PANCE Blueprint EENT (7%)

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.

Transient partial or complete loss of vision in one eye - The most common cause of amaurosis fugax is a cholesterol plaque emboli from a carotid artery plaque

  • Blockage of the central retinal artery leads to sudden, painless, monocular vision loss due to retinal hypoxia
  • Vision loss is classically described as a curtain coming down over one eye
  • 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

DX: A fundus exam may reveal optic disk pallor, a cherry-red macula, 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 it does not resolve spontaneously, treatment is recommended within an hour of the occlusion

  • Treatment involves surgical decompression, but, if unavailable, digital massage of the globe and CO2 rebreathing should be initiated in an attempt to pass the clot
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 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 lens, dark environment, acute loss of vision, nausea, and vomiting.

  • Classic triad: injected conjunctivasteamy cornea, and fixed dilated pupil, this is an ophthalmic emergency

DX: 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

TX:

Acute narrow angle-closure glaucoma

  • Acetazolamide IV is the first-line agent - decrease IOP by decreasing aqueous humor production
  • Topical beta-blocker (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), Timolol
Scleritis
Patient will present as → a 42-year-old white female complaining of a severely painful right eye. The pain is a constant, boring pain that worsens at night and in the early morning hours and radiates to the face and periorbital region. Additionally, she reports a headachewatering of the eye, and ocular redness.

Inflammation of the sclera associated with systemic immunologic disease, such as rheumatoid arthritis

  • It causes significant eye pain (severe, deep pain)

DX: On examination, there is ocular redness and pain on palpation of the eyeball. It can cause visual impairment

  • Labs should include screening for systemic immunologic diseases - ANCAs, ANA, CRP, ESR, Lyme, RA, ACE, RPR, etc.

TX: Refer the patient for prompt evaluation by an ophthalmologist

  • Treatment involves topical and sometimes systemic corticosteroids
Strabismus (ReelDx)
ReelDx Virtual Rounds (Strabismus )
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

TX: Patch exercises, if untreated after age two, amblyopia results

Retinal vascular occlusion (Lecture) (Prev Lesson)
(Next Lesson) Amaurosis fugax
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