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Eye Spy A Case of Acute Vision Loss Tony S. Chang, MD Primary Care Conference October 6, 2004

Eye Spy A Case of Acute Vision Loss Tony S. Chang, MD Primary Care Conference October 6, 2004. Disclosures. I have no financial disclosures. Case. An 82 y.o. woman presents to her ophthalmologist 6 hours after waking up with vision loss in her right eye. PMH. Monoclonal gammopathy

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Eye Spy A Case of Acute Vision Loss Tony S. Chang, MD Primary Care Conference October 6, 2004

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  1. Eye Spy A Case of Acute Vision Loss Tony S. Chang, MD Primary Care Conference October 6, 2004

  2. Disclosures • I have no financial disclosures.

  3. Case An 82 y.o. woman presents to her ophthalmologist 6 hours after waking up with vision loss in her right eye.

  4. PMH • Monoclonal gammopathy • Left inferior pubic ramus fracture • Osteoporosis • Hypothyroidism • Hypertension • Depression & anxiety • Possible TIA in July 2000 • Macular degeneration

  5. Aspirin HCTZ Potassium Chloride Levothyroxine Paroxetine Alprazolam Fosamax Calcium with D Oxycodone/APAP Promethazine Multivitamin Meds No Known Drug Allergies

  6. FH/SH • Widowed, lives alone • Smokes 1-2 cigarettes a day • No alcohol use • Both parents had cancer when older

  7. ROS • Decreased appetite • Groin pain from pubic ramus fracture • No headaches or weakness • No fever, chills, or weight loss

  8. Differential Diagnosis 1 • Corneal Edema • Hyphema • Cataract • Vitreous Hemorrhage

  9. Differential Diagnosis 2 • Retinal Disease • Detachment • Macular Disease • Vascular Occlusion • Optic Nerve Disease • Optic Neuritis • Papillitis • Ischemic Optic Neuropathy • Giant Cell Arteritis • Trauma

  10. Medical Exam • Pleasant thin woman, mildly concerned • Vitals: Blood pressure 122/58, pulse 88 • Neck: no bruits • CV: regular without murmur or gallop • Chest: clear • Abdomen: no bruits • Extremities: no edema

  11. Ocular Exam • Visual Acuity • External Inspection • Pupillary reactions (swinging flashlight) • Ocular Motility testing • Anterior chamber depth assessment • Intraocular pressure testing • Ophthalmoscopy

  12. Pupillary Pathways

  13. Pupillary Reactions • Patient had a right eye afferent defect

  14. Anterior Chamber Depth • Shallow depth - angle closure glaucoma • Patient’s depth: normal

  15. Tonometry • Mean pressure: 15 (10-21 for 2 SD) • Patient’s intraocular pressure: 11 mmHg

  16. Retinal Detachment

  17. Central Retinal Artery Occlusion

  18. Central Retinal Vein Occlusion

  19. Papillitis

  20. Ischemic Optic Neuropathy

  21. Data • ESR 58 • Lipid Profile: • Total Cholesterol 215 • Triglycerides 214 • HDL 54 • LDL 118 • Carotid ultrasound: extensive plaque without significant stenosis

  22. Central Retinal Artery Occlusion

  23. Anecdotal Therapy • Manual compression of eye • Retrobulbar anesthesia with paracentesis of the anterior chamber • What about t-PA?

  24. EBM Search • Ovid: Cochrane Database of Systematic Reviews, ACP Journal Club, DARE • “Retinal artery” • 8 hits, 2 relevant • ACP Journal Club: “Elderly patients had an increased 5-year risk for death, coronary events, and stroke after retinal infarction” (prognosis) • CDSR: “Interventions for acute non-arteritic central retinal artery occlusion” (treatment)

  25. Prognosis and prognostic factors of retinal infarctionGJ Hankey. BMJ 1991. Mar 2;302:499-504 • Design: Cohort study, enrolled 1977-86 followed until death or end of study (1-10 years) • Patients: 98 consecutive patients with retinal infarction at Oxford Eye Hospital • Prognostic factors: Age, gender, smoking, causes of infarction, carotid bruit, blood pressure, lipids, therapeutic interventions

  26. Prognosis, continued • Outcome measures: death, stroke, coronary events, contralateral retinal infarctions • Conclusion: Elderly patients with retinal infarction and no history of stroke had a poor 5-year prognosis for death, coronary events, and stroke particularly if they had carotid bruit and cardiomegaly.

  27. ACP Journal Club CommentaryAW Feinberg. July-Aug 1991. v115 p.24 • Results of this study similar to larger studies of amaurosis fugax • Higher risk for ipsilateral stroke for 1st 6 months • Afterwards, death from MI exceeds stroke • Study limited by lack of doppler exam • Prognosis may now be better for patients who have carotid endarterectomy

  28. Interventions for acute non-arteritic central retinal artery occlusionS Fraser. Cochrane Database of Systematic Reviews 2004. • Literature review • Selection criteria: randomized controlled trials to re-establish blood supply to retina • Search results: no trials met criteria • Conclusions: There is not enough evidence to decide which interventions would result in any beneficial or harmful effect.

  29. Case Conclusion Interventions: • Warfarin planned for 6 months • Lovastatin • Consider Plavix

  30. Useful Link • National Eye Institute (patient education) • http://www.nei.nih.gov/health/

  31. References • Bradford CA. Basic Ophthalmology. 7th Ed. 1999. American Academy of Ophthalmology. • Feinberg AW. Elderly patients had an increased 5-year risk for death, coronary events, and stroke after retinal artery infarction. ACP Journal Club 1999. v115:p.24. Abstract and commentary for Hankey GJ, Slattery JM, Warlow CP. Prognosis and prognostic factors of retinal infarction: a prospective cohort study. BMJ 1991. Mar 2;302:499-504 • Fraser s, Siriwardena D. Interventions for acute non-arteritic central retinal artery occlusion. Cochrane Database of Systematic Reviews.

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