Case #8
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Vision Change Tutorial and Case Studies
Recommended way to proceed:
- It is recommended that you skim (at least read the bold print) the tutorial
section (I. Tutorial), before going through the case studies (II. Case Studies). You can
then refer back to the tutorial/outline as necessary while doing the case study/questions.
Outline of Vision Change Tutorial/Case Study:
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-
- I. History of Present Illness
- Questions should identify any:
- Injury. If it exists, how it occurred (how, when, where)
- Any associated symptoms. Such as change in acuity, floaters, light flashes,
"curtains"
- Questions should include the basic PQRST qualities:
- Palliation. What makes it (any symptom or pain) better
- Quality of pain: stabbing, dull, etc
- Remitting. What makes it
- Severity. Intensity of the pain/symptom
- Temporal/Onset (eg, sudden loss may represent vascular occlusion and should be promptly
evaluated by an ophthalmologist (#4, Silverman, 1992))
- II. Past Medical History:
this is sometimes overlooked, but it can be an important
piece of information. Systemic illness can present with eye/sight pathology.
- Systemic Disease:
- Diabetes
- a. retinal microaneurysms, hemorrhages, exudates, venous beading
- b. intraretinal microvascular abnormalities
- c. retinal neovascularization
- d. vitreous and/or preretinal hemorrhage
- Hypertension (HTN)
- a. Exudates, Cotton Wool Spots, Copper and Silver Wiring, AV Nicking
- b. sometimes Papilledema, Hemorrhage
- Hyperlipidemia
- Coronary Artery Disease (CAD)
- Carotid Stenosis
- Miscellaneous:
- tetanus immunization status
- e-existing/known eye conditions
- Medications: current medications (some exacerbate acute angle glaucoma) and allergies
- I. Observation/Palpation
-- proceed methodically from anterior to posterior
Without the ophthalmoscope:
- a. lids:
- b. orbit: palpate the rim for fracture if trauma
- c. cornea: look for clarity and corneal sensation with a wisp of cotton. Also,
fluorescein staining and cobalt blue light highlight corneal epithelial defects
- d. conjunctiva: injection, chemosis (edema of the conjunctiva around the cornea)
and subconjunctival hemorrhage
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With the ophthalmoscope, check (for):
- e. pupils: size, symmetry, shape and reaction to light and accommodation
- f. lens: size, symmetry, shape and reaction to light and accommodation
- g. vitreous abnormalities
- h. retina: red reflex, retinal abnormalities (including looking for papilledema)
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Other:
- i. tonometry: If acute angle closure glaucoma is suspected, and
there is no penetrating trauma, corneal abrasion, foreign bodies, or active infection
(which are contraindications) check for increased intraocular pressure.
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II. Determine Function
- a. Acuity: size, symmetry, shape and reaction to light and accommodation
- b. Visual Fields: size, symmetry, shape and reaction to light and accommodation
- c. Extraocular Muscle Function: (tests CN III, IV, VI) ask the patient to follow
an object in all six directions: right/up, right, right/down, left/up, left, left/down
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- a. Infection/Inflammatory: Orbital Cellulitis, Conjunctivitis, Blepharitis,
Hordeolum, Chalazion
- b. Neoplasia: Optic nerve impingement and astrocytoma
- c. Trauma: Foreign Body, Corneal Abrasion, Hyphema, Retinal detachment
- d. Degenerative: Retinal Disease: diabetic retinopathy, age-related changes,
macular degeneration, retinal vascular occlusion
- e. Toxic: Chemical Exposure
- i. Strabismus: optic axes cannot be directed to the same object:
- ii. Nystagmus (lateral, vertical and rotary): constant, involuntary, cyclical movement
of the eyeball:
- iii. Nerve palsies:
- Bell's: sudden U/L facial paralysis, presumed to be by swelling of 7th cranial n.
- Horner's Syndrome: pupil contraction, partial lid ptosis, enophthalmos, sometimes
sweating over involved side, paralysis of the cervical sympathetic nerve trunk
- i. Blepharitis: inflammation of the eyelid edges involving
hair follicles and glands
- ii. Hordeolum: inflammation of the sebaceous gland of the
eyelid
- iii. Chalazion: small, hard tumor, formed by distention of a
meibomian gland
- iv. Orbital Cellulitis:
- i. Corneal edema, abrasion, burn or foreign body:
- ii. Pterygium: triangular thickening of bulbar conjunctiva, apex
toward the pupil
- iii. Keratitis: inflammation of the cornea
- iv. Conjunctivitis: inflammation of the conjunctiva
- v. Episcleritis: inflammation of the subconjunctival
layers of the sclera
- vi. Scleritis: superficial and deep inflammation of
the sclera
- vii. Iritis: inflammation of the iris
- viii. Cataract: lens opacity
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- i. Glaucoma: increased intraocular pressure, results in optic
n. atrophy, poss blindness
- angle closure: pts are predisposed
- open angle glaucoma: angle permitting aqueous humor drainage is insufficient
- congenital: ideopathic
- ii. Hyphema: blood in the anterior chamber
- iii. Vitreous detachments
- iv. Vitreous hemorrhage
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- i. Retinal Disease: detachment and macular disease
- ii. Retinal Vascular Occlusion: Central and Branch
Retinal Artery and Central Retinal Vein Occlusion
- iii. Diabetic Pathology: Neovascularization => subretinal hemorrhage, exudates, etc
- iv. Hypertension Pathology: Copper and Silver Wiring, AV Nicking, Papilledema,
Hemorrhage, Exudates and Cotton Wool Spots
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Visual Pathway:
- i. Hemianopia
- ii. Cortical Blindness
Other Neuropathy
- i. Bell's Palsy (thought to be 7th cranial nerve pathology)
- ii. Horner's Syndrome (cervical sympathetic nerve trunk palsy)
g. Misc
- i. Functional/Psychosocial: hysteria and malingering
- A. Case Study 1 - Sudden, monocular,
transient vision loss
B. Case Study 2 - Watery, red eyes
C. Case Study 3 - Yearly physical exam
D. Case Study 4 - Yearly physical exam
#2
E. Case Study 5 - Eye Pain/Irritation
