Need help with solving this ophtho case!!!

[rajvosa]

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Hi guys,

I really would appreciate some help in figuring out this ophtho case. If anybody would try to give at least differential dx. or some clue what is going on.

Thanks

Here we go:
A 65yr F came to clinic complaning of a clearly defined blur over her central
vision in the left eye. The blurred patch was first noticed shortly before
christmas and has worsened in the intervining period. She can plot the edge
of the blurred area quite easily on an Amsler Grid. The right eye is
exotropic (turns out) following squint surgery and pathcing as a child. An
ophthalmologist said the problem was due to a cataract and advised surgery.

Visual Acuity in right eye is 20/30.
Pupil testing revealed a left afferent defect. A red target appeared
desaturated in the left eye compared to the right eye in Tangent screen
visual field testing.

 

[Richard_Hom]

Hi guys,

I really would appreciate some help in figuring out this ophtho case. If anybody would try to give at least differential dx. or some clue what is going on.

Thanks

Here we go:
A 65yr F came to clinic complaning of a clearly defined blur over her central
vision in the left eye. The blurred patch was first noticed shortly before
christmas and has worsened in the intervining period. She can plot the edge
of the blurred area quite easily on an Amsler Grid. The right eye is
exotropic (turns out) following squint surgery and pathcing as a child. An
ophthalmologist said the problem was due to a cataract and advised surgery.

Visual Acuity in right eye is 20/30.
Pupil testing revealed a left afferent defect. A red target appeared
desaturated in the left eye compared to the right eye in Tangent screen
visual field testing.

Diff Dx
1. Left Optic Neuritis
2. Exudative AMD
3. RPE exudative detachment
4. Wasn't sure if an internal was described but BRVO near the optic nerve head.
5. IOP's? Onset unclear from history? Arcuate defect from glaucoma?

Suggestions:

1. History is a bit brief and could lead to many things.
2. The details of the physical exam are also sketchy. May need more data to further differentiate.

HTH,
Richard

 

[Andrew_Doan]

Hi guys,

I really would appreciate some help in figuring out this ophtho case. If anybody would try to give at least differential dx. or some clue what is going on.

Thanks

Here we go:
A 65yr F came to clinic complaning of a clearly defined blur over her central
vision in the left eye. The blurred patch was first noticed shortly before
christmas and has worsened in the intervining period. She can plot the edge
of the blurred area quite easily on an Amsler Grid. The right eye is
exotropic (turns out) following squint surgery and pathcing as a child. An
ophthalmologist said the problem was due to a cataract and advised surgery.

Visual Acuity in right eye is 20/30.
Pupil testing revealed a left afferent defect. A red target appeared
desaturated in the left eye compared to the right eye in Tangent screen
visual field testing.

First, I like to know if there is a history of DM or other systemic illnesses. Second, I need to know what the dilated fundus exam showed. Third, a Goldmann Visual Field is helpful in this case. Fourth, how large is the RAPD OS? Also, what is the vision of the LEFT eye? What are the intraocular pressures?

With only the above info, I'd have to argue that optic neuritis is unlikely in a 65 y.o. woman. Optic neuritis is typically seen in younger patients.

Other causes of gradual vision loss that may produce central vision loss in a 65 y.o. woman associated with a RAPD:

1) giant cell arteritis
2) normal tension glaucoma or primary open angle glaucoma
3) non-arteritic ischemic optic neuropathy
4) old and resolving branch retinal or central retinal artery occlusion
5) optic tumor or optic neuropathy associated with systemic malignancy
6) large ARMD scar or CNVM

Clearly, with a more complete description of the ocular examination and findings, we can exclude some of the above diagnoses.

 

[rajvosa]

How about optic neuropathy as a no1 ddx. given only these details in her history and exam?

 

[Andrew_Doan]

How about optic neuropathy as a no1 ddx. given only these details in her history and exam?

Optic neuropathy from what?

Many of the above can cause an "optic neuropathy".

Is this vascular vs non-vascular? There's not enough information to make a diagnosis here. We need more details about the exam. For instance, is the nerve pale or not pale? Is the nerve cupped or not cupped?

 

[Richard_Hom]

How about optic neuropathy as a no1 ddx. given only these details in her history and exam?

Dear rajvosa,

Are you preparing this prospective patient for a grand rounds case or for presentation to an attending? Just a thought...

At this juncture, a further description of your physical findings and several ancillary tests might be more enlightening. If you have done so, you could post more of your findings or if you can reexamine the patient and garner these additional details.

As Dr. Doan suggested, these eye related findings would be helpful
1. Pallor or color of the optic nerve heads right vs. left
2. Shape and size of the disks
3. Cupping
4. State of the macula
5. Any hemorrhages anywhere
6. threshold visual field

Richard

These would be great starters.

 

[mdkurt]

Are you sure about the APD? Sounds like retina to me.