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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.