Case Follow Up Sepi Jooniani PGY-1
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
Chief Complaint Black spot in my vision
Approach to the Patient with Visual Loss
Definitions Acute Transient Visual Loss (ATVL) Acute Persistent Visual Loss (APVL)
1 2 3
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
Timing Sudden Laterality Monocular Quality Partial Hemianopia Pain No Redness No Associated symptoms None Trauma None History
Past Medical History Vascular Disease No BP 203/115 Refractive Status No Contact Lens Wearer No Eye Surgery No Medications No
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
Physical Exam- Continued Cranial Nerves No Focal deficits No Cerebellar Signs Gait Normal Speech Normal Heart, Lungs, Abdomen unremarkable
Stroke Scale
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?
Retinal Vein vs. Artery Occlusion
RVO 2 nd MCC of visual loss 50-70 y/o Risk Factors: Age, HTN, DM, smoking, obesity, hypercoaggulable state, glaucoma Complications: neovascularization, vitreous hemorrhage, glaucoma Prognosis: 3 months, improvement unlikely
Findings in RVO Retinal hemorrhage Edema Dilated retinal veins Cotton wool spots CRVO Blood and Thunder
RVO Branch RVO Hemi-RVO Central RVO
Fluorescein Angiography in CRVO Retinal Nonperfusion Predict prognosis
Treatment of RVO Observation & Follow Up Macular edema, Neovascularization Anti VEGF Glucorticoid Laser Photocoaggulation
RAO Ocular Emergency 100-240 minutes Form of stroke ICA opthalmic artery retinal artery Risk Factors: arteriosclerosis Carotid atherosclerotic disease, Temporal arteritis, Fibromuscular dysplasia, Moyamoya, Sickle cell Cardiogenic embolus
Presentation in RAO Preceded by fluctuating, transient course Profound vision loss Pupillary Afferent defect Findings: Ischemic retinal whitening Cherry Red Spot
Fluorescein Angiography in CRAO
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)
Back to Our Patient...
Admission A1c 11.1 Lipid Profile Cholestrol 267 HDL 38 LDL 171 TG 489 Endocrine, Diabetic Educator, Dietician
Discharge Diagnoses: DM HTN Dyslipidemia CRVO Home Medications ASA Statin Lisinopril Metformin
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
In Summary
Need Opthalmology NOW! CRAO/BRAO IOP>40 Temporal Arteritis Retinal Detachment Hyphema Endopthalmitis Infectious Keratitis
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