optho physical exam question

Kalel

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    Well, I'm sure that this is going to sound like a dumb question to all of you optho people, but I'd still like some help with it anyways. I had a patient c/o intermittent blurry vision for the past year. She had no real signficant PMHx, and upon further questioning, she stated that every time she went to an optometrist with this complaint, the optometrist would increase her prescription (she was now on bifocals, but claimed to be able to see better without them so she never wore them, didn't have them in the office). I was pressed for time because she had multiple other complaints, so I didn't do a complete optho exam, but I did try to do a fundoscopic exam (on undilated pupils) just for kicks. The odd part was that the bottom pupil was hazy b/l on fundoscopic exam. No matter how I tried to adjust my fundoscope, I couldn't see through the bottom half of the pupil; it was just a dark black shadow overlying it. Could this have been some real pathology, or was this just due to physical examiner incompetence? I kind of regret not checking visual fields, and I couldn't check acuity without her glasses; so we just referred her to outpatient optho.
     

    LASIKguy

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      How old was she? I guess older than 50?

      It is probably your fundoscopic technique or she got cataract in that eye.

      But that doesn't answer the intermittent blurry vision question.


      Its good that you refered your patient to an ophthalmologist.
      BTW I bet Dr. Doan will come up with atleast 100+ things in DDX since he is interested in neuro ophtho :p and they get excited with anything dealing wiht pupils :laugh:
       

      Andrew_Doan

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      1. Attending Physician
        Hi there Kalel!

        If her vision was good, then I doubt there was major 'structural' pathology; and, what you saw is likely due to examiner difficulty with an undilated pupil. However, we need more info.

        How old is the patient?

        What's the duration of the intermittent blurry vision? Is it unilateral or bilateral? Is it associated with pain?

        How often does the blurry vision occur?

        Is the blurry vision worse with distance or at near?

        Is there a RAPD? Is there anisocoria?

        Does she describe any symptoms of double vision, which can be blurry images if there is only slight diplopia?

        What medications are she taking?
         
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        ckyuen

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          most likely poorly controlled blood sugar resulting in her fluctuating prescription and psc for the inferior blur. sounds like it from the description of your direct fundoscopic exam. But more history would be helpful
           

          Andrew_Doan

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          1. Attending Physician
            Originally posted by ckyuen
            most likely poorly controlled blood sugar

            Did she have DM or are you just suggesting?

            You're up late or early!? ;)

            What's the call schedule as a PGY-3 at UTSW? Mine is about twice monthly, but the first years take all weekend and holiday calls. It's really nice. :D
             

            ckyuen

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              my mistake i misread. he said she had multiple other complaints but not really sure of what nature, anything to suggest dm. maybe a fasting bg or hga1c would be in order.

              I'm just awake b/c one of three weekends this year I'm on call.
               

              Andrew_Doan

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              1. Attending Physician
                Originally posted by ckyuen
                my mistake i misread. he said she had multiple other complaints but not really sure of what nature, anything to suggest dm. maybe a fasting bg or hga1c would be in order.

                I'm just awake b/c one of three weekends this year I'm on call.

                Diabetes is a good thought. :)

                Any traumas tonight or interesting cases in Dallas?
                 

                Kalel

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                  Yeah, I thought that it was probably just due to poor PE skills on my part. I played around with it for ~5 minutes though, and it didn't seem to matter what angle I was at, the bottom half just seemed hazy black. I thought that it might be an early stage for a cataract too. Anyways, I didn't take too much history on the intermittent blurry vision because I assumed that it was due to her not wearing her prescribed glasses and she had multipe other complaints that brought her in (edema b/l in LE, URI sx, breast tenderness, hadn't been to a doc in 5 yrs). The patient was ~50. We thought about diabetes too, and checked a random blood sugar on her; it was 83. She wasn't taking anything except an OTC cold medicine (theraflu). PERRL, no aniscoria. She was a new patient so we didn't have much in the way of old lab records or anything too. I think that an optho referral was probably the most appropriate thing to do at the time since it was an office visit and she had so many other complaints; I didn't think that it was an opthalmologic emergency or anything given that it had been going on for the past year. Thanks for the help guys!
                   
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