Case Study 7 - CC: Vision loss L eye

HPI:
A 61-year-old Caucasian male university professor presents with loss of vision in his left eye that began yesterday morning and has become progressively worse. The patient describes the sensation that a curtain was coming up over his affected eye and this curtain is now affecting his center vision. In addition, 7 days ago the patient noticed what he described as flashing lights on the left and noticed subsequent floaters. The patient has no pain, diplopia, halos, metamorphopsia or other symptoms. The patient reports having cataract surgery in his left eye 3 weeks ago.

Past Ocular History:
Cataract surgery L eye, 3 weeks ago; no other history of surgery, trauma, amblyopia or strabismus.

Ocular Medications:
None

Past Medical History:
Hypertension – well controlled on medication
Osteoarthritis

Surgical History:
Right knee replacement in 2005

Past Family Ocular History:
Mother – AMD
No history of retinal detachment, glaucoma, blindness

Social History:
Non-smoker

Medications:
Hydrochlorothiazide
Lisinopril

Allergies:
None

ROS:
Denies recent illness or any new CNS, heart, lungs, GI, skin or joint symptoms
Ocular Exam

Visual Acuity (cc):
OD: 20/25
OS: Counting fingers at 3 feet

IOP (tonoapplantation):
OD: 16 mmHg
OS: 11 mmHg

Pupils:
Equal, round and reactive to light, no APD

Extraocular Movements:
Full OU. No nystagmus.

Confrontational Visual Fields:
Full to finger counting R; central, inferior, and nasal field deficits OS

External:
Normal, both sides

Slit Lamp:

Lids and Lashes	Normal OU
Conjunctiva/Sclera	Normal OU
Cornea	Clear OU
Anterior Chamber	Deep and quiet OU
Iris	Normal OU
Lens	1+ nuclear sclerotic cataract OU
Anterior Vitreous	Normal OD, Pigmented cells OS (Shafer’s sign)

Dilated Fundus Examination:

OD	Clear view, CDR 0.3 with sharp optic disc margins; flat macula with normal foveal light reflex; normal vessels and peripheral retina
OS	Clear view, CDR 0.3 with sharp optic disc margins; large area of subretinal fluid extending from 10 o’clock to 4 o’clock with fluid under the macula (mac off retinal detachment). A horseshoe tear is identified at 2 o’clock. Small amount of vitreous hemorrhage noted at the site of the tear.

Other:
Amsler Grid:
OD: Normal
OS: Blurry throughout, with nasal regions missing completely

Diagnosis
Rhegmatogenous retinal detachment resulting from a peripheral retinal tear.

Discussion

Differential Diagnosis:
This patient is presenting with a retinal detachment (RD) due to a retinal tear. Other diseases in the differential diagnosis include choroidal detachment, choroidal effusion, choroidal hemorrhage, subretinal mass.

Definition:
Rhegmatogenous RD - these detachments are caused by liquefied vitreous passing through a retinal break and in between the retinal pigment epithelium and the neurosensory retinal. This causes the retina to be lifted up and is seen as undulating bullae or folds on exam. A retinal break can be found in 90-97% of cases of rhegmatogenous RD, and if not found, a break is presumed to be present.

Tractional RD - Vitreous membranes that may be caused by penetrating injuries or proliferative retinopathies such as seen in diabetes can lead to retinal traction and pull the neurosensory retinal away from the retinal pigment epithelium without a retinal tear. The retina typically has a smooth surface with concave borders and is immobile, peaking to traction points. These detachments can develop breaks and become rhegmatogenous.

Exudative RD - May be caused by either retinal or choroidal disease in which fluid leaks into and accumulates underneath the neurosensory retinal. Most exudative detachments are small and are associated with choroidal neovascularization. Large detachments as seen in tractional and rhegmatogenous types are rare but can occur. Large exudative RDs are normally due to neoplasia or inflammatory disease. These large exudative detachments often exhibit shifting fluid, are smooth and without folds. When sitting up the inferior retina will be detached, and when laying supine the posterior retinal will detach, including the macula (shifting fluid).

This particular patient has a rhegmatogenous retinal detachment resulting from a peripheral retinal break. This retinal break is likely due to vitreous traction on the periphery, and may have been precipitated by the recent cataract surgery. Cataract surgery creates more space in the vitreous chamber (the new lens is thinner than the extracted cataract) and allows the vitreous jelly to shift. As the vitreous jelly moves to fill this new space it can tug on the retina and cause a retinal break. Other etiologies for a rhegmatogenous retinal detachment may include peripheral lattice, highly myopic eyes, posterior vitreous detachment, trauma, aphakia and sickle cell disease.

Examination:
Any patient with complaints of flashes of lights or new/change in floaters needs a thorough eye evaluation. In addition to visual acuity and IOP (chronic RDs can decrease IOP) a dilated exam of both eyes is imperative. The vitreous is examined for pigmented cells. If present it could indicate a hemorrhage or the release of pigmented retinal cells in the vitreous (Schafer sign). Both could signal the presence of a retinal tear. The peripheral retina is examined for any signs of retinal tears or small detachments. Depression of the peripheral retina to better visualize the far periphery and highlight any flat tears is important.

Treatment:
Rhegmatogenous detachments are often treated surgically. Common procedures include scleral buckle, pneumatic retinopexy and vitrectomy. The purpose of the surgery is to relieve vitreous traction and approximate the retina to the underlying choroid. Overall, the current surgical techniques have an 80-90% success rate of anatomical reattachment.

Postoperative visual acuity in patients with “mac on” retinal detachments results in 20/50 or better in 87% of cases. When the detachment involves the macula, only one third to one half of patients recover to a VA of 20/50 or better. If the macula off detachment is repaired within 1 week then 75% of patients will recover with a VA of 20/70 or better. This drops to 50% if repaired between 1 and 8 weeks.

1. A 73 year-old female presents with a recent history of flashing lights and new floaters in her right eye. Two days ago she noticed a “curtain” coming over her vision from right to left. She has a visual acuity of 20/25 in the right eye. On your indirect exam you see a retinal detachment in the right eye. Which region of the retina would you be most likely to see the detachment?
   • Inferior retina
   • Superior retina
   • Temporal retina
   • Nasal retina
   • Central retina
2. Which of the following is not a typical symptom of a retinal detachment?
   • Flashing lights
   • Decreased vision
   • Ocular pain
   • Increased floaters
   • A “curtain” coming over visual field

References/Resources:
Carl Regillo, MD, Nancy Holekamp, MD, Mark W. Johnson, MD, Peter K. Kaiser, MD, Hermann D. Schubert, MD, Richard Spaide, MD, Paul Bennett Griggs, MD, Ursula M. Schmidt-Erfurth, MD, Retina and Vitreous BCSC, American Academy of Ophthalmology 2009.

A 73 year-old female presents with a recent history of flashing lights and new floaters in her right eye. Two days ago she noticed a “curtain” coming over her vision from right to left. She has a visual acuity of 20/25 in the right eye. On your indirect exam you see a retinal detachment in the right eye. Which region of the retina would you be most likely to see the detachment?
d. Nasal retina
Patients that see visual phenomena on the temporal side of the visual field usually have retina pathology in the opposite side of the retina (nasal side).

Which of the following is not a typical symptom of a retinal detachment?
c. Ocular pain
Retinal breaks and detachments are usually painless.