Grand Rounds The Blurry Vision Consult: Something or Nothing? Frederick Blodi, DO 9/28/18 Department of Ophthalmology and Visual Sciences

Patient Presentation CC HPI “Blurry Vision” 48 yo WM, who was recently hospitalized for a right below the knee amputation (R BKA) due to gas gangrene after he stepped on a piece of wood. On the day of discharge, the patient fell while getting out of the car. His foot tangled in the wheelchair and he was readmitted for stump dehiscence. The patient underwent washout and revision of the R BKA. After that procedure, he had an episode of light-headedness and dyspnea. A CTA revealed extensive bilateral pulmonary emboli. Vision has been "hazy and blurry" since then (about 2 weeks). He has difficulty describing his vision but he "just has trouble seeing."

History (Hx) Past Ocular Hx: None Past Medical Hx: Morbid obesity, HTN, DM, R BKA Fam Hx: non-contributory Meds: Hydrocodone, amlodipine, lovenox bridge until therapeutic on warfarin, lantus, humalog, metoprolol, among others Allergies: NKDA Social Hx: Non-smoker, non-drinker, no illicits

External Exam OD OS VA N CC 20/20 -1 Pupils 4→2mm No rAPD IOP 17 mmHg EOM full

External Exam OD OS VA* 20/20 -1 Pupils 4→2mm No rAPD IOP 17 mmHg EOM full

External Exam Visual Fields by confrontation

Anterior Segment Exam PLE OD OS External/Lids WNL Conj/Sclera White Cornea Clear Ant Chamber Formed Iris Flat Lens

Posterior Segment Exam Fundus OD OS Optic Nerve Pink and sharp Macula WNL Vessels Periphery

Assessment 40 yo M with vague complaints of blurry vision, VA is 20/20 OU, however pt has left superior homonymous quadrantanopia. Exam otherwise normal. Differential Diagnosis Stroke Intracranial hemorrhage secondary to head trauma Space occupying lesion Demyelination

Plan Consult stroke team “I fear that he may have suffered a stroke in his right temporal lobe in his optic radiations thus causing his vision problems” Recommend neuroimaging including CT Head, MRI.

CT Head WO contrast

CT Head WO contrast

Discussion - Retrochiasmal lesions Homonymous VF defects respecting midline Most common causes in adults: Stroke 60%. Trauma ~10% Hemorrhage ~10% Children: trauma and tumors

Discussion - Temporal lobe Lesions become more congruous more posteriorly Associated with seizure activity, including olfactory seizures and visual hallucinations

Discussion - Driving with VF defects States treat hemianopia as any other restricted peripheral field Hemianopia pts ~90° of horizontal vision Federal gov’t requires field of 70° horizontally but most states are more stringent (avg around 110°) Only KY and UT have vertical VF requirements (25°) United Kingdom: driving explicitly prohibited with hemianopia

Discussion - Driving with VF defects

Discussion - Driving with VF defects

Discussion - Driving with VF defects

Hospital Course MRI unable to be performed due to body habitus TEE: patent foramen ovale Discharged on aspirin, lipitor, and warfarin (for PE) To follow up in clinic

Conclusions Something or nothing? Ophthalmology can be on the front line History is key Small clues can be valuable Lesions in temporal lobe become more congruous posteriorly and can be associated with seizures and visual hallucinations Driving should be considered on an individual basis

References American Journal of Occupational Therapy BCSC Neuro-ophthalmology Hemianopsia.net Ophthalmology Secrets Clinical Neuro-ophthalmology: The Essentials “Visual field requirements in the USA.” E Peli, Harvard Thank you to Dr. Piri for your help!