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Posted: May 23rd, 2023
D5
Case 5
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A 79-year-old male remarks on his first visit that he has noticed a gradual decrease in vision in both his eyes since last year. His old medical record has not yet arrived at your office. He states that since he moved from Florida a year ago, he has not had an eye examination and does not yet know an ophthalmologist. He is having difficulty carrying on his activities of daily living that involve his sight. He states that he cannot recognize people at some distance until they come quite close and he is often frightened by his perception of strangers speaking to him. Watching television and reading are becoming increasingly difficult for him. He states that glare is a problem and notes that a few times he almost tripped over something on the floor. He still drives his car in the local community. He asks if you think he may have a cataract. He says his wife had two cataracts in the past and he remembers her complaining of vision problems which have now resolved.
Vital Signs: BP 128/84; HR 82; RR 18; BMI 24.
Chief Complaint: Decrease in my vision; glare is very bothersome!
Discuss the following:
1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?
2) What additional objective data will you be assessing for?
3) What are the differential diagnoses that you are considering?
4) What laboratory tests will help you rule out some of the differential diagnoses?
5) What radiological examinations or additional diagnostic studies would you order?
6) What treatment and specific information about the prescription that you will give this patient?
7) What are the potential complications from the treatment ordered?
8) What additional laboratory tests might you consider ordering?
9) What additional patient teaching may be needed?
10) Will you be looking for a consult?
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Additional subjective data that can be sought include:
Detailed information about the patient’s visual symptoms, such as the exact nature of the decrease in vision (blurry vision, double vision, etc.), any associated pain or discomfort, and whether the symptoms are present in both eyes or one eye.
History of any eye diseases or conditions, such as glaucoma, macular degeneration, or diabetic retinopathy.
History of any eye surgeries or procedures.
Any systemic diseases or conditions that could affect vision, such as diabetes or hypertension.
Medications the patient is currently taking, including over-the-counter medications and supplements, as some medications can have ocular side effects.
Occupational history and hobbies, as certain activities or exposures may contribute to visual problems.
Social history, including smoking and alcohol use, as these factors can impact eye health.
Family history of eye diseases, especially cataracts or other hereditary eye conditions.
Additional objective data to be assessed for:
Visual acuity testing using an eye chart.
External examination of the eyes, looking for any abnormalities, such as redness, swelling, or discharge.
Pupillary examination to assess the reaction of the pupils to light.
Evaluation of visual fields to check for any peripheral vision loss.
Assessment of intraocular pressure to rule out glaucoma.
Slit-lamp examination to examine the structures of the anterior segment of the eye, including the lens, cornea, and iris.
Fundus examination to evaluate the retina and optic nerve.
The differential diagnoses to consider in this case include:
Cataracts: Given the patient’s symptoms, history of gradual vision loss, and his wife’s history of cataracts, cataracts are a likely possibility.
Age-related macular degeneration: This condition can cause central vision loss and difficulty recognizing faces.
Glaucoma: Increased intraocular pressure can lead to peripheral vision loss and difficulty with glare.
Diabetic retinopathy: If the patient has a history of diabetes, this condition should be considered.
Refractive errors: Myopia, hyperopia, or astigmatism can cause blurred vision and difficulty with distance vision.
Other ocular conditions: Retinal detachment, uveitis, or optic neuritis could also present with similar symptoms.
Laboratory tests that can help rule out some of the differential diagnoses include:
Fasting blood glucose or HbA1c levels to assess for diabetes.
Complete blood count (CBC) to check for any systemic abnormalities.
Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) to evaluate for systemic inflammation associated with certain ocular conditions.
Radiological examinations or additional diagnostic studies that may be ordered include:
Optical coherence tomography (OCT) to assess the structures of the retina and macula.
Visual field testing to evaluate the patient’s peripheral vision.
Ultrasound biomicroscopy or A-scan ultrasound to assess the structures within the eye, such as the lens and anterior chamber.
The treatment for cataracts typically involves surgical intervention. The specific information about the prescription that can be given to the patient includes:
Referral to an ophthalmologist for further evaluation and confirmation of the diagnosis.
Explaining the surgical procedure for cataract removal, such as phacoemulsification with intraocular lens implantation.
Discussing the potential benefits of surgery, including improved vision, reduced glare, and enhanced quality of life.
Informing the patient about the risks and potential complications of surgery, such as infection, bleeding, or retinal detachment.
Advising the patient to continue with current visual aids, such as glasses or contact lenses,
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