Grand Rounds - Routine Eye Examination?

[Richard_Hom]

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PHI:
40 year old presents c/o

1. Decreasing near vision of gradual onset, equal in both eyes.
2. Decreasing distance vision of gradual onset, equal in both eyes
3. Malaise and tiredness
4. Inability to concentrate
5. 10 pound loss of weight in 1 month

Questions:

1. What further history would you take?
2. What lab studies, if any?
3. What, if any, imaging studies?
4. What eye or physical examination testing would you do?

 

[TAL]

Order thyroid panel, exophthalmometry.

Any fundus photos?

 

[Richard_Hom]

Order thyroid panel, exophthalmometry.

Any fundus photos?

Very good.

What test in the optometrists office could have helped make this tentative diagnosis of ocular implications of Grave's Disease?

 

[cpw]

Very good.

What test in the optometrists office could have helped make this tentative diagnosis of ocular implications of Grave's Disease?

IOP in upgaze, EOMs and exopthalmometry.

 

[Andrew_Doan]

Hertel exophthalmometry will confirm proptosis. Look for signs of ocular motility problems. Look for lid retraction and inferior scleral show. Look for injection of the muscle insertions particularly the inferior and medial recti.

If available, orbital ultrasound will assess the muscle enlargement.

Check RAPD. With vision loss, we're extremely concerned about optic neuropathy. A CT scan would help to visualize the extraocular muscles and strain placed on the optic nerve. A Goldmann or automated visual field helps to determine the degree of visual loss. Emergent consult to oculoplastics for orbital decompression surgery if there are signs of vision loss due to thyroid orbitopathy.

Consult internal medicine to manage thyroid disease.

 

[Tony.]

Very good.

What test in the optometrists office could have helped make this tentative diagnosis of ocular implications of Grave's Disease?

Graves Disease !! TOO MANY 'T' CELLS ....

sorry, thats all i remember about that disease from my A&P class.....(I think it was the chapter about immunity etc.)
sorry! carry on discussing, BUT I CANT WAIT FOR MY CLINCALS TO BEGIN IN 2 YEARS ! 😍

 

[optcom]

thyroid vs MG
ICE test for MG at OD office.
Hertel or just a ruler
+Force duction test if EOM swollen