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Doctor, Why Can't I See? Evaluation of the Patient Uncorrectable to 20/20

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8/26/2019 Speakers Bureau for Aeri, Allergan, Bausch & Lomb, Glaukos, Ivantis, Optovue, Reichert Robert P. Wooldridge, O.D., F.A.A.O. Always be able to account for a patient’s VA Always be able to account for a patient’s VF Always be able to account for a patient’s C/O LOV ◦ vague complaint Anatomical Approach Refractive How to Evaluate Media opacity/distortion Refraction Macula problem ◦ Retinoscopy-lost skill look for scissors/distorted reflex Optic nerve/Neurologic Pinhole VA Amblyopia High order aberrations Hysteria/malingering 1 8/26/2019 Tear film Grade the View! Cornea VA vs View ◦ PEK, Central Cloudy Dystrophy of Francois (CCDF) Anterior Chamber 20/80 ◦ Careful evaluation for C/F hem, etc Lens ◦ Milky white NS vs yellow brown NS; vacuoles Vitreous 20/20 ◦ Hemorrhage ◦ Clarity: variable, cloudy ◦ Punctate Keratopathy Slit Lamp exam PEK, SPK Tear BUT ◦ Opacity: Oculus Topographer Scar Epithelial edema Stromal edema Central Cloudy Dystrophy of Francois (CCDF) Slit Lamp exam Keratoconus Corneal topography Pellucid Marginal Retinoscopy Degeneration (PMD) Pachymetry Post LASIK/PRK ◦ Ultrasonic Post PKP ◦ OCT CL induced 2 8/26/2019 Unusual cause of Nuclear sclerosis (NS) unclear media ◦ Milky white vs. Careful slit lamp brunescent yellow/brown NS exam ◦ Vacuoles ◦ Cells/flare Cortical cataract ◦ RBC’s ◦ Anterior (ACC) Turn the SL light ◦ Posterior (PCC) up high! Posterior Subcapsular (PSC) Easier to see with dilated pupil Myopic shift is a good hint of cataract progression! Slit Lamp exam 50yo WM referred as Glaucoma suspect Direct and Retro VA 20/20 OU illumination C/O occasional cloudy vision OD Contrast Sensitivity ◦ Without glare H/O RD repair 1981 ◦ With glare 18yo WF referred: VA uncorrectable to 20/20 Patient unsure of course of VA Wears DWSCL MH: mild congenital hear defect FH: Father has poor VA cc BVA R 20/25- L 20/40 low myopia Pupils, SLE Normal OU CT: Orthophoric Stereo 5/9 SLE NL OU DFE: OD NL OS mild RPE change in macula 3 8/26/2019 Amsler grid Color Vision Corneal Topography Fluorescein Angiogram OCT Disc OCT Macula ERG/EOG MRI Brain and orbits Fundus Flavimaculatus Autosomal recessive Early stage may show little/no visible retinal signs Fluorescein angiogram often diagnostic ERG may be NL 4 8/26/2019 VA R 20/30 L 20/40 38 yo Nepalese Male moved to US in 1996 Referred for glaucoma evaluation H/O good VA as a child ◦ Began to have decreased vision with light at 18yo ◦ First glasses in 1996; not diagnosed with glaucoma ◦ Has been on glaucoma drops x 1 year ◦ Using Travatan-Z, Cosopt, Alphagan-P OU Medical history: NL FH: 5 siblings; sister has similar symptoms VAsc R 20/200 L 20/100 NI with refraction Pupils, motility NL OU CT: Orthophoric SLE NL OU with mild hyperemia OU; ◦ lenses clear IOP R 18 L 16 CCT R 542 L 542 Color vision R 2/15 L 2/15 Fundus as seen 5 8/26/2019 Glaucoma Other optic nerve disease Media opacity Macular problem Amblyopia Neurological problem Corneal Topography Fluorescein Angiogram OCT Disc OCT Macula ERG/EOG MRI Brain and orbits 6 8/26/2019 VEP’s very poor OU mfERG’s abnormal outside central macular area Full field ERG: ◦ Very attenuated photopic responses ◦ Normal scotopic responses No diagnosis given Referred to neuro-ophthalmology for second opinion who then referred him to retinal specialist for third opinion Retinal Cone Dystrophy 42yo WM Life-long H/O poor VA OU Diagnosed as amblyopia OU since childhood VA R20/30 L 20/30 Pupils NL Neg. APD CT:orthophoric SLE NL OU DFE NL but thin macular RPE, ◦ No foveal reflex Bilateral amblyopia No strabismus No uncorrected refractive error/astigmatism No H/O ocular surgery 7 8/26/2019 SL with: ◦ HH lens, fundus CL BIO Direct O-scope Amsler Grid OCT Photo Fundus Autofluoresence (FAF) Fluorescein Angiography (FA) Multifocal ERG 2009 Congenital Dystrophies 65yoWF C/O Acquired diseases distorted VA OS ◦ Age-related Macular Degeneration (AMD) ◦ Diabetic retinopathy VA 20/20- OU ◦ Edema Pupils, VF NL ◦ Epi-retinal Membrane (ERM) A Grid ◦ Hole ◦ OD Nl ◦ Hypoplasia ◦ OS distorted ◦ Toxicity-drug SLE 1+ NS OU ◦ Vascular disease/event ◦ Inflammatory diseases Trauma 5/05/2011 5/06/13 20/20-20/25 20/20-20/25 8 8/26/2019 Pre-retinal membrane VERY common Usually due to PVD causing tear in ILM ◦ Glial cells proliferate on retinal surface May also be associated with diabetic retinopathy and other retinopathies Treatment is PPV/membrane peel if visually significant ◦ VA criteria variable 60yo WF referred with VA uncorrectable to 20/20 Previous exam showed no apparent cause VA R 20/20 L 2030 Minimal distortion on A grid OS Pupils, CVF NL OU Cover test orthophoric OU SLE NL OU 9 8/26/2019 66 yo WM C/O “barrel distortion” OD ◦ X1 week; constant, notices at near only ◦ No complaints OS VA R 20/80 L 20/20 A. Grid +distortion OD only Pupils NL SLE 1+ NS OU Larry Pre PPV/MP Larry Post PPV/MP PPV/MP 12/05/12 Last visit July 2013 VA R 20/80 L 20/25 Still has some distortion OD SLE OD 3+ NS OS 1+ NS DFE OD: Mild RPE change OS 2+ ERM 10 8/26/2019 68 yo WF treated for glaucoma Visual Acuity OS? VA R 20/20 L 20/25 Measured in 2013 as R 20/15 L20/15- with PTMH present ERM PTMH 20/20- OU 11 8/26/2019 PTMH FTMH Patient may be asymptomatic Patient usually symptomatic VA may be good/excellent 20/15-20/30 VA usually 20/70-20/400 ERM and/or PVD often co-existent Treatment: PPV/gas bubble No treatment indicated 73yo WF 6 weeks postop. phaco patient C/O decreasing VA for past 2 weeks 12 8/26/2019 1995 20/20 OU no complaints; NL exam Young adult 2002 vertical diplopia: LSO; MRI shows UBO’s Males> females ◦ No specific systemic diagnosis made Unilateral 2005: VA R 20/20-25 L 20/25-30 ◦ Central oval RPE change OU noted ◦ Attempted FA; could not find vein ◦ Retinal specialist noted mild macular pigmentary changes, no need to WU further, mfERG if desired ◦ mfERG=Normal 2007: FA at JMEC confirms parafoveal telangiectasia 2012 OD 20/30 OS 20/50-70 S/P multiple Avastin injections 13 8/26/2019 68yo WF C/O poor VA OU S/P phaco/IOL OD Sep. 2009;poor VA since then; no reason given VA R 20 25- L 20/50 Pupils, color VA, CT NL OU SLE: OD 2+ PCO OS Cataract DFE:“Trace central sensory retinal change OU” 28yo WM C/O blurred VA OD x 3 months Corneal topography MH No medical illnesses or complaints OCT macula VAsc R 20/70 L 20/20; NI with refraction OCT disc Pupils NL Neg APD Visual field CVF FTFC OU Fluorescein angiogram Motilities full OU; CT orthophoric MRI brain/orbits Color VA R 4/14 L 13/14 ERG/EOG/VEP Amsler grid OD IT paracentral scotoma; OS nl SLE, DFE completely NL OU OCT macula is normal VF has some bitemporal flavor Plan: MRI/MRA brain and orbits c/s contrast 14 8/26/2019 Had pituitary tumor resected Jan. 22 VAsc R 20/15 L 20/15 Color Vision R 15/15 L 15/15 Pupils NL Last seen in 2012: all findings normal Slit lamp with hand-held lens Visual Evoked Potential (VEP) Direct ophthalmoscope MRI/CT Fundus photography Ultrasound ◦ Fundus autofluoresence Fluorescein angiography OCT HRT Visual field Pupil reactions Color vision Glaucoma Arcuate bundle defect Optic Neuritis Does NOT respect vertical midline ◦ Anterior NO early CENTRAL scotoma ◦ Retro-bulbar ◦ But paracentral possible! Optic nerve drusen Nasal usually worse than temporal Papilledema Temporal to blind spot last to go Ischemic Optic Neuropathy (AION) Remember to correlate with cupping! 15 8/26/2019 57yoWF referred with poor VA OS, cause BVA R 20/25+ L 20/70 unknown Pupils NL Neg APD ◦ Thought to have some AMD OS Motility full; CT orthophoric 3 mos ago pat. was looking at Amsler grid IOP R 13 L 14 with friends at home and noted distortion OS Amsler grid OD NL OS paracentral distortion ◦ Does not know if onset was sudden or gradual SLE NL; lenses clear OU ◦ No VA complaint OD ◦ H/O seeing 20/20 OU in past years DFE as seen MH: Normal, no medical illnesses ◦ 8 children (post traumatic stress??) ◦ No significant HA’s or other complaints Normal Tension glaucoma Anterior ischemic optic neuropathy Optic atrophy Intracranial mass Prostaglandin QHS OU MRI CBC, ESR, CRP ◦ reveals Pituitary adenoma Fluorescein angiogram OCT macula Tumor resected MRI brain/orbits 16 8/26/2019 Confrontation VF are Not Enough!! Just Another Day With the Wooldridge Teens Mental disorder that impairs physical Conscious attempt to deceive for personal functions with no physiological basis; sensory gain motor symptoms include seizures, paralysis, temporary blindness; increase in stress or avoidance of unpleasant responsibilities may precipitate Subconscious response Patient believes he/she has a real problem But may have something to gain 17 8/26/2019 Patient has a true organic disease/problem Hysteria: But also has a functional component ◦ Young: 9-13yo most common Adults possible ◦ Female Malingering ◦ Late teens to adults Loss of Vision Reads every line at same slow speed, letter by ◦ Monocular or binocular letter ◦ Central or peripheral Ambulates well despite C/O severe LOV ◦ Usually sudden in onset Severely constricted CVF Can be dated/connected to an event ◦ Sometimes vague, uncertain NO APD despite severe unilateral LOV Careful history 1.
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