Problem Solving Case 1 History 22 years old

Problem Solving Case 1

History Ø 22 years old female presents to ER physician with history of sudden redless decrease in vision in the rt. eye 10 days ago with mild headaches and pain on eye movement. Her past medical history is insignificant of any ophthalmic or systemic illness.

Examination • On examination she showed the following Vitals: – Pulse: 72/regular – Temp. 37 – Resp: 14 – B. P 120/80

Eye Examination ØVA OD 20/100 OS 20/20 ØPain on abduction of Rt. eye ØEOM: full ØRed reflex: normal ØFundus ex. : normal disc, vessels, maculae

Case Management 1. Summarize the case (+ve and -ve) 2. Any further information you needs to know in history? 3. Any further information you need to know in the examination 4. What is your provisional diagnosis? 5. What is your role as an ER physician in this case? ? ? Who treats such a case 6. How does the ophthalmologist manage such a case?

Case Summary Positive Negative 22 years old (Young not old PMH insignificant Female ( Not male) Normal Vitals Sudden (Not gradual) decrease in Vision Decreased vision in one eye Headaches Normal Red Reflex Pain on Eye Movement (Symptom) Normal Fundus Decreased vision OD Pain on Eye Movement (sign)

Further History • Onset: how? When? What • Progression of vision, headaches, pain • Headaches Relieving & PPT factors • Uhthoff’s Phenomenon • Diplopia/ Oscillopsia /Dizziness • Parasthesia and weakness • Bowl symptoms

Further History • • Onset of Visual loss: How? When? What Progression of vision, headaches, pain Relieving & PPT factors Social History – Smoking – Alcohol – Others • Family History • Drug History

Further Examination • Proptosis • Ptosis • Tenderness over sinuses • Multiple pinhole • Pupil examination • Visual field

Diseases Onset & Progress Acute Ischemia-Hge. Infections Inflammation Minutes 24 hours Subacute Infections Inflammations 24 hours to several days Chronic Compressive Infections 4 weeks to years

Provisional Diagnosis Optic Neuritis

Differential Diagnosis

Differential Diagnosis • Other causes of Optic Neuropathies ØIschemia ØInfections ØNutritional ØCompressive ØHereditary ØTraumatic

Differential Diagnosis • Other causes of acute visual loss ØSinus disease ØCRVO ØCRAO ØRetinal Detachment ØVitreous Hge.

Why? ? ? 22 years Female Sudden Pain on eye movement Unlikely ischemic but could be any other process Demylination or any other process Ischemia/Inflam. /Infection/ Sudden discovery Sinusitis- Myositis- Cellulitis. Optic neuritis-Acute Grave’s Scleritis & rules out vascular event (CRAO/CRVO/ION)

Why? ? ? Normal Vitals Unlikely infectious Regular Pulse Unlikely shooting emboli Unlikely Grave’s Unlikely Cellulitis or myosiitis or Grave’s Absence of proptosis & Lid Signs Absent tenderness Unlikely sinusitis over sinuses

Why? ? ? Vision MPH no improvement Sluggish Pupil reaction with RAPD Visual Field Central Scotoma Refractive Error/ Media Problem / Retina /Neurological Psychological Not refractive Disease affecting visual pathway anywhere from ON to lateral geniculate body ON disease or macular disease

Why? ? ? Visual Field Central Scotoma ON disease or macular disease Fundus Normal Not retinal disease but can not rule out ON or visual pathway disease.

Differential Diagnosis • Other Causes of ON Disease • Sinus Disease • CRAO +CRVO • Retinal Detachment