Neuro-oph Case 1: Additional History and Physical Exam

Neuro-oph Case 1 Index

Additional History:

On further questioning, he reports an episode of blacking out of his vision in the left eye, about one month ago, which lasted for a few minutes before resolving. 

A review of his chart shows a recent Carotid doppler exam which showed a heterogeneous plaque and 65% stenosis of the proximal left internal carotid.

His medications include aspirin, metformin, glyburide, rosuvastatin, lisinopril, and metoprolol.

On review of family history, he shares that his father had an MI in his 60s and his mother suffered from a stroke in her 70s.

Physical Exam: 

Vitals: Temp: 37C, BP: 142/85, HR 77, RR 18, BMI: 29.0 kg/m2
VA with correction: OD 20/30, OS Hand motions at 1 foot (cannot see big “E” on chart, can only see movement at 1 foot)
Pupils: reactive OU, 4+rAPD OS
Intraocular pressures (IOP) by tonopen in ED: OD 17 mmHg, OS 15 mmHg
EOM: full OU, no nystagmus
Confrontation Visual Fields (CVF): OD visual fields intact to finger count in all 4 quadrants of right eye, OS can perceive hand motion in all 4 quadrants of left eye 

External ocular exam:
Eyelids: flat OU, no ptosis OU
Conjunctiva: white and quiet OU
Cornea: Clear OU
Anterior Chamber: Formed OU
Iris: flat OU
Lens: 2-3+nuclear sclerotic cataract OU
(for more information on cataracts, see 2020sim case 1)

Fundoscopic exam of the right eye appears within normal limits. On fundoscopic examination of the left eye, you see the following:

CRAO image

Above image credit: CC BY-SA 4.0

How would you describe the left fundus appearance?
Scattered hemorrhages throughout the macula
Diffuse retinal whitening with cherry red spot centrally
Scattered yellow fleck like lesions throughout macula
Arterio-venous (AV) nicking of the retinal vessels

What’s at the top of your differential diagnosis now? 
Hypertensive retinopathy
Central retinal artery occlusion (CRAO)
Central retinal vein occlusion (CRVO)
Retinal detachment
Amaurosis fugax
Macular degeneration
Diabetic retinopathy

Click here to move on!

Neuro-oph Case 1 Index

Neuro-oph Case 1: Introduction