Download View

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
Left inferior pubic ramus fracture
Osteoporosis
Hypothyroidism
Hypertension
Depression & anxiety
Possible TIA in July 2000
Macular degeneration
Meds






Aspirin
HCTZ
Potassium Chloride
Levothyroxine
Paroxetine
Alprazolam
No Known Drug Allergies





Fosamax
Calcium with D
Oxycodone/APAP
Promethazine
Multivitamin
FH/SH
 Widowed,
lives alone
 Smokes 1-2 cigarettes a day
 No alcohol use
 Both parents had cancer when older
ROS
 Decreased
appetite
 Groin pain from pubic ramus fracture
 No headaches or weakness
 No fever, chills, or weight loss
Differential Diagnosis 1

Corneal Edema
 Hyphema
 Cataract
 Vitreous Hemorrhage
Differential Diagnosis 2

Retinal Disease




Detachment
Macular Disease
Vascular Occlusion
Optic Nerve Disease



Optic Neuritis
Papillitis
Ischemic Optic
Neuropathy
• Giant Cell Arteritis
• Trauma
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
Ocular Exam







Visual Acuity
External Inspection
Pupillary reactions (swinging flashlight)
Ocular Motility testing
Anterior chamber depth assessment
Intraocular pressure testing
Ophthalmoscopy
Pupillary
Pathways
Pupillary Reactions
 Patient
had a right eye afferent defect
Anterior Chamber Depth
 Shallow
depth - angle closure glaucoma
 Patient’s
depth: normal
Tonometry
 Mean
pressure: 15 (10-21 for 2 SD)
 Patient’s
intraocular pressure: 11 mmHg
Retinal Detachment
Central Retinal Artery
Occlusion
Central Retinal Vein
Occlusion
Papillitis
Ischemic Optic Neuropathy
Data
 ESR
58
 Lipid Profile:




Total Cholesterol 215
Triglycerides 214
HDL 54
LDL 118
 Carotid
ultrasound: extensive plaque
without significant stenosis
Central Retinal Artery
Occlusion
Anecdotal Therapy
 Manual
compression of eye
 Retrobulbar anesthesia with paracentesis
of the anterior chamber
 What about t-PA?
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)

Prognosis and prognostic factors of retinal infarction
GJ 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
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.
ACP Journal Club Commentary
AW 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
Interventions for acute non-arteritic
central retinal artery occlusion
S 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.
Case Conclusion
Interventions:
 Warfarin planned for 6 months
 Lovastatin
 Consider Plavix
Useful Link
 National

Eye Institute (patient education)
http://www.nei.nih.gov/health/
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 nonarteritic central retinal artery occlusion. Cochrane
Database of Systematic Reviews.