1. Eye Spy A Case of Acute Vision Loss Tony S. Chang, MD Primary Care Conference October 6, 2004

2. Disclosures  I have no financial disclosures.

3. Case An 82 y.o. woman presents to her ophthalmologist 6 hours after waking up with vision loss in her right eye.

4. PMH  Monoclonal gammopathy  Left inferior pubic ramus fracture  Osteoporosis  Hypothyroidism  Hypertension  Depression & anxiety  Possible TIA in July 2000  Macular degeneration

5. Meds  Aspirin  HCTZ  Potassium Chloride  Levothyroxine  Paroxetine  Alprazolam  Fosamax  Calcium with D  Oxycodone/APAP  Promethazine  Multivitamin No Known Drug Allergies

6. FH/SH  Widowed, lives alone  Smokes 1-2 cigarettes a day  No alcohol use  Both parents had cancer when older

7. ROS  Decreased appetite  Groin pain from pubic ramus fracture  No headaches or weakness  No fever, chills, or weight loss

8. Differential Diagnosis 1  Corneal Edema  Hyphema  Cataract  Vitreous Hemorrhage

9. Differential Diagnosis 2  Retinal Disease Detachment Macular Disease Vascular Occlusion  Optic Nerve Disease Optic Neuritis Papillitis Ischemic Optic Neuropathy Giant Cell Arteritis Trauma

10. Medical Exam  Pleasant thin woman, mildly concerned  Vitals: Blood pressure 122/58, pulse 88  Neck: no bruits  CV: regular without murmur or gallop  Chest: clear  Abdomen: no bruits  Extremities: no edema

11. Ocular Exam  Visual Acuity  External Inspection  Pupillary reactions (swinging flashlight)  Ocular Motility testing  Anterior chamber depth assessment  Intraocular pressure testing  Ophthalmoscopy

12. Pupillary Pathways

13. Pupillary Reactions  Patient had a right eye afferent defect

14. Anterior Chamber Depth  Shallow depth - angle closure glaucoma  Patient’s depth: normal

15. Tonometry  Mean pressure: 15 (10-21 for 2 SD)  Patient’s intraocular pressure: 11 mmHg

16. Retinal Detachment

17. Central Retinal Artery Occlusion

18. Central Retinal Vein Occlusion

19. Papillitis

20. Ischemic Optic Neuropathy

21. Data  ESR 58  Lipid Profile: Total Cholesterol 215 Total Cholesterol 215 Triglycerides 214 Triglycerides 214 HDL 54 HDL 54 LDL 118 LDL 118  Carotid ultrasound: extensive plaque without significant stenosis

22. Central Retinal Artery Occlusion

23. Anecdotal Therapy  Manual compression of eye  Retrobulbar anesthesia with paracentesis of the anterior chamber  What about t-PA?

24. EBM Search  Ovid: Cochrane Database of Systematic Reviews, ACP Journal Club, DARE  “Retinal artery”  8 hits, 2 relevant  ACP Journal Club: “Elderly patients had an increased 5-year risk for death, coronary events, and stroke after retinal infarction” (prognosis)  CDSR: “Interventions for acute non-arteritic central retinal artery occlusion” (treatment)

25. Prognosis and prognostic factors of retinal infarction GJ Hankey. BMJ 1991. Mar 2;302:499-504  Design: Cohort study, enrolled 1977-86 followed until death or end of study (1-10 years)  Patients: 98 consecutive patients with retinal infarction at Oxford Eye Hospital  Prognostic factors: Age, gender, smoking, causes of infarction, carotid bruit, blood pressure, lipids, therapeutic interventions

26. Prognosis, continued  Outcome measures: death, stroke, coronary events, contralateral retinal infarctions  Conclusion: Elderly patients with retinal infarction and no history of stroke had a poor 5-year prognosis for death, coronary events, and stroke particularly if they had carotid bruit and cardiomegaly.

27. ACP Journal Club Commentary AW Feinberg. July-Aug 1991. v115 p.24  Results of this study similar to larger studies of amaurosis fugax  Higher risk for ipsilateral stroke for 1st 6 months  Afterwards, death from MI exceeds stroke  Study limited by lack of doppler exam  Prognosis may now be better for patients who have carotid endarterectomy

28. Interventions for acute non-arteritic central retinal artery occlusion S Fraser. Cochrane Database of Systematic Reviews 2004.  Literature review  Selection criteria: randomized controlled trials to re-establish blood supply to retina  Search results: no trials met criteria  Conclusions: There is not enough evidence to decide which interventions would result in any beneficial or harmful effect.

29. Case Conclusion Interventions:  Warfarin planned for 6 months  Lovastatin  Consider Plavix

30. Useful Link  National Eye Institute (patient education) http://www.nei.nih.gov/health/ http://www.nei.nih.gov/health/

31. References  Bradford CA. Basic Ophthalmology. 7th Ed. 1999. American Academy of Ophthalmology.  Feinberg AW. Elderly patients had an increased 5-year risk for death, coronary events, and stroke after retinal artery infarction. ACP Journal Club 1999. v115:p.24. Abstract and commentary for Hankey GJ, Slattery JM, Warlow CP. Prognosis and prognostic factors of retinal infarction: a prospective cohort study. BMJ 1991. Mar 2;302:499-504  Fraser s, Siriwardena D. Interventions for acute non- arteritic central retinal artery occlusion. Cochrane Database of Systematic Reviews.