Case Follow Up. Sepi Jooniani PGY-1
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1 Case Follow Up Sepi Jooniani PGY-1
2 Triage 54 year old M Pt presents to prelim states noticed today he had reddness to eyes, states worse in R eye. Pt denies any pain or itching. No further complaints. Vitals T 36.6, P 70, R 16, 98%, BP 203/115 Wt 78kg, BMI 26.2 No other History in EPIC/CPNG
3 Chief Complaint Black spot in my vision
4 Approach to the Patient with Visual Loss
5 Definitions Acute Transient Visual Loss (ATVL) Acute Persistent Visual Loss (APVL)
6 1 2 3
7 Differentials 1. Media Keratitis, Corneal edema, Hyphema, Lens changes, Vitreous hemorrhage, Uveitis 2. Retina Artery occlusion (temporal arteritis), Vein occlusion, Detachment, Maculopathy 3. Neural Visual Pathway Ischemic neuropathy, Neuritis, Papilledema Chiasmal Retrochiasmal Visual Cortex 4. Psychogenic
8 Timing Sudden Laterality Monocular Quality Partial Hemianopia Pain No Redness No Associated symptoms None Trauma None History
9 Past Medical History Vascular Disease No BP 203/115 Refractive Status No Contact Lens Wearer No Eye Surgery No Medications No
10 Inspection No erythema or hyphema Pupils 4mm, BL reactive EOM Intact Visual Acuity L 20/30 R 20/50 Visual Fields RLQ right eye Tonometry L14 R13 Fluorescein Slit Lamp Opthalmoscopic Exam No papilledema Physical Exam
11
12 Physical Exam- Continued Cranial Nerves No Focal deficits No Cerebellar Signs Gait Normal Speech Normal Heart, Lungs, Abdomen unremarkable
13 Stroke Scale
14 Management Repeat BP 189/114 Consult to Ophthalmology and Neurology K-11: Edematous, hyperemic nerve Flame shaped hemorrhage Nasal macular edema Hypertensive retinopathy Head CT: negative Dx?
15 Retinal Vein vs. Artery Occlusion
16 RVO 2 nd MCC of visual loss y/o Risk Factors: Age, HTN, DM, smoking, obesity, hypercoaggulable state, glaucoma Complications: neovascularization, vitreous hemorrhage, glaucoma Prognosis: 3 months, improvement unlikely
17 Findings in RVO Retinal hemorrhage Edema Dilated retinal veins Cotton wool spots CRVO Blood and Thunder
18 RVO Branch RVO Hemi-RVO Central RVO
19 Fluorescein Angiography in CRVO Retinal Nonperfusion Predict prognosis
20 Treatment of RVO Observation & Follow Up Macular edema, Neovascularization Anti VEGF Glucorticoid Laser Photocoaggulation
21 RAO Ocular Emergency minutes Form of stroke ICA opthalmic artery retinal artery Risk Factors: arteriosclerosis Carotid atherosclerotic disease, Temporal arteritis, Fibromuscular dysplasia, Moyamoya, Sickle cell Cardiogenic embolus
22 Presentation in RAO Preceded by fluctuating, transient course Profound vision loss Pupillary Afferent defect Findings: Ischemic retinal whitening Cherry Red Spot
23
24 Fluorescein Angiography in CRAO
25 Work Up & Treatment of RAO >50 y/o: ESR, CRP Full stroke work up Conservative Treatments Digital massage Anterior chamber paracentesis Pharmacologic reduction IOP Mannitol, Acetozolamide NTG, Pentoxyfylline Intraarterial Thrombolytics (phase II trial)
26 Back to Our Patient...
27 Admission A1c 11.1 Lipid Profile Cholestrol 267 HDL 38 LDL 171 TG 489 Endocrine, Diabetic Educator, Dietician
28 Discharge Diagnoses: DM HTN Dyslipidemia CRVO Home Medications ASA Statin Lisinopril Metformin
29 Medical Course To Date 12/30/14 Initial ED visit 1/6/15 PCP follow up 1/29/15 Eye follow up, BP 171/91 20/200 New inferior hemi-field defect, concerned for progressive end-organ damage 2/11/15 PCP: Chlorthalidone added 2/27/15 PCP: BS 288, started on glyburide 3/10/15 Next eye appointment
30 In Summary
31 Need Opthalmology NOW! CRAO/BRAO IOP>40 Temporal Arteritis Retinal Detachment Hyphema Endopthalmitis Infectious Keratitis
32 References Leveque, T. Approach to the adult with acute persistent visual loss. In: UptoDate, Post TW (Ed). (Accessed March, 2015) Douglas, J. Retinal Vein Occlusion: Epidemiology, clinical manifestations and diagnosis. In: UptoDate, Post TW (Ed). (Accessed March, 2015) Thomas, R. Central and branch retinal artery occlusion. In: UptoDate, Post TW (Ed). (Accessed March, 2015) Yuzurihara, D. Visual outcome in central retinal and branch retinal artery occlusion. Jpn J Ophthalmol 2004;48:490 Rogers, S. The prevalence of retinal vein occlusion: pooled data from population studies from the United States, Asia, and Australia. Opthalmology 2010;117:313
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