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A Differential Guide to 5 Common Eye Complaints

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Linda Vorvick, MD; Rachel Reinhardt, MD A differential guide Department of Family Medicine, University of Washington School to 5 common eye complaints of Medicine, Seattle (Dr. Vorvick); Cascade Eye MDs, Mill Creek, Wash Here’s help identifying conditions you can’t afford (Dr. Reinhardt). to miss, including a handy mnemonic to ensure a [email protected] comprehensive eye exam. The authors reported no potential conflict of interest relevant to this article. nowing how to respond when patients present with PracticE problems involving the eye is crucial for family physi- recommendations K cians. Yet it is often difficult to know whether to treat › Provide an urgent oph- or refer and which signs and symptoms are indicative of an thalmology referral for ophthalmologic emergency with the potential to cause loss of any patient with a sudden sight. decrease in visual acuity. C Categorizing ophthalmologic conditions based on pa- › Record bilateral pupil tients’ chief complaints, we have found, can help to narrow size as part of a compre- the differential diagnosis and home in on emergent signs and hensive eye exam, and symptoms. Thus, we’ve used that approach in this review. provide an urgent referral In the pages that follow, common complaints like “I can’t for a patient whose pupils see,” “I’m seeing things,” and “My eye hurts” are used to high- are of unequal size. C light disorders—both benign and emergent—associated with › Involve an ophthalmolo- each. You’ll also find an at-a-glance table listing the differential gist or other specialist in the diagnosis for each presentation, and a mnemonic to guide you management of eye condi- through the elements of a comprehensive eye exam. tions caused by systemic diseases such as stroke or giant cell arteritis. C 1 “I can’t see” strength of recommendation (SOR) Patients may use words like “cloudy vision,“ “a veil over my A Good-quality patient-oriented eyes,” or “fuzziness” to describe diminished vision. Some will evidence WATCH report black areas within their visual field; others will have B Inconsistent or limited-quality THE VIDEO patient-oriented evidence a loss of peripheral vision or total vision loss in one eye, or Hyphema: C Consensus, usual practice, possibly even both. Some causes of vision problems, such as opinion, disease-oriented What you’ll see evidence, case series cataracts, are not emergencies. Causes of more severe (but at jfponline.com painless) vision loss include central retinal artery occlusion (CRAO) or vein occlusion (CRVO), giant cell arteritis (GCA), courtesy of: eye stroke or transient ischemic attack (TIA), nonarteritic anterior Teachers of america foundation ischemic optic neuropathy (NAION), and nonorganic (func- tional) vision loss (TABLE).1-11 When the cause is ischemic Patients with CRAO experience acute loss of vision in one eye, usually occurring within seconds to minutes. Most patients with CRVO will have a similar presentation, depending on jfponline.com Vol 62, no 7 | jUlY 2013 | The joUrnal of familY pracTice 345 table In patients with CRAO, an eye exam Patient complaints guide the will show profoundly decreased visual acu- ity, and the swinging light test (see “Use this differential Dx mnemonic to ensure a comprehensive eye exam” on page 348) will reveal a relative af- “I can’t see” (painless loss of vision)1-11 ferent pupillary defect (RAPD). Fundoscopy • crao/crVo is diagnostic, revealing a pale retina due to • Giant cell arteritis decreased blood flow.4 Emergent referral to • naion ophthalmology is indicated to establish a definitive diagnosis and initiate treatment • nonorganic visual disturbances based on the cause of the occlusion. If emer- • Stroke/Tia gency care is not immediately available, mas- “I’m seeing things”4,12-14 saging the eye globe through closed lids, then • ocular migraines releasing, in 10- to 15-second cycles, may be helpful.5 • retinal detachment z Risk factors for cRVo include age • Vitreous detachment older than 65 and a number of chronic condi- “My eye hurts and is red”1,2,4,12,15-27 tions. One analysis attributed 48% of cases to • acute angle closure glaucoma hypertension, 20% to hyperlipidemia, and 5% to diabetes.3 Fundoscopy will reveal dilated If emergency • Bacterial keratitis treatment is veins, retinal hemorrhages, and cotton wool not immediately • Blunt trauma spots, which look like puffy white patches on available for a • chemical burns the retina.6 patient thought • herpes simplex keratitis As with CRAO, an urgent ophthalmology referral is critical to establish the diagnosis to have central • hyphema retinal artery and develop a treatment plan. Outcomes are occlusion (shown • iritis (anterior uveitis) poor in patients with visual acuity of 20/200 7,8 above), “My eye is red” (but pain free)4,9,28-32 or worse at the time of diagnosis. z GcA. Patients with GCA may develop ar- massaging • conjunctivitis the eye globe teritic ischemic optic neuropathy, resulting in through closed • orbital cellulitis (can have pain) vision loss in one or both eyes. Risk factors for lids in 10- to • periorbital cellulitis GCA include age (>50 years), polymyalgia rheu- 15-second cycles • Subconjunctival hemorrhage matica, Caucasian race, and female sex. Sys- temic symptoms include fever, muscle aches, may be helpful. “My eye hurts”1,2,4 33-38 headache, jaw claudication, and scalp pain.6 • corneal abrasion The swinging light test will reveal an • optic neuritis RAPD;1,2 fundoscopy findings typically in- crao, central retinal artery occlusion; crVo, central reti- clude disk edema and disk hemorrhages, or nal vein occlusion; naion, nonarteritic anterior ischemic 6 a pale retina if GCA is associated with CRAO. optic neuropathy; Tia, transient ischemic attack. Testing, including an erythrocyte sedimenta- e o Ey G S tion rate and a C-reactive protein, will pro- hica c vide supportive evidence, and biopsy of the llinoi T i , 4 a S the presence or absence of ischemia and in- temporal artery will confirm the diagnosis. AA volvement of the macula. Those with branch Blindness from GCA is often profound. llinoi i retinal vein occlusion may have no vision loss Bilateral disease is treated immediately with of anowicz, j 1-3 ty i . S at all. high-dose corticosteroids; when just one eye j er V z Risk factors for cRAo ark include cardio- is affected, high-dose steroids should also be m , Uni Y vascular disease, hypertension, diabetes, and started right away to prevent vision loss in the of: sy other disorders associated with systemic in- other eye. Whenever GCA is suspected, initi- e T r nfirmar U i flammation. In patients older than 60 years, it ate treatment and provide an urgent referral ar e co e is also important to consider GCA, which we’ll to an ophthalmologist for biopsy and further G 6 and ima talk more about shortly, as a cause of CRAO. treatment. 346 The joUrnal of familY pracTice | jUlY 2013 | Vol 62, no 7 5 commOn EyE complainTs z strokes and TIAs that affect vision may describe what they see. When this phenome- be a result of ischemia of the visual cortex, non is accompanied by decreased visual acu- or the eye itself. Visual cortex ischemia will ity, emergent or urgent referral is required. present as a homonymous visual field cut be- Normal vision in a patient who reports “see- tween the eyes; TIAs that affect only one eye ing things” calls for careful consideration of (known as amaurosis fugax) are associated the etiology, and referral if the diagnosis is with ischemia to the optic nerve or retina. uncertain or the suspected disorder is sight- Patients with amaurosis fugax will expe- threatening (TABLE).4,12-14 Migraine and psy- rience unilateral loss of vision that extends chiatric disorders should be considered if like a dark shade from the top or bottom pe- suggested by history. (Patients with ocular riphery to the center of vision. When a TIA is migraine—which may or may not be associ- the cause, vision will return to normal within ated with a headache—may also report see- minutes. The underlying pathology is usually ing light patterns off to one side, typically carotid artery atherosclerosis. If left untreat- lasting 20-45 minutes.) ed, evidence suggests that 30% to 50% of pa- tients will have a stroke within a month.9 Vitreous or retinal detachment Visual acuity may or may not be decreased, Patients with vitreous detachment, which is depending on whether the ischemia involves far more common and less serious than reti- the macula. Symptoms suggestive of amau- nal detachment, report seeing new floaters or rosis fugax should prompt an urgent ophthal- peripheral flashing lights in one eye. Risks for Patients who mology referral, while patients with persistent vitreous detachment include myopia, older have decreased vision loss or visual field deficit require urgent age, eye trauma, and previous eye surgery.4 visual acuity or referral to a stroke treatment center.9 Physical examination and visual acuity will a visual field z nAIon is also associated with acute be normal unless there is an accompanying defect, or who monocular vision loss, particularly in older retinal detachment.12 describe a patients.10 Visual acuity will be markedly de- z A full ophthalmologic evaluation is “curtain of creased, and fundoscopic exam will show indicated to detect or rule out a retinal de- darkness” are a swollen and hemorrhagic optic disc. The tachment or tear—which has been found to at risk for vision loss can be profound, and is usually co-occur with acute vitreous detachment in retinal permanent; neither medical nor surgical treat- 14% of cases.13 Those who present with de- detachment ment has been shown to improve outcomes.10 creased visual acuity or a visual field defect (shown above) or describe a “curtain of darkness” are at risk and require a When the cause is functional for retinal detachment and require a same- same-day Functional (nonorganic) visual disturbanc- day referral.13 referral.
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