic nerve head in a 55-year-old male, while the image on the right displays the same optic nerve head one year later following treatment for systemic hypertension and raised cholesterol neuritis or papilloedema, an appointment was arranged for the patient to be seen by a consultant ophthalmologist for further investigation. A referral letter was given to the patient to take with him to the appointment along with a copy for him and one for his GP. One year after this eye examination, the patient returned to the practice for a followup eye examination. On questioning during history and symptoms, it transpired that the patient had not attended the hospital appointment. Instead, having been to see his own GP to provide a copy of the referral letter, his GP had taken the opportunity to examine the patient s eyes and perform systemic investigations. The patient revealed that his blood pressure was elevated and upon conducting further blood tests his cholesterol was also found to be raised. For these reasons, the patient had been prescribed Lisinopril 10mg and Simvastatin 20mg by his GP, for hypertension and high cholesterol, respectively. The patient s GP had monitored his blood pressure, cholesterol and eyes on four separate occasions during the past year, and was now satisfied that all were stable. Fundus assessment at the eye examination now revealed a normal optic nerve head appearance in the right eye, with a flat optic disc and well defined margins visible (Figure 1, right). Established optic disc swelling A 39-year-old male patient attended for an eye examination as a walk-in addition to the diary. His last eye examination was 10 years ago and he attended now owing to problems he was experiencing with his right eye. He had noticed that his vision had been blurry for about six days and that whenever he became stressed at work he experienced tunnel vision and lost his sight. He was an area sales manager and felt his general health was good and he was taking no medication. The best-corrected VA was 6/30 in the right eye and 6/6-2 in the left eye. The IOP (by non-contact method) was 20.0mmHg in the right eye and 19.3mmHg in the left eye and pupil reactions were normal with no RAPD in either eye. Visual fields assessment (Henson central 25 field test) revealed an absolute and complete loss of the visual field in the right eye but a normal and full visual field in the left eye, with a threshold of 34db. Fundus examination revealed bilateral blurred optic disc margins with elevation of the disc (more prominent in the right eye) accompanied by exudates, cotton wool spots and flame-shaped haemorrhages around the optic disc (Figure 2). Further examination 45 Find out when CET points will be uploaded to the GOC at For the latest CET visit

3 46 Figure 2 Established papilloedema. Obvious blurred disc margins accompanied with flame haemorrhages, exudates and cotton wool spots indicate a severe case of papilloedema of colour vision with Ishihara plates, tested monocularly was normal. Suspecting a case of established papilloedema, the HES was contacted by telephone and an appointment was arranged for the patient to be seen by a consultant ophthalmologist the same day. The patient was advised of the findings and the potential seriousness of any underlying causes, hence the need for immediate investigation at hospital. The patient was contacted by telephone four days later and he confirmed that he had been admitted into hospital to manage malignant hypertension intravenously. His blood pressure was 240/140, which had not only caused problems to his vision and eyes, but also had resulted in some damage to his kidneys. The patient said that the treating consultant had advised him that a few more days and he would have had a stroke or even worse. Discussion Optic disc swelling can be caused by a number of problems, with papilloedema specifically relating transmitted to the optic nerves. There are four stages of papilloedema: 1. Early papilloedema (Figure 1) may be difficult to diagnose with certainty. The main features include normal VA, hyperaemia and mild elevation of the optic disc with indistinct disc margins and swelling of the parapapillary retinal nerve fibre layer. 1 There is also loss of any previous spontaneous venous pulsation (SVP) that might be present; this is why it is important to record the presence of SVP if you see this in any patient. 2. Established papilloedema (Figure 2) causes transient visual obscuration, which can last only for a few seconds, in one or both eyes, often upon standing. VA is reduced or normal and the optic discs appear severely to swelling of the optic nerve heard secondary hyperaemic and moderately elevated to raised intracranial pressure. In the first case with indistinct margins, which may be described in this article, optic disc swelling was asymmetric initially. The optic cup and only evident in one eye, which points towards optic the small vessels on the disc are obscured. neuritis. However, there were no other associated Venous engorgement, parapapillary signs and symptoms (normal pupil reactions, visual flame-shaped haemorrhages and cotton fields and colour vision), and it transpired that this wool spots may be seen. As the swelling was early stage disc swelling secondary to systemic increases, the optic nerve head appears hypertension. The second case was a more obvious enlarged and hard exudates may radiate case of bilateral optic disc swelling, with the from the centre of the fovea in the form of hallmark features present (blurred disc margins, a macular fan an incomplete star with the elevated disc, flame haemorrhages, exudates and temporal part missing. 1 cotton wool spots). The cause in this patient was 3. Longstanding (vintage) papilloedema malignant hypertension, that is blood pressure presents with variable VA, constricted visual greater than 200 systolic and 100 diastolic. 1 fields, and markedly elevated optic discs There is normally decreased VA and episodes with a champagne cork appearance. There of temporary visual loss associated with this are no haemorrhages or cotton wool spots, condition (amaurosis fugax). Due to the possibility but drusen appearing as crystalline deposits of blockage of the carotid artery in patients with may be present on the optic disc surface. 1 amaurosis fugax, they will need to have immediate 4. Atrophic papilloedema (secondary optic investigations (e.g. carotid Doppler imaging) as this atrophy) presents with severely reduced is a potentially life-threatening problem. 2,3 VA and the optic nerve is slightly elevated and becomes pale in colour, sometimes Papilloedema appearing as a dirty grey (Figure 3). This Papilloedema typically presents as bilateral optic type of papilloedema typically occurs when disc swelling as raised intracranial pressure is the condition is undiagnosed and untreated,

4 copy was given to the patient to take to the HES with her. The patient was contacted about two weeks after this examination to follow-up on the referral to the HES. Following investigations by the consultants, the patient had been told that the retinal discolouration observed was a side effect of the Rifater medication she was taking and that this should become normal over time once she has ceased taking the medication. The patient had been discharged from the hospital. 47 Figure 3 Atrophic papilloedema causing pale optic nerve head appearances in both eyes. The VA is count fingers (CF) in both eyes resulting in severe visual impairment. 1 All cases of optic disc swelling and papilloedema should be investigated urgently and preferably the same day owing to the potentially life-threatening nature of many of the causes. Most areas will have protocols in place for referral of patients to be seen at HES, in which case practitioners need to be aware of these and follow the advice given by their local secondary care units. As the cases presented in this article highlight, practitioners need to be vigilant when examining the optic disc as some presentations can be subtle and therefore easily missed. Ocular side effect of tuberculosis medication A 32-year-old housewife presented for a routine eye examination. She was asymptomatic and although she reported that her general health was good, it was only upon further questioning that she stated that she had tuberculosis for which she was taking Rifater medication; before this she had been taking Ethambutol. She reported that the active phase of her tuberculosis was over though. The best-corrected VA was 6/6 and N5 at 40cm in both eyes. A small change in refractive error was present (RE: -5.00/-0.25x60, LE: -4.75/-0.75x105) and the patient was advised to update her distance spectacles. The IOP (by non-contact method) was 16.0mmHg in the right eye and 13.5mmHg in the left eye. Pupil reactions were normal with no RAPD and visual fields were full (Henson central 25 field test, threshold 39dB in both eyes). Fundus examination revealed a demarcation line in all quadrants of the peripheral retina in both eyes. The retinal colour was different on either side of the demarcation line, the discoloration being apparent only when examining the peripheral retina; the central fundus appeared normal in colour when examined alone (Figure 4). Dilated fundus examination confirmed the presence of the demarcation lines and discolouration, and ruled out retinal detachment and retinoschisis. The patient was scheduled to go to Pakistan on holiday soon and so the HES was contacted by telephone for advice. The consulting doctor arranged to see the patient the following day. The patient was given two copies of the referral letter; one for her to keep and the other for her GP. A third Discussion Tuberculosis is an infectious disease of the lungs caused by airborne transmission of Mycobacterium tuberculosis (tubercle bacillus). It is estimated that 2-3 million people in the world die from tuberculosis and the prevalence is increasing according to the latest Health Protection Agency s report. 4 In the UK, the incidence of tuberculosis is 14.4 cases per 100,000 of the population, with London being most susceptible (39%) followed by the West Midlands (11%). Most of these people are from South Asia and sub-saharan Africa. Transmission occurs through birth too, with the incidence of tuberculosis in the UK-born population being 4.1 cases per 100, Mycobacterium tuberculosis works by invading macrophages, multiplying inside and then rupturing the cell before proceeding to infect other cells. It works particularly well in those individuals who are immunocompromised. 5 The most common ocular manifestation is uveitis, with the posterior form being more common than the anterior form, the latter of which normally appears as an iridocyclitis associated with classic, granulomatous, mutton-fat keratic precipitates, hypopyon and posterior synechiae. 6 It may also present as an intermediate uveitis in the form of pars planitis, giving rise to vitritis, vitreous snowballs and snow-banking, peripheral granulomas and vascular sheathing. 7,8 If there is posterior uveitis, the retina can be involved indirectly owing to the choroiditis. 9 Direct retinal involvement is rare and only occurs in Eales disease, whereby there is vasculitis affecting the peripheral retina and vitreous haemorrhage or floaters. It occurs in India, Pakistan and the Middle East. 10 In the case presented here, the retinal changes observed were not due to the Find out when CET points will be uploaded to the GOC at For the latest CET visit

5 neuritis. 12 There are no reports of discolouration and so this drug is unlikely to be the cause of the retinal discolouration seen in this case Figure 4 Peripheral retinal discoloration suspected to be caused by Rifater medication for tuberculosis tuberculosis itself but most likely due to Rifater medication. Rifater is bacteriostatic for Mycobacterium tuberculosis and contains isoniazid, pyrazinamide and rifampin. The medication leaflet for Rifater does not mention any side effects relating to changes to the colour of the retina. However, although infrequent, the reported ocular side effects mentioned are optic neuritis and discolouration (orange/brown/red) of the tears caused by rifampin. It is also possible for similar discolouration of the urine and sweat to occur. Therefore, it is possible that discolouration of the peripheral retina has occurred in the case presented here, through a similar yet unknown mechanism. 11 As with all known and new ocular side effects, this was reported to the Medicines and Healthcare Products Regulatory Agency (MHRA) on their website Ethambutol is bacteriostatic for Mycobacterium tuberculosis in the dosages that can safely be given, and is used to prevent the emergence of strains resistant to other drugs. It should be avoided in the treatment of patients with impaired renal function as it may accumulate and cause serious ocular toxicity. It should also not be given to young children or any patient unable to report early symptoms of ocular toxicity. The drug can cause reduced VA, scotoma and impaired colour vision, thought to be due to optic or retrobulbar Summary History and symptoms is a very important part of the eye examination, and with vital bits of information missing it can be difficult to devise an effective management plan. In the case of the patient taking medication for tuberculosis, referral and management might have been very different if questioning did not reveal the history of medication being taken. Practitioners also need to be vigilant about subtle changes to ocular appearance, as highlighted by the first case in this article. Advances in medicine and accessing health care mean that optometrists are increasingly likely to detect systemic diseases, especially as the eyes offer a window for non-invasive examination that can give clues to systemic vasculature. Indeed, many people leading busy lives might not have the time to attend routine systemic health checks with their GP, yet visual problems will lead them to seek optometric attention, where signs of more sinister problems might be detected. MORE INFORMATION References Visit click on the article title and then on references to download. Exam Questions Under the new Enhanced CET rules of the GOC, MCQs for this exam appear online at Please complete online by midnight on February 22, You will be unable to submit exams after this date. Answers will be published on co.uk/cet/exam-archive and CET points will be uploaded to the GOC on March 8, You will then need to log into your CET portfolio by clicking on MyGOC on the GOC website ( to confirm your points. Reflective learning Having completed this CET exam, consider whether you feel more confident in your clinical skills how will you change the way you practice? How will you use this information to improve your work for patient benefit?