Download Environment (if using as a simulation case)

Melanie Smith; 32 6/13/1978
Author: Colin M. O’Dea, MD
Reviewer: Sharon Griswold, MD
Case Title: Painful Monocular Visual Loss in a Young Adult Female
Target Audience: Medical Students and Residents
Primary Learning Objectives:
1. Verbalize the differential diagnosis for a patient who presents with painful visual loss
2. Perform components of a proper emergency department eye examination including
visual acuity and IOP.
3. Demonstrate understanding of necessary examination findings sufficient to rule out
acute angle-closure glaucoma.
4. Demonstrate an understanding of the imaging and treatment options for a patient that
presents with optic neuritis.
5. Obtains appropriate consultation and/or referral to ophthalmology.
Secondary Learning Objectives: detailed technical goals, behavioral goals, didactic points
1. Avoids delay in thorough examination of eye.
2. Demonstrates understanding that normal IOP with reactive pupils rules out acute angleclosure glaucoma.
3. Formulate plan for either inpatient care with urgent MRI and IV methylprednisolone
therapy or outpatient workup in consultation with ophthalmology.
Critical Actions Checklist
1. Completes thorough eye examination including visual acuity, IOP and attempted
fundoscopic examination.
2. Consults ophthalmology.
3. Demonstrates ability to effectively communicate diagnosis of optic neuritis with the
patient.
Environment (if using as a simulation case)
1.
Room Set Up – Emergency Department Room
a. Manikin Set Up – Sim Man with Pupillary Response Capability
b. Props
i. Snellen Eye Chart
ii. Tonopen
iii. Slit lamp
2.
Distractors – None
Actors (optional)
1.
Roles – Patient, nurse, ophthalmologist
2.
Who May Play Them – Other residents, other students, actors
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Melanie Smith; 32 6/13/1978
For Examiner Only
Author: Colin M. O’Dea, MD
Reviewer: Sharon Griswold, MD
Case Title: Painful Monocular Visual Loss in a Young Adult Female
CASE SUMMARY
CORE CONTENT AREA
Ophthalmology
Neurology
SYNOPSIS OF HISTORY/ Scenario Background
This case is of a 34 year-old female with no known medical problems who presents to the ED
with chief complaint of “I can’t see out of my right eye.” Symptoms occurred suddenly with
rapid progression to current severity and occurred 30 minutes prior to arrival.
The candidate should recognize the potential for permanent visual loss in this scenario,
immediately perform appropriate physical examination of the eye including visual acuity with
confrontation visual fields, Pupillary response, extra-ocular motion, measurement of intraocular
pressure and fundoscopic examination, and consult ophthalmology to discuss the need for
emergent MRI and IV steroid administration.
SYNOPSIS OF PHYSICAL
Initial scenario conditions:
1. Vitals: BP 146/78, HR 96, RR18, Temp 36.9, SpO2 100%
2. Physical Examination: Normal outside of ocular examination. Patient will show normal
exam of the left eye with 20/25 vision, but an abnormal exam of the right eye with light
perception only, a normal external examination, an afferent papillary defect, pain with
extra-ocular motion and papilledema on fundoscopy.
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Melanie Smith; 32 6/13/1978
For Examiner Only
CRITICAL ACTIONS
SCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES
Key teaching points or branch points that result in changes in patient’s condition
1. Critical Action – Check Visual Acuity
This should be done very early in the patient interaction. When the patient states that she
cannot see the Snellen chart, ability to see a waving hand and, ultimately, ability to perceive
light should be tested.
Cueing Guideline: Triage nurse can ask, “are they other methods of showing visual acuity if
a patient cannot read an eye chart?”.
2. Critical Action – Complete Thorough Eye Examination
The candidate should complete a thorough eye examination. The candidate should inspect
the external eye, check visual fields, check pupillary response and evaluate for afferent
pupillary defect by first checking each pupil individually and then swing a light between the
two eyes, check extraocular motion, perform fundoscopy, check intraocular pressure using
the tonopen, examine the eye using fluorescein and examination the eye with a slit lamp.
Cueing Guideline: The nurse confederate may bring in the props of the slit lamp/ eye tray/
tonopen or other resources to prompt the learner.
3. Critical Action – Consult Ophthalmology
The candidate should consult ophthalmology to discuss the need for MRI and IV steroids.
While data is inconclusive regarding the necessity of either, the candidate should
demonstrate the knowledge of appropriate outpatient imaging workup and the appropriate
medical therapy.
Cueing Guideline: Have the patient ask “what will be the next steps?” “Do I need any more
tests today?” Consultant can provide scripted help for lower level learners.
SCORING GUIDELINES/ CASE BRANCHPOINTS
(Critical Action No.)
1. Completes thorough eye examination including visual acuity, visual fields, relative
afferent papillary defect (RAPD), IOP and attempted fundoscopic examination.
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Melanie Smith; 32 6/13/1978
a. A successful candidate must obtain the essential parts of the history and physical
examination to rule out diagnoses such as acute angle closure that would require
more immediate definitive therapy. A candidate should not pass the case
without consideration of alternative diagnoses.
2. Consults ophthalmology.
a. It is likely that ophthalmology consultation will occur via telephone. A successful
candidate will discuss the case over the phone with the ophthalmologist and
arrange for further care if discharged.
3. Demonstrates ability to effectively communicate diagnosis of optic neuritis with the
patient.
a. The patient may become more emotional during the ED visit and the provider
should remain compassionate and answer the patient’s questions with empathy.
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Melanie Smith; 32 6/13/1978
For Examiner Only
HISTORY
Onset of Symptoms:
Symptoms occurred suddenly with rapid progression to current
severity and occurred 30 minutes prior to arrival.
Background Info:
Patient was at home watching television when she began noticing
pain in her right eye and that she was having trouble seeing out of
her right eye. The symptoms progressed over only a few minutes to
the degree to which they are currently. Her eye is more painful
with movement.
Chief Complaint:
“I can’t see out of my right eye.”
Past Medical Hx:
None
Past Surgical Hx:
None
Habits:
Smoking: Denies
ETOH: Socially
Drugs: Denies
Family Medical Hx:
Mother with osteoporosis. Father with Hyperlipidemia.
Social Hx:
Marital Status: Married
Children: Two
Education: Bachelors Degree
Employment: Teaches second grade
ROS:
Pertinent Positives: Right sided visual loss, pain in right eye, and
pain in right eye worsening with extraocular motion
ROS otherwise negative
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Melanie Smith; 32 6/13/1978
For Examiner Only
PHYSICAL EXAM
Patient Name: Melanie Smith
Age & Sex: 32 year old Female
General Appearance: Well-developed, well-nourished female in moderate distress
Vital Signs: BP 146/78, HR 96, RR18, Temp 36.9, SpO2 100%
Head: Normal
Eyes: Visual Acuity:
OD: Able only to perceive light
OS: 20/25
Visual Fields:
OD: Unable to test
OS: Normal
External Eye Exam:
Normal
Pupils:
Pupils equal, round, reactive to light, however, afferent pupillary
defect is present.
Extraocular Motion: Extraocular motion intact but considerable pain in right eye with
extraocular motion.
Fundoscopy:
OD: Optic nerve photo, Note grade 2 papilledema, characterized
by 360 degree nerve elevation without obscuration of the vessels
OS: Normal
IOP:
6
OD: 16, 18, 18
Melanie Smith; 32 6/13/1978
OS: 17, 18, 16
Fluorescein Exam:
Normal
Slit Lamp Exam:
Normal
Ears: Normal
Mouth: Normal
Neck: Normal
Skin: Normal
Chest: Normal
Lungs: Normal
Heart: Normal
Back: Normal
Abdomen: Normal
Extremities: Normal
Rectal: Not Performed
Pelvic: Not Performed
Neurological: Normal except for right eye
Mental Status: Normal
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Melanie Smith; 32 6/13/1978
For Examiner Only
STIMULUS INVENTORY
Suggested items as relevant to the case
#1
Emergency Admitting Form
#2
Results of Eye Examination
#3
CBC
#4
BMP
#5
MRI Brain/Orbits
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Melanie Smith; 32 6/13/1978
For Examiner Only
LAB DATA & IMAGING RESULTS
Learner Stimulus #2
Results of Eye Exam (Must Demonstrate Desire to Perform 6 of 9 Portions of Exam to Receive
Learner Stimulus Sheet #2)
See reference for photo citation
http://webeye.ophth.uiowa.edu/eyeforum/cases/30-AcuteDemyelinatingEncephalomyelitis.htm. Retrieved
February 1, 2011.
Learner Stimulus #3
Intraocular Pressure:
OD: 16, 18, 18
OS: 17, 18, 16
http://www.optivision2020.com/image-files/tono-pen-reichert-xl.jpg. Retrieved February
8, 2011.
For Examiner Only
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Melanie Smith; 32 6/13/1978
LAB DATA & IMAGING RESULTS
Learner Stimulus #4
Complete Blood Count (CBC)
WBC
6.8 /mm3
Hgb
12.6 g/dL
Hct
37.4 %
Platelets 212 /mm3
Differential
Segs
75%
Bands
0%
Lymphs
20%
Monos
4%
Eos
1%
Learner Stimulus #5
Basic Metabolic Profile (BMP)
Na+
140 mEq/L
+
K
4.0 mEq/L
Cl109 mEq/L
CO2
22 mEq/L
Glucose
100 mg/dL
BUN
15 mg/dL
Creatinine 0.8 mg/dL
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Melanie Smith; 32 6/13/1978
For Examiner Only
LAB DATA & IMAGING RESULTS
Learner Stimulus #6
MRI Brain/Orbits: MRI brain, axial T1 post-gadolinium. Enhancement of the right optic nerve is
evident
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Melanie Smith; 32 6/13/1978
Learner Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name:
Melanie Smith
Age:
32 years
Sex:
Female
Method of Transportation:
Private car
Person giving information:
Patient
Presenting complaint:
“I cannot see out of my right eye”
Background: Patient was at home watching television when she began noticing pain in her
right eye accompanied by an acute loss of vision. The symptoms started approximately 30
minutes ago and have progressed rapidly to the current severity.
Triage or Initial Vital Signs
BP:
146/78
HP:
96
RR:
18
Temp:
36.9 orally
SpO2:
100%
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Melanie Smith; 32 6/13/1978
Learner Stimulus #2
Fundoscopy:
OD:
OS: Normal
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Melanie Smith; 32 6/13/1978
Learner Stimulus #3
Intraocular Pressure:
OD: 16, 18, 18
OS: 17, 18, 16
http://www.optivision2020.com/image-files/tono-pen-reichert-xl.jpg. Retrieved February
8, 2011.
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Melanie Smith; 32 6/13/1978
Learner Stimulus #4
Complete Blood Count (CBC)
WBC
6.8 /mm3
Hgb
12.6 g/dL
Hct
37.4 %
Platelets
212 /mm3
Differential
Segs
75%
Bands
0%
Lymphs
20%
Monos
4%
Eos
1%
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Melanie Smith; 32 6/13/1978
Learner Stimulus #5
Basic Metabolic Profile (BMP)
Na+
140 mEq/L
+
K
4.0 mEq/L
CO2
22 mEq/L
Cl
109 mEq/L
Glucose
100 mg/dL
BUN
15 mg/dL
Creatinine
0.8 mg/dL
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Melanie Smith; 32 6/13/1978
Learner Stimulus #6
MRI Results:
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Melanie Smith; 32 6/13/1978
Optional Addendum #1
Feedback/ Assessment Forms (may choose form dependent on use of case)
Painful Monocular Visual Loss in a Young Adult Female
Candidate ________________________
Examiner _________________________
Critical Actions:
 Critical Action #1 – Check Visual Acuity
 Critical Action #2 – Complete Thorough Eye Examination
 Critical Action #3 – Consult Ophthalmology
Dangerous Actions: (Performance of one dangerous action results in failure of the case)
 Dangerous Action #1 – Failure to Check Visual Acuity
 Dangerous Action #2 – Failure to Check IOP
Overall Score:
 Pass
 Fail
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Melanie Smith; 32 6/13/1978
Optional Addendum 2:
Core Competency Assessment
Painful Monocular Visual Loss in a Young Adult Female
Candidate ________________________
Examiner _________________________
Does Not Meet
Expectations
Patient Care
Medical
Knowledge
Interpersonal
Skills and
Communication
Professionalism
Practice-based
Learning and
Improvement
Systems-based
Practice
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Meets
Expectations
Exceeds
Expectations
Melanie Smith; 32 6/13/1978
For Examiner
Date: _________ Examiner: _____________________ Examinee(s): ______________________
Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)
The learner should be scored (based on level of training) for each item above with one of the
following:
NI = Needs Improvement
ME = Meets Expectations
AE = Above Expectations
NA= Not Assessed
Critical Actions
Obtained Visual Acuity
Completed Eye Exam including IOP to
Rule Out Acute Angle-Closure
Glaucoma
Obtained necessary consultation from
Ophthalmology to develop ED and
outpatient plan of care.
Demonstrate / utilize effective
communication techniques such as
specifying order details and closed loop
communication
NI
ME
AE
NA
Category
PC, MK, PBL
PC, MK, PBL
PC, MK, PBL
P, ICS
Category: One or more of the ACGME Core Competencies as defined in the SDOT
PC=
MK=
PBL=
ICS=
P=
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Patient Care
Compassionate, appropriate, and effective for the treatment of health problems
and the promotion of health
Medical Knowledge
Residents are expected to formulate an appropriate differential diagnosis with
special attention to life-threatening conditions, demonstrate the ability to utilize
available medical resources effectively, and apply this knowledge to clinical
decision making
Practice Based Learning & Improvement
Involves investigation and evaluation of their own patient care, appraisal and
assimilation of scientific evidence, and improvements in patient care
Interpersonal Communication Skills
Results in effective information exchange and teaming with patients, their
families, and other health professionals
Professionalism
Melanie Smith; 32 6/13/1978
Manifested through a commitment to carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to a diverse patient population
SBP= Systems Based Practice
Manifested by actions that demonstrate an awareness of and responsiveness to
the larger context and system of health care and the ability to effectively call on
system resources to provide care that is of optimal value
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Melanie Smith; 32 6/13/1978
Debriefing Materials:
Please attach any powerpoint lectures, diagrams, images or other pertinent material the
instructor may use for debriefing material.
Debriefing Discussions:
Emergency Department Eye Examination
Afferent Pupillary Defect
Painful Monocular Visual Loss
Optic Neuritis
Add 4-6 keywords for future searching functions
Optic Neuritis
Acute Angle-Closure Glaucoma
Eye Examination
Has this work been previously published?
No
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Melanie Smith; 32 6/13/1978
Debriefing Discussion:
Emergency Department Eye Examination
As this case illustrates, proper history regarding ocular complaints and proper
examination of the eye are both essential in the management of patients who present to the
emergency department with eye complaints.
A proper history relating to ocular emergencies should, as always, begin with a history
of present illness. Important aspects of HPI as related to ocular emergencies should always
begin with questions of acuity, including general acuity, ability to differentiate color, loss of
specific visual fields and, if pertinent, the pattern of acuity loss including a “curtain or veil”,
tunneling of vision or central visual loss. Following questions of acuity should be questions
regarding pain, either at rest or with extraocular movement, rate of progression of symptoms,
any associated symptoms and circumstances surrounding onset of symptoms including trauma
and environmental or chemical exposure.
After the HPI past medical, surgical, family and social histories should be taken. It is
important to remember that these histories should all be taken both generally and as
specifically relates to the eye. While a history of diabetes or atrial fibrillation is very important
to elucidate in a case such as this, past history of type of visual correction used, contact lens
hygiene including leaving contacts in while sleeping, and past ocular surgeries is just as
important.
Following an appropriate history examination of the eye should begin. However, in the
case of a potentially emergent eye complaint as in all potentially emergent complaints, it is
important to consider taking only a very brief history before immediately continuing to
examination of the eye so as not to delay necessary diagnosis and intervention. The
components of an emergency department eye exam are as follows. While listed in a particular
order, certain components are more or less important in the evaluation of different eye
complaints and should be performed earlier or later in the evaluation of the eye depending on
the complaint.
1. Visual Acuity: This should be done using a Snellen chart if available. If a patient is
unable to read a Snellen chart, have the patient count fingers at the furthest possible
distance. If the patient is unable to count fingers, check basic light perception.
2. External Eye: The external eye, lids and periorbital skin should be examined both grossly
and, if appropriate, with fluorescein to evaluate for trauma, infection, deformity,
crepitus or proptosis. If appropriate, the orbital rims should be palpated for step-offs.
3. Confrontation Visual Fields: Visual field testing should be performed in both eyes.
Visual field defects can provide considerable information and can be particularly difficult
to elicit from history as many patient describe visual field defects simply as “blurry.”
4. Pupils: Evaluate both pupils for reaction to both light and accommodation, both directly
and consensually.
5. Ocular Motility: Extraocular motility should be checked bilaterally.
6. Anterior Segment: A slit-lamp should be used to evaluate the anterior segment of the
eye to evaluate the conjunctiva, cornea, anterior chamber, iris, lens and ciliary body.
The slit lamp can be used to visualize hemorrhage, deformity, discharge, inflammation,
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Melanie Smith; 32 6/13/1978
foreign body, abrasions, dendrites, perforations, aqueous humor leakage, hyphema,
hypopion, cell and flare.
7. Fundoscopic Examination: Fundoscopic examination is used to evaluate the optic nerve,
macula and retina. Chemical dilation of the pupil aids in fundoscopic examination but is
not often practical in the emergency department. Performing fundoscopic examination
in a dark room often allows sufficient pupillary dilation to complete the exam.
8. Intraocular Pressure: Intraocular pressure should be checked using whichever tool is
available. While several different tools may be available, most emergency departments
now have tono-pens available and most tono-pen kits include instruction manuals for
calibration and use.
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Melanie Smith; 32 6/13/1978
Debriefing Discussion:
Afferent Pupillary Defect
An afferent pupillary defect exists when pupillary response to light in one eye is not as
great as pupillary response to light in the other eye, or when pupillary response to light in one
eye is lost entirely. This is tested using the “Swinging Flashlight Test” which is depicted here.
These illustrations demonstrate an afferent pupillary defect of the left eye.
A. Evaluate both pupils at
baseline
B. Light shined into right
pupil causes bilateral
pupillary constriction
C. Swinging the light to the
left pupil causes dilation
of both pupils as the light
reflex on the left is either
diminished compared
with the right or absent
D. Swinging the light into
right pupil causes bilateral
constriction once again
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Melanie Smith; 32 6/13/1978
Debriefing Discussion:
Painful Monocular Visual Loss
This case illustrates a presentation of undifferentiated painful monocular visual loss in
the absence of trauma to the Emergency department. The differential diagnosis for visual loss
is quite long, including globe rupture, retinal detachment, retrobulbar hematoma, acute angleclosure glaucoma, optic neuritis, central retinal vain occlusion, central retinal artery occlusion
and temporal arteritis. Excluding very obscure etiologies and very late findings in infectious
diseases such as orbital cellulitis, however, the differential diagnosis for painful monocular
visual loss in the absence of trauma is only two things: acute angle-closure glaucoma vs. optic
neuritis.
Recognition of this differential is essential because of the need for emergent treatment
for patient presenting with acute angle-closure glaucoma. The patient in this case presented
with painful monocular visual loss due to optic neuritis. As you will learn, the treatment for
optic neuritis is controversial with observation and outpatient follow up alone remaining a
viable option. As such, the two most important aspect of the management of this case are the
performance of a proper eye exam and the use of findings from the history and physical exam
to rule out acute angle-closure glaucoma as the etiology of this patient’s complaint.
Acute angle closure glaucoma occurs when dilation of the pupil blocks flow of the
aqueous humor from the posterior chamber where it is produced by the ciliary body through
the pupil to the anterior chamber where it drains through the Canal of Schlemm. The blockage
of aqueous humor flow causes a build up of pressure in the eye. Excessive build-up of pressure
has the potential to irreversibly damage the eye, causing permanent blindness. Diagnosis of
angle-closure glaucoma is based on an appropriate history along with a mid-dilated nonreactive pupil and increased intraocular pressure on exam. Treatment for acute angle-closure
glaucoma is aimed at decreasing IOP through the use of topical beta-blockers, topical alphaagonists, topical steroids, IV diamox and IV mannitol. During an acute attack, pressure-induced
ischemia causes paralysis of the iris. Once the pressure is decreased, topical pilocarpine may be
used to promote miosis and increase aqueous humor flow into the anterior chamber and out of
the eye.
In this case, the patient had reactive pupils, with an afferent pupillary defect, and
normal IOP bilaterally. This information is sufficient to rule out acute angle-closure glaucoma
as the etiology of the patient’s symptoms and to allow the clinician to focus on optic neuritis as
the likely etiologic agent.
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Melanie Smith; 32 6/13/1978
Debriefing Discussion:
Optic Neuritis
Optic neuritis is caused by demyelinating inflammation of the optic nerve and may occur
alone or as a symptom of, and sometimes an initial presentation of, multiple sclerosis. It may
also occur in the setting of adjacent infection involving the orbits or paranasal sinuses or in the
setting of systemic viral illness. It occurs more commonly in Caucasians, affects women twice
as often as men and typically presents initially between the ages of 20-45.
Symptoms of optic neuritis include rapidly progressing painful visual loss in one or both
eyes that is typically worse with extraocular movement. The visual loss may range from slightly
blurry vision to complete visual loss, may include changes in color perception, may be
exacerbated by heat and may include perception that objects moving in a straight line have a
curved trajectory.
On physical examination, patients’ with optic neuritis are found to have a decrease
either in visual acuity or color perception, pain exacerbated by extraocular movement while
extraocular movement remaining intact, an afferent pupillary defect and, in 1/3 of cases,
papilledema present on fundoscopy. Aside from possible injection, the external eye exam
should be normal, as should the anterior segment, the IOP and visual fields relative to one
another. A red desaturation test, performed by having the patient stare at a dark red object
with one eye and then testing the other eye to see if the object appears the same color, is often
abnormal in optic neuritis.
Laboratory studies are not particularly useful in the diagnosis of optic neuritis as most
laboratory studies are typically found to be normal. Optic neuritis can be detected on MRI but
other imaging modalities, like laboratory studies, are typically not of use.
Treatment of optic neuritis was studied extensively in The Optic Neuritis Treatment
Trial, a large, randomized study on the treatment of optic neuritis. While very informative, the
study showed no statistically significant difference between high dose IV steroids and
observation alone in terms of visual acuity at the five-year mark. The study did suggest that IV
steroids may be slightly beneficial in the shorter term and may be slightly beneficial in keeping
optic neuritis from progressing to multiple sclerosis, but these differences were small and
remain somewhat controversial. The study did show, however, that both observation and high
dose steroids lead to better outcomes than high dose oral steroids, which should be avoided.
Being that observation without treatment is a reasonable course of action, the need for
emergent MRI from the ER for definitive diagnosis is controversial. As such, the best approach
is to consult an ophthalmologist and develop with the ophthalmologist a plan either for
observation with outpatient follow up and outpatient MRI or MRI for definitive diagnosis in the
ED and IV steroids.
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Melanie Smith; 32 6/13/1978
References:
Andreoli, T.E., et al (Eds.). Cecil Essentials of Medicine (6th ed). Philadelphia, PA: Saunders.
Beck RW. The Optic Neuritis Treatment Trial. Arch Ophthalmol. 1988;106(8):10511053.
Ergene, E, Machens, NA. (2009, July 30). Adult Optic Neuritis. Retrieved from eMedicine
website: http://emedicine.medscape.com/article/1217083-overview
Kumar, V., et al (Eds.). Robbins and Cotran Pathologic Basis of Disease (7th ed). Philadelphia, PA:
Elsevier Saunders.
Tantri, AP, Lee, AG. (2005, Feb 21). Acute Demyelinating Encephalomyelitis (ADEM) with
associated optic neuritis: 9 year-old girl presents to an outside hospital with fatigue, poor
appetite, and decreased activity for 3 weeks. Retrieved from EyeRounds.org website:
http://webeye.ophth.uiowa.edu/eyeforum/cases/30AcuteDemyelinatingEncephalomyelitis.htm
Tintinalli, J., et al (Eds.). Emergency Medicine A Comprehensive Study Guide (6th ed). New York,
NY: McGraw Hill.
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