The Case of the 20/90 Student in Denial

The Case of the 20/90 Student in Denial

Subjective Findings • 32-y.o. WM presents with chief complaint of “blurry vision” • HPI: Blur OD = OS; “It’s been like this ever since I broke my glasses last year”; no assoc. pain; “near vision okay” • OHx: unremarkable • MHx: unremarkable • Social History: UMSL accounting student • Note: Patient has no health insurance

Objective Findings • VA s Rx: OD 20/9025+ OS 20/90PHNI • BVA: OD 20/20 OS 20/90 • Pupils: ERRLA (-)APD • EOMs: Full OU • CF: FTFC OU • CT: ortho @ distance

Objective Findings (cont.) • SLEx: L/L: clear OU Conj: Gr.I injection 360, OU K: clear OU Iris: clear OU A/C: no c/f OU, +4 VH est. OU Lens: clear…. • Gonioscopy: Not performed (should it be?!) • TA: 16 OU @ 10:45 am

Fundus OD

Fundus OS

Fundus OS (cont.)

Assessment • DDx: • Diabetic retinopathy • Ocular ischemic syndrome • Venous stasis retinopathy • Hypertensive retinopathy • Leukemic retinopathy • Anemic retinopathy • Papilledema • Papillophlebitis • Others…?

Assessment (cont.) • What do the new retinal vessels represent? • How do they influence your DDx? • Why do you not expect to see them OD? • Do they always occur with this condition? • Do they promote macular edema?

Retinal Collateralization • Beneficial to retinal health and vision! • Develop within existing retinal vessel framework, near areas of capillary non-perfusion OR large vessel occlusion • Develop as capillaries and grow to vein-vein structures (after vein occlusion), artery-artery structures (after branch artery occlusion), and rarely artery-vein structures (after capillary bed obstruction) • Typically do not leak fluorescein • Usually develops 6-24 months after occlusive retinal vascular disease

Retinal Collateralization • Earlier collateralization has a greater chance of preventing VA loss • Occluded retinal vessels may re-perfuse to cause regression of collaterals • Collaterals may become permanent • Optociliary shunt vessels are a variant of retinal collateral that forms at the optic nerve head, typically occurring after CRVO & HRVO (another type occurs in POAG) • Important to diagnose and treat the underlying cause of the vascular event resulting in collaterals

Plan • Work-up? • Includes: • Cardiovascular work-up (electrocardiogram, echocardiogram, and carotid Doppler studies) • FA • HVF • BP • Labs: fasting glucose, CBC w. diff., platelets, PT/PTT, ANA, RF, ACE, ESR, FTA-ABS, VDRL • Additional labs in patient < 40 y.o.: check HIV status, protein S/protein C/antithrombin III deficiency, lupus anticoagulant, anticardiolipin antibody titer, and activated protein C resistance

Plan (cont.) • Macular grid/focal photocoagulation (100 micron spots) when macular edema lasts greater than 3-6 months, and VA < 20/40 in BRVO (BVOS conclusion) • Prognosis: 50% of patients with BRVO have VA > 20/40 , unless foveal ischemia or chronic macular edema present

Plan (cont.) • Made appointment for patient at BRI (FA, grid laser?) • Patient no-showed to appointment

The Case of the 20/90 Student in Denial