Eye Spy A Case of Acute Vision Loss Tony S. Chang, MD Primary Care Conference October 6, 2004.
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Eye Spy Eye Spy A Case of Acute Vision A Case of Acute Vision Loss Loss Tony S. Chang, MD Tony S. Chang, MD Primary Care Conference Primary Care Conference October 6, 2004 October 6, 2004
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Transcript of Eye Spy A Case of Acute Vision Loss Tony S. Chang, MD Primary Care Conference October 6, 2004.
Eye SpyEye SpyA Case of Acute Vision LossA Case of Acute Vision Loss
Tony S. Chang, MDTony S. Chang, MD
Primary Care ConferencePrimary Care Conference
October 6, 2004October 6, 2004
DisclosuresDisclosures
I have no financial disclosures.I have no financial disclosures.
CaseCase
An 82 y.o. woman presents to her An 82 y.o. woman presents to her ophthalmologist 6 hours after waking ophthalmologist 6 hours after waking up with vision loss in her right eye.up with vision loss in her right eye.
PMHPMH
Monoclonal gammopathyMonoclonal gammopathy Left inferior pubic ramus fractureLeft inferior pubic ramus fracture OsteoporosisOsteoporosis HypothyroidismHypothyroidism HypertensionHypertension Depression & anxietyDepression & anxiety Possible TIA in July 2000Possible TIA in July 2000 Macular degenerationMacular degeneration
MedsMeds
AspirinAspirin HCTZHCTZ Potassium ChloridePotassium Chloride LevothyroxineLevothyroxine ParoxetineParoxetine AlprazolamAlprazolam
FosamaxFosamax Calcium with DCalcium with D Oxycodone/APAPOxycodone/APAP PromethazinePromethazine MultivitaminMultivitamin
No Known Drug AllergiesNo Known Drug Allergies
FH/SHFH/SH
Widowed, lives aloneWidowed, lives alone Smokes 1-2 cigarettes a daySmokes 1-2 cigarettes a day No alcohol useNo alcohol use Both parents had cancer when olderBoth parents had cancer when older
ROSROS
Decreased appetiteDecreased appetite Groin pain from pubic ramus fractureGroin pain from pubic ramus fracture No headaches or weaknessNo headaches or weakness No fever, chills, or weight lossNo fever, chills, or weight loss
Differential Diagnosis 1Differential Diagnosis 1
Corneal EdemaCorneal Edema HyphemaHyphema CataractCataract Vitreous HemorrhageVitreous Hemorrhage
Differential Diagnosis 2Differential Diagnosis 2
Retinal DiseaseRetinal Disease DetachmentDetachment Macular DiseaseMacular Disease Vascular OcclusionVascular Occlusion
Optic Nerve DiseaseOptic Nerve Disease Optic NeuritisOptic Neuritis PapillitisPapillitis Ischemic Optic Ischemic Optic
NeuropathyNeuropathy• Giant Cell ArteritisGiant Cell Arteritis• TraumaTrauma
Medical ExamMedical Exam
Pleasant thin woman, mildly concernedPleasant thin woman, mildly concerned Vitals: Blood pressure 122/58, pulse 88Vitals: Blood pressure 122/58, pulse 88 Neck: no bruitsNeck: no bruits CV: regular without murmur or gallopCV: regular without murmur or gallop Chest: clearChest: clear Abdomen: no bruitsAbdomen: no bruits Extremities: no edemaExtremities: no edema
Ocular ExamOcular Exam
Visual AcuityVisual Acuity External InspectionExternal Inspection Pupillary reactions (swinging flashlight)Pupillary reactions (swinging flashlight) Ocular Motility testingOcular Motility testing Anterior chamber depth assessmentAnterior chamber depth assessment Intraocular pressure testingIntraocular pressure testing OphthalmoscopyOphthalmoscopy
Pupillary Pupillary PathwaysPathways
Pupillary ReactionsPupillary Reactions
Patient had a right eye afferent defectPatient had a right eye afferent defect
Anterior Chamber DepthAnterior Chamber Depth
Shallow depth - angle closure glaucomaShallow depth - angle closure glaucoma
Patient’s depth: normalPatient’s depth: normal
TonometryTonometry
Mean pressure: 15 (10-21 for 2 SD)Mean pressure: 15 (10-21 for 2 SD)
Patient’s intraocular pressure: 11 mmHgPatient’s intraocular pressure: 11 mmHg
Retinal DetachmentRetinal Detachment
Central Retinal Artery Central Retinal Artery OcclusionOcclusion
Central Retinal Vein Central Retinal Vein OcclusionOcclusion
PapillitisPapillitis
Ischemic Optic NeuropathyIschemic Optic Neuropathy
DataData
ESR 58ESR 58 Lipid Profile:Lipid Profile:
Total Cholesterol 215Total Cholesterol 215 Triglycerides 214Triglycerides 214 HDL 54HDL 54 LDL 118LDL 118
Carotid ultrasound: extensive plaque Carotid ultrasound: extensive plaque without significant stenosiswithout significant stenosis
Central Retinal Artery Central Retinal Artery OcclusionOcclusion
Anecdotal TherapyAnecdotal Therapy
Manual compression of eyeManual compression of eye Retrobulbar anesthesia with paracentesis Retrobulbar anesthesia with paracentesis
of the anterior chamberof the anterior chamber What about t-PA?What about t-PA?
EBM SearchEBM Search
Ovid: Cochrane Database of Systematic Ovid: Cochrane Database of Systematic Reviews, ACP Journal Club, DAREReviews, ACP Journal Club, DARE
““Retinal artery”Retinal artery” 8 hits, 2 relevant8 hits, 2 relevant
ACP Journal Club: “Elderly patients had an ACP Journal Club: “Elderly patients had an increased 5-year risk for death, coronary events, increased 5-year risk for death, coronary events, and stroke after retinal infarction” (prognosis)and stroke after retinal infarction” (prognosis)
CDSR: “Interventions for acute non-arteritic CDSR: “Interventions for acute non-arteritic central retinal artery occlusion” (treatment)central retinal artery occlusion” (treatment)
Prognosis and prognostic factors of retinal infarctionPrognosis and prognostic factors of retinal infarctionGJ Hankey. BMJ 1991. Mar 2;302:499-504GJ Hankey. BMJ 1991. Mar 2;302:499-504
Design: Cohort study, enrolled 1977-86 Design: Cohort study, enrolled 1977-86 followed until death or end of study (1-10 followed until death or end of study (1-10 years)years)
Patients: 98 consecutive patients with Patients: 98 consecutive patients with retinal infarction at Oxford Eye Hospitalretinal infarction at Oxford Eye Hospital
Prognostic factors: Age, gender, smoking, Prognostic factors: Age, gender, smoking, causes of infarction, carotid bruit, blood causes of infarction, carotid bruit, blood pressure, lipids, therapeutic interventionspressure, lipids, therapeutic interventions
Prognosis, continuedPrognosis, continued
Outcome measures: death, stroke, Outcome measures: death, stroke, coronary events, contralateral retinal coronary events, contralateral retinal infarctionsinfarctions
Conclusion: Elderly patients with retinal Conclusion: Elderly patients with retinal infarction and no history of stroke had a infarction and no history of stroke had a poor 5-year prognosis for death, coronary poor 5-year prognosis for death, coronary events, and stroke particularly if they had events, and stroke particularly if they had carotid bruit and cardiomegaly.carotid bruit and cardiomegaly.
ACP Journal Club CommentaryACP Journal Club CommentaryAW Feinberg. July-Aug 1991. v115 p.24AW Feinberg. July-Aug 1991. v115 p.24
Results of this study similar to larger Results of this study similar to larger studies of amaurosis fugaxstudies of amaurosis fugax
Higher risk for ipsilateral stroke for 1st 6 Higher risk for ipsilateral stroke for 1st 6 monthsmonths
Afterwards, death from MI exceeds strokeAfterwards, death from MI exceeds stroke Study limited by lack of doppler examStudy limited by lack of doppler exam Prognosis may now be better for patients Prognosis may now be better for patients
who have carotid endarterectomywho have carotid endarterectomy
Interventions for acute non-arteritic Interventions for acute non-arteritic central retinal artery occlusioncentral retinal artery occlusion
S Fraser. Cochrane Database of Systematic Reviews 2004.S Fraser. Cochrane Database of Systematic Reviews 2004.
Literature reviewLiterature review Selection criteria: randomized controlled trials to Selection criteria: randomized controlled trials to
re-establish blood supply to retinare-establish blood supply to retina Search results: no trials met criteriaSearch results: no trials met criteria Conclusions: There is not enough evidence to Conclusions: There is not enough evidence to
decide which interventions would result in any decide which interventions would result in any beneficial or harmful effect.beneficial or harmful effect.
Case ConclusionCase Conclusion
Interventions:Interventions: Warfarin planned for 6 monthsWarfarin planned for 6 months LovastatinLovastatin Consider Plavix Consider Plavix
Useful LinkUseful Link
National Eye Institute (patient education)National Eye Institute (patient education) http://www.nei.nih.gov/health/http://www.nei.nih.gov/health/
ReferencesReferences
Bradford CA. Bradford CA. Basic Ophthalmology.Basic Ophthalmology. 7th Ed. 1999. 7th Ed. 1999. American Academy of Ophthalmology.American Academy of Ophthalmology.
Feinberg AW. Elderly patients had an increased 5-year Feinberg AW. Elderly patients had an increased 5-year risk for death, coronary events, and stroke after retinal risk for death, coronary events, and stroke after retinal artery infarction. ACP Journal Club 1999. v115:p.24. artery infarction. ACP Journal Club 1999. v115:p.24. Abstract and commentary for Hankey GJ, Slattery JM, Abstract and commentary for Hankey GJ, Slattery JM, Warlow CP. Prognosis and prognostic factors of retinal Warlow CP. Prognosis and prognostic factors of retinal infarction: a prospective cohort study. BMJ 1991. Mar infarction: a prospective cohort study. BMJ 1991. Mar 2;302:499-5042;302:499-504
Fraser s, Siriwardena D. Interventions for acute non-Fraser s, Siriwardena D. Interventions for acute non-arteritic central retinal artery occlusion. Cochrane arteritic central retinal artery occlusion. Cochrane Database of Systematic Reviews. Database of Systematic Reviews.
