Case #20 - Presented by Erin O'Malley, MD 9-18-2004

[Andrew_Doan]

CC: 81 y.o. white man with sudden, painless vision loss OS.

HPI: The patient described a sudden black spot in his vision that spread out over his complete visual field OS over a 15-minute time frame. He drove directly to his optometrist. The optometrist documented visual acuities of 20/40 OD and light perception (LP) vision OS. The RAPD was not checked/documented. It was noted that the patient had a normal fundus examination. The patient was sent to the University of Iowa for further evaluation on the following day.

PMH/FH/POH: coronary artery disease s/p CABG & balloon angioplasty, right carotid endarterectomy (1980s), left carotid stenting (endovascular) recently with transient right hemiparesis (resolved). No history of ocular surgeries or trauma.

MEDS: ASA, Plavix, nitroglycerine PRN and alfalfa pills

ROS: denied headaches, jaw claudication, scalp tenderness, weight loss, and loss of appetite

EXAM
Best corrected visual acuities: 20/30 OD and HM OS.
Pupils: greater than 2.5 LU RAPD OS.
GVF: full OD. Small inferior island of V4e OS.
EOM: full OU
Anterior segment: mild nuclear sclerosis cataracts OU
Fundus: normal OD, see photos OS

Montage of Posterior Pole OS.

Closer view of area around optic nerve OS.

View of arteriole.

High magnified view of same arteriole.

Feel free to discuss the following:

What tests should you order (I'll post labs when asked for them)?

What's the differential diagnosis?

What's the diagnosis?

What is the treatment of choice, surgically and/or medically?

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[Richard_Hom]

CC: 81 y.o. white man with sudden, painless vision loss OS.

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Diff Dx:
1. AION
2. CRVO

CBC, Sed, head CT

Richard

 

[Andrew_Doan]

Diff Dx:
1. AION
2. CRVO

CBC, Sed, head CT

Richard

Do you see AION without disc swelling? Or did you mean PION?

Also, do you see acute CRVO without intraretinal and retinal flame hemorrhages?

 

[Richard_Hom]

Do you see AION without disc swelling? Or did you mean PION?

Also, do you see acute CRVO without intraretinal and retinal flame hemorrhages?

Yes, PION.

CRAO rather than CRVO.

Too early in the morning in the first post.

Richard

 

[Andrew_Doan]

A CT scan is not useful here, and none was ordered.

Any other tests to order to help with the diagnosis? Any clinical signs above that supports one diagnosis?

 

[PBEA]

A CT scan is not useful here, and none was ordered.

Any other tests to order to help with the diagnosis? Any clinical signs above that supports one diagnosis?

IVFA
carotid duplex
How bout the sed rate that Dr. Hom asked for?
How bout a referral to the pts cardiologist? (yes I am an OD, I of course will not attempt to manage the ensuing systemic crisis with this pt., I will refer to an appropriate specialist)
You did a VF on him?! Did you do this before or after you checked VA and fundus? Why bother?
PION

Speak of the devil, what is your opinion of ocular blood flow measurement? Is it accurate enough? And if so, do you think it would be clinically useful for say your above case?

 

[Andrew_Doan]

IVFA
carotid duplex
How bout the sed rate that Dr. Hom asked for?
How bout a referral to the pts cardiologist? (yes I am an OD, I of course will not attempt to manage the ensuing systemic crisis with this pt., I will refer to an appropriate specialist)
You did a VF on him?! Did you do this before or after you checked VA and fundus? Why bother?
PION

Speak of the devil, what is your opinion of ocular blood flow measurement? Is it accurate enough? And if so, do you think it would be clinically useful for say your above case?

I don't have enough experience with ocular blood flow measurements to comment. However, an IVFA is useful because it tells you the blood flow status of the eye.

ESR/CRP were normal.

VF was not done and not indicated here.

http://webeye.ophth.uiowa.edu/eyeforum/case20.htm

 

[Andrew_Doan]

VF was not done and not indicated here.

Dr. O'Malley informed me that a Goldmann VF was done per request by the patient. The patient stated that he had some vision in the eye. They ordered a baseline GVF while waiting for neurology to admit the patient.

Most practices will not have access to a GVF, which is a good test to map out remaining visual field in this setting. This is helpful to establish a new baseline VF for patients. On the other hand, a HVF 24-2 is of little value in this setting.

 

[PBEA]

Dr. O'Malley informed me that a Goldmann VF was done per request by the patient. The patient stated that he had some vision in the eye. They ordered a baseline GVF while waiting for neurology to admit the patient.

Most practices will not have access to a GVF, which is a good test to map out remaining visual field in this setting. This is helpful to establish a new baseline VF for patients. On the other hand, a HVF 24-2 is of little value in this setting.

Interesting, I think HVF 120 pt field, or other automated full field (with threshold) compares nicely enough with GVF in this instance.

What is the general consensus there of ocular blood flow measurement, especially as alternative to IVFA (both as a less invasive modality as well as no side effects). Is it a test that is available in your setting?

 

[JennyW]

Dr. O'Malley informed me that a Goldmann VF was done per request by the patient. The patient stated that he had some vision in the eye. They ordered a baseline GVF while waiting for neurology to admit the patient.

Most practices will not have access to a GVF, which is a good test to map out remaining visual field in this setting. This is helpful to establish a new baseline VF for patients. On the other hand, a HVF 24-2 is of little value in this setting.

Most late model Humphrey field testers have a goldmann field option in the test library. If you have one of these, you likely have a goldmann option.

Jenny

 

[Andrew_Doan]

Most late model Humphrey field testers have a goldmann field option in the test library. If you have one of these, you likely have a goldmann option.

Jenny

There's not much experience or data with the computerized Goldmann VF, and I don't think they are as accurate and good as an experienced perimetrist to map out complex visual field defects. We're lucky at Iowa to have extremely talented perimetrists who produce awesome visual fields.

Goldmann field option on a Humphrey machine does not substitute for real Goldmann visual fields. Until there's more data with the automated Goldmann, I'm not sure how to interpret these fields.

 

[JennyW]

There's not much experience or data with the computerized Goldmann VF, and I don't think they are as accurate and good as an experienced perimetrist to map out complex visual field defects. We're lucky at Iowa to have extremely talented perimetrists who produce awesome visual fields.

Goldmann field option on a Humphrey machine does not substitute for real Goldmann visual fields. Until there's more data with the automated Goldmann, I'm not sure how to interpret these fields.

That is true, but as you pointed out Goldmann fields require a lot of skill and experience to produce them. Most offices don't have that luxury. In those cases, while it would not be ideal the automated Humphrey program is likely adequate. At the very least is is likely to produce "usable" data.

Jenny