Problem Solving

1
Problem Solving

• Case 1

2
History

• 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.

3
Examination

• On examination she showed the following Vitals
• Pulse72/regular
• Temp. 37
• Resp14
• B.P 120/80

4
Eye Examination

• VA OD 20/100 OS 20/20
• Pain on abduction of Rt. eye
• EOM full
• Red reflex normal
• Fundus ex. normal disc, vessels, maculae

5
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?

6
Case Summary
Positive Negative
22 years old (Young not old PMH insignificant
Female ( Not male) Normal Vitals
Sudden (Not gradual) decrease in Vision in one eye Decreased vision
Headaches Normal Red Reflex
Pain on Eye Movement (Symptom) Normal Fundus
Decreased vision OD
Pain on Eye Movement (sign)
7
Further History

• Onset how? When? What
• Progression of vision, headaches, pain
• Headaches Relieving PPT factors
• Uhthoffs Phenomenon
• Diplopia/ Oscillopsia /Dizziness
• Parasthesia and weakness
• Bowl symptoms

8
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

9
Further Examination

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

10
Diseases Onset Progress
Acute Ischemia-Hge. -Infections Inflammation
Subacute Infections Inflammations
Chronic Compressive Infections
Minutes-24hours
24 hours to several days
4 weeks to years
11
Provisional Diagnosis

• Optic Neuritis

12
Differential Diagnosis
Sudden discovery of chronic visual loss
13
Differential Diagnosis

• Other causes of Optic Neuropathies
• Ischemia
• Infections
• Nutritional
• Compressive
• Hereditary
• Traumatic

14
Differential Diagnosis

• Other causes of acute visual loss
• Sinus disease
• CRVO
• CRAO
• Retinal Detachment
• Vitreous Hge.

15
Why???
22 years Unlikely ischemic but could be any other process
Female Demylination or any other process
Sudden Ischemia/Inflam./Infection/ Sudden discovery
Pain on eye movement Sinusitis- Myositis- Cellulitis- Optic neuritis-Acute Graves Scleritis rules out vascular event (CRAO/CRVO/ION)
16
Why???
Normal Vitals Unlikely infectious
Regular Pulse Unlikely shooting emboli Unlikely Graves
Absence of proptosis Lid Signs Unlikely Cellulitis or myosiitis or Graves
Absent tenderness over sinuses Unlikely sinusitis
17
Why???
Vision Refractive Error/ Media Problem / Retina /Neurological Psychological
MPH no improvement Not refractive
Sluggish Pupil reaction with RAPD Disease affecting visual pathway anywhere from ON to lateral geniculate body
Visual Field Central Scotoma ON disease or macular disease
18
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.



19
Differential Diagnosis

• Other Causes of ON Disease
• Sinus Disease
• CRAO CRVO
• Retinal Detachment