Patient History
HPI:
The patient is a 65 year-old male with a history of smoking, hypertension and hyperlipidemia who states that the vision in his R eye became blurred and then completely black, and then returned in about one or two minutes. This happened while he was having dinner one week ago. He had a second similar episode a day later in the same eye, this time while reading the newspaper. Since these two episodes, his vision seems normal. He also has noted a nagging right temporal headache, that is severe at times. He denies any jaw claudication. He has been more fatigued recently. He has had a ten-pound unintentional weight loss in the last 6 months. He was started on a new medication for cholesterol 2 months ago and experienced sore achy muscles. Workup was done by his primary care doctor for the muscle ache. As part of this work-up, an erythrocyte sedimentation rate (ESR) was checked and found to be elevated at 116.
Past Ocular History:
Corneal abrasion 3 years ago in the R eye due to trauma. No prior eye surgeries, amblyopia or strabismus.
Ocular Medications:
None
Past Medical History:
Hypertension under good control, hyperlipidemia
Surgical History:
Knee surgery a few years ago
Past Family Ocular History:
Negative for macular degeneration, glaucoma or blindness
Social History:
Current smoker, 1 pack per day x 40 years
Medications:
Hydrochlorothiazide, lisinopril, simvastatin
Allergies:
None
ROS:
Mild chronic cough that is longstanding. Denies recent illness or any other CNS, heart, lung, GI, skin or joint symptoms.
Ocular Exam
Visual Acuity (cc):
OD: 20/20
OS: 20/25+1
IOP (tonoapplantation):
OD: 14 mmHg
OS: 13 mmHg
Pupils:
Equal, round and reactive to light OU, no APD
Extraocular Movements:
Full OU. No nystagmus.
Confrontational Visual Fields:
Full to finger counting OU
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, no neovascularization |
Lens |
1+ nuclear sclerotic cataract OU |
Anterior Vitreous |
Clear OU
|
Dilated Fundus Examination:
OD |
Clear view, CDR 0.2 with one hemorrhage superiorly and some cotton-wool spots around the nerve; flat macula with normal foveal light reflex; normal vessels and peripheral retina. |
OS |
Clear view, CDR 0.2 with sharp optic disc margins; flat macula with normal foveal light reflex; normal vessels and peripheral retina.
|
Other:
Diagnostic studies:
Fluorescein angiogram – mild to moderate leakage of right optic nerve
Right temporal artery biopsy – giant cells in the wall of the temporal artery