2 ObjectivesDevelop a safe approach to the disposition of patients complaining of both...sudden onset of unilateral flashers and floatersdouble vision
3 Case 1 62 y.o. female with hypertension and no ocular history 1 week of a large floater in her left eyeBelieves her vision on the left has deterioratedIn this same week she had an episode of “light flashes” in the left peripheryAssessed by optometry 6/12 ago and says “everything was normal”
4 Case 1 corrected right 20/20, left 20/50 pupil exam, field testing normalno RAPDdilated direct ophthalmoscopy normalU/S not done
5 OcularFloaters and/or flashersPVD - 24% (50-59) 87% (80-89)RD - 0.3% (lifetime), 14% (if complaining of flashes/floaters)Predominate Floatersvitreous hemorrhage - usually proliferative diabetic retinopathyPredominate Flashersoculodigital stimulationrapid eye movementsage related macular degenerationNon-ocularmigraine with aura - binocular visual problemoccipital lobe disorder - binocular visual problempostural hypotension- binocular visual problem
7 Disposition ? What would you do in this case at 1pm on Monday? What would you do in the case at 1am on Saturday?Is this case an “emergency” or “urgency”
8 Does this patient have retinal detachment? Flashes/Floaters (one/both) LR ofSubjective OR objective visual loss with flashes / floaters LR of 5.0Vitreous Hemorrhage or Pigment on slit lamp exam LRNo data for “sudden grey curtain obstructing vision”
9 Can bedside U/S safely rule out retinal detachment? prospective study of U/S scan by ED physicians in patients with sx/sx of RD yielded a 97% sensitivity, 92% specificity (Shinar Z. Chan L. Orlinsky M. Use of Ocular Ultrasound for the Evaluation of Retinal Detachment. J Emerg Med. Jul )another study with similar methodology demonstrated a 100% sensitivity and 83% specificity (Yoonessi R. Hussain A. Jang TB. Bedside Ocular Ultrasound for the Detection of Retinal Detachment in the emergency Department. Acad Emerg Med. Sep 2010.)
10 Is RD a true emergency?MORD pilot study identified no R.F. other than distance of the tear from the fovea for progression of MORD to macula-off RD (a finding not done in the ED). In this study 26% of patients were treated out-of hours.The 1995 AAO stance is that MORD be treated within 24 hours (American Academy of Ophthalmology. Ophthalmic procedure assessment. The repair of rhegmatogenous retinal detachment. Ophthalmology 1995; 103: ).A growing body of literature suggests no long term difference providing that repair occurs within 3 days of symptom onset. (Anatomic and visual outcomes in early versus late macular-on primary retinal detachment repair. Retina jan; 31(1):93-8.)“best evidence practice for MORD would indicate that surgery be scheduled no later than 7 days of symptom onset.” (Letter in Eye (2006), )Macula-off Detachment - a recent study found that repair of macula-off detachment in the first three days after the event results in equivalent outcomes to repair in 24 hours, but repair of greater than one week had significantly worse outcomes.
11 Case 1- Resolution62 y.o. female with OS flashers / floaters, objective visual loss, an normal eye exam.Referred that day for opthalmology assessmentFound to have PVD with a supra- temporal retinal tear.Referred to a retinal surgeon at a tertiary centre for definitive management.
13 Disposition ? What would you do in this case at 1pm on Monday? What would you do in the case at 1am on Saturday?Is this case an “emergency” or “urgency”
14 RD SummaryPatients with acute onset of either flashers &/or floaters with subjective/objective visual loss, and signs of vitreous hemorrhage need a same day referral.RD likely represents an urgency vs. emergency based on available literature.
15 Case 275 y.o. male with double vision and left eyelid ptosis, previously completely well.Awoke in the AM c/o he was seeing double esp. when looking up.Denies any visual blurring, headache, fever, neck pain or “b symptoms.”Remainder of R.O.S is normal.PMHx: HTN, lipids, GERD, CAD, AF - therapeutic INR, Pacemaker - SSS
16 Physical Findings obvious droopy left eyelid right 20/25, left 20/40 PERL, no RAPDright normal EOMleft cannot elevate, depress or adductIOP 13 mmHg bilaterallySLE normal anterior chamber & corneaFundi exam attempted - but limited (not dilated)
18 The can’t miss diagnosis have more than just CN findings. Differential?Binocular DiplopiaCranial Nerve - idiopathic (microvascular), stroke, compressive lesion, infectious (sinus thrombosis), alcohol related (WE)Mechanical - typically assc. with proptosis and pain - i.e. Grave’s dx, orbital myositis, base of skull tumorsNeuromuscular - typicall assc. with systemic illness - i.e. botulism, GBS (Miller Fisher Variant), MG, MSThe can’t miss diagnosis have more than just CN findings.
20 Disposition? Should I order a CT/MRI, what type? Can I safely send this patient to the family physician for follow up in 4-6 weeks?Can I safely send this patient for opthalmology f/u tomorrow?Do I need to call the opthalmogist now?Do I need to call the stroke MD now?
21 Red Flags - Admit/Image More than one cranial nerve deficitPupillary involvement of any degreeAny neurologic symptoms besides diplopiaPainProptosis
22 Who Can I d/c without any imaging? UnilateralSingle Cranial Nerve PalsyNormal pupillary light responseNo other signs or symptoms
23 Case 2 Patient was f/u by opthalmology 2 days post d/c. Visit % ptosis, pupil sparing, no adduction, elevation, depression of L eyeVisit 2 (2/52) - near 100% ptosis, pupil sparing, no adduction, elevation, depression L eyeVisit 3 (4/52) - 30% ptosis, able to adduct past midline, slight elevation and depressionVisit 4 (8/52) - no ptosis, normal EOM, no double vision
24 Diploplia SummaryPatients with isolated pupil sparing 3rd, 4th and 6th CN palsies likely have idiopathic or microvascular disease.EXTREMELY CAREFUL NEURO EXAMIn the above cases emergent management is not often necessary, although urgent opthalmology referral, with a call from the ER physician should be encouraged.