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Last updated on 23 Jul 2015 at 5:22 PM (Oph04)
Sudden painless loss of vision
A 74 year old South African male presents with sudden painless loss of vision in his
right eye. This occurred shortly after waking. He has no associated symptoms and no
past ocular history of note. His medical history includes hypertension, atrial
fibrillation, and he is a smoker. On examination, the best visual acuity was measured
at 'count fingers only' in the right eye and 6/9 in the left eye. There was a right relative
afferent pupillary defect. On ophthalmoscopy of the right eye, there was narrowing of
the retinal arterioles, whitening of the retina and a cherry-red spot at the macula.
Applied Science for Medicine
Anatomy and physiology of the retina, the retinal vascular supply, the optic nerve and
the visual tracts within the brain
Common pathologies of the retina, the retinal vascular supply and the optic nerve
Pathogenesis of central and branch retinal artery and vein occlusions
Definition and mechanism of amaurosis fugax
Clinical and Communication Skills
Elicit a relevant history of visual loss and its associated features
Elicit a relevant past medical history, medication history, and systems review to
identify risk factors for central retinal artery occlusion
Differential diagnosis of visual loss
Relevance of giant cell arteritis (temporal arteritis) to central retinal artery occlusion
Clinical features of retinal detachment
Perform a focused ophthalmic examination including measurement of visual acuity,
pupil reactions, colour vision, visual field testing to confrontation, slit lamp
examination and ophthalmoscopy examination of the optic nerve and retina
Perform a relevant cardiac and neurologic examination, including measurement of
blood pressure, assessment for murmurs and carotid bruits
Interpret FBC with differential, erythrocyte sedimentation rate (ESR) , C-reactive
protein (CRP), lipid profile, and other relevant blood test results, carotid artery
evaluation (Doppler ultrasound) and cardiac investigations
Personal and Professional Skills
Empathic approach with a distressing presentation
Team work: interaction with relevant specialists (GP, ophthalmology, cardiology,
neurology)
Hauora MÄ•ori
Understanding of inequities in access to health services and quality of medical care
for MÄ•ori, and application of this to clinical decision making and management
Population Health
Cardiovascular risk factors - elevated blood pressure, diabetes, hyperlipidaemia
Conditions to be considered relating to this scenario
central or branch retinal artery occlusion,
Common
cerebrovascular accident (stroke), central or branch
retinal vein occlusion, anterior ischaemic optic
neuropathy (arteritic (giant cell arteritis) and nonarteritic), retinal detachment, vitreous hemorrhage,
optic neuritis, exudative (wet) age-related macular
degeneration