Vision abnormalities (PEARLS)

NCCPA™ PANCE EENT Content Blueprint eye disorders ⇒ vision abnormalities

Amaurosis fugax	Patient will present as → an 82-year-old man who presents to the emergency department complaining of vision loss in his left eye. He states that it suddenly appeared as if a curtain was coming down over his left eye. It resolved after five minutes, and his vision has returned to normal. He has a history of coronary artery disease and type 2 diabetes. Amaurosis fugax (amaurosis meaning darkening, dark, or obscure, fugax meaning fleeting) is a painless temporary loss of vision in one or both eyes Amaurosis fugax is not itself a disease. Instead, it is a sign of other disorders. Vision loss is classically described as a curtain coming down over one eye Other descriptions of this experience include monocular blindness, dimming, fogging, or blurring Five distinct classes based on their supposed cause: embolic, hemodynamic, ocular, neurologic, and idiopathic Embolic/hematologic causes of amaurosis fugax: Most episodes of amaurosis fugax are the result of stenosis or atherosclerosis of the ipsilateral carotid artery Retinal artery occlusion: blockage of the central retinal artery or ophthalmic artery leads to sudden, painless, monocular vision loss due to retinal hypoxia The most common source of these emboli is an atherosclerotic carotid artery Amaurosis fugax (an example of a TIA) occurs if the clot passes and the vision loss is transient. If the clot cannot pass, central retinal artery occlusion occurs Other causes in this class include hypercoagulability states, thrombocytosis, SLE, and giant cell arteritis Ocular causes of amaurosis fugax include keratitis and posterior vitreous detachment Neurologic causes of amaurosis fugax include migraine, tumor, optic neuritis, and multiple sclerosis Idiopathic: despite extensive workups, a cause will not be found in some patients DX: A fundus exam may reveal optic disk pallor, a cherry-red macula (retinal vascular occlusion), and retinal edema Laboratory tests should also be ordered to investigate some of the more common systemic causes, including a CBC, ESR, lipid panel, EKG, and blood glucose level Noninvasive carotid duplex ultrasound studies are recommended to identify carotid artery disease if ophthalmic and laboratory findings are inadequate for explanation TX: If the diagnostic workup reveals a systemic disease process, directed therapies to treat that underlying cause should be initiated If the amaurosis fugax is caused by an atherosclerotic lesion, aspirin is indicated, and carotid endarterectomy is considered based on the location and grade of the stenosis Left untreated, this event carries a high risk of stroke; after carotid endarterectomy, which has a low operative risk, there is a very low postoperative stroke rate
Amblyopia	Patient will present as → a 5-year-old male is brought by his parents and referred by his teacher for suspected decreased vision in his left eye. His mother had not noticed any vision problems. He has had normal growth and development. On exam, the patient has an abnormal vision screen of the left eye and red reflex asymmetry. Amblyopia (lazy eye) is reduced visual acuity that is not correctable by refractive means It may be caused by strabismus (crossed eye), uremia, or toxins, such as alcohol, tobacco, lead, and other toxic substances DX: screening to detect amblyopia in all children younger than five years of age Screening includes vision risk assessment at all health maintenance visits and vision screening at three, four, and five years of age TX: Includes correction of refraction error as well as forced use of the amblyopic eye by patching the better eye or blurring with glasses or drops
Glaucoma	*Patient with open-angle glaucoma* present as → a 47-year-old African American male presents for an ophthalmic examination. Medical history is significant for hypertension and type II diabetes mellitus. On slit-lamp examination, there is cupping of the optic disc, with a cup-to-disc ratio > 0.6. Tonometry reveals intraocular pressure of 45 mmHg (normal is 8-21 mmHg). Peripheral field vision loss is noted on the visual field exam. Patient with acute angle-closure glaucoma will present with → a 60-year-old Asian American woman presents with sudden ocular pain. She reports she was visiting the planetarium when the pain started, and when she walked outside, she saw halos around the street lights. The pain was so bad that she began to vomit. She reports her vision is decreased. Physical examination reveals conjunctival injection, a cloudy cornea, and pupils Open-angle glaucoma: most common, aqueous outflow obstruction > 40 y/o, African Americans, often asymptomatic Peripheral to central gradual visual loss (versus macular degeneration which is a central loss) Acute narrow angle-closure glaucoma: Iris against the lens, dark environment, acute loss of vision, nausea, and vomiting. Classic triad: injected conjunctiva, steamy cornea, and fixed dilated pupil. This is an ophthalmic emergency DX: Diagnosis is confirmed by tonometry demonstrating increased intraocular pressure May demonstrate cupping of the optic nerve All patients should be screened at age 40 - may present for routine fundoscopy with a cup-to-disk ratio > 0.5 (<0.5 is normal). This is suggestive but not diagnostic of glaucoma, so you will progress to the next step, which is tonometry Perform tonometry (IOP testing): pressure > 21 mmHg is concerning but not diagnostic - proceed to the next step, which is peripheral field testing Peripheral field testing and optic disc changes confirm the diagnosis in normal pressure glaucoma Gonioscopy is the gold-standard method of diagnosing angle-closure glaucoma. This technique involves using a special lens for the slit lamp, which allows the ophthalmologist to visualize the angle TX: Acute narrow angle-closure glaucoma Acetazolamide IV is the first-line agent - decrease IOP by decreasing aqueous humor production Topical beta-blockers (ex. timolol) reduces IOP without affecting visual acuity Miotics/cholinergics (ex. Pilocarpine, Carbachol) Peripheral iridotomy is the definitive treatment Chronic open-angle glaucoma Prostaglandin analogs are 1st line (ex. latanoprost) - increases the outflow of aqueous humor Topical beta-blocker (Timolol) - decrease production of aqueous humor Trabeculoplasty** - opens the trabecular meshwork
Strabismus (ReelDx)	ReelDx Virtual Rounds (Strabismus ) Strabismus You are called to see a 2 y/o with “eye drifting” x 1 month Patient Gender: Female Age: 34 months Weight: 30 lbs/13.6 C Vitals Temperature: 97.7 F/36.5 C Signs and Symptoms “lazy eye” Click here to work through this patient case simulation. Patient will present as → a 3-year-old girl brought to you by her mother, who is worried about her daughter’s “lazy eye.”She reports that her daughter’s symptoms are exaggerated when she has a cold. Past medical history is negative for trauma or headaches. The patient has an asymmetric corneal light reflex, and the cover/uncover test reveals a right-sided esotropia. You refer the patient to a pediatric ophthalmologist. Strabismus is defined as any form of ocular misalignment Exotropia: Out-turning of eyes Esotropia: In-turning of eyes (see ReelDx video in presentation tab) Hypertropia: Upward deviation of eyes Hypotropia: Downward deviation of eyes DX: The cover/uncover test is used to diagnose strabismus Cover: cover one, observe other (+) uncovered eye shifts to re-fixate Cover/uncover: (+) deviated affected eye TX: Treatment options can include glasses, occlusion therapy, orthoptic exercises, surgery, or a combination of these therapies If untreated after age two, amblyopia results
Presbyopia	Patient will present as → a 45-year-old female, accountant, presents with complaints of difficulty reading small print and needing to hold reading materials farther away to see clearly. She mentions headaches and eye strain after prolonged reading or computer use. These symptoms started gradually over the past year and have become more bothersome. She denies any significant changes in vision aside from these near-vision difficulties. Presbyopia is an age-related condition causing gradual loss of the eye's ability to focus on nearby objects, typically starting in the early to mid-40s and affecting nearly everyone by age 65 Common symptoms include difficulty reading small print, needing to hold reading materials farther away, eye strain, and headaches during close work It results from the hardening of the lens inside the eye, reducing its flexibility and ability to change shape for focusing on close objects DX: Diagnosis involves a comprehensive eye exam with visual acuity tests, refraction assessments, near vision tests, and slit-lamp examinations. TX: Treatment options focus on improving near vision and include eyeglasses, contact lenses, refractive surgery, lens implants, and lifestyle modifications such as using good lighting and taking breaks during prolonged near work