OPHTHALMOLOGY 1

A 65-year-old African American man comes to the emergency department with sudden loss of vision in his right eye. He is a diabetic, on treatment with metformin and glyburide for the past 10 years. Examination reveals visual acuity reduced to light perception in his right eye and normal in his left. Ophthalmoscopy reveals loss of fundus details, floating debris and dark red glow. His vital signs are normal. What is the likely diagnosis?
A. Retinal detachment
B. Diabetic retinopathy
C. Vitreous hemorrhage
D. Central retinal vein occlusion
E. Age related macular degeneration

Explanation:
In vitreous hemorrhage, patients present with sudden, acute loss of vision and sudden onset of floaters, as in this patient. Diabetic retinopathy is the most common cause of vitreous hemorrhage. The important clue to diagnosis is the fact that the fundus will be hard to visualize and even if visualized details may be obscured. Immediate ophthalmoscopic consultation is required. In patients with underlying medical condition conservative treatment with upright positioning for sleep to enhance settling of hemorrhage is advised.

Choice A: Retinal detachment refers to separation of the inner layers of the retina. It may be associated with metabolic disorders such as diabetes mellitus, trauma including ocular surgery, vascular disease, myopia, or degeneration. These patients complain of photopsia accompanied with showers of floaters.

Choice B: Diabetic retinopathy patients are usually asymptomatic even though changes in fundoscopy are seen. The symptoms of sudden acute onset of visual loss with numerous floaters are suggestive of vitreous hemorrhage, which frequently occurs in patients with proliferative diabetic retinopathy.

Choice D: Central retinal vein occlusion, presents with sudden, painless, unilateral loss of vision. It is also noted in patients with a history of hypertension. Ophthalmoscopic signs are disk swelling, venous dilation and tortuosity, retinal hemorrhages, and cotton wool spots.

Choice E: Patients with macular degeneration typically present with painless progressive blurring of central vision, which can be acute or insidious. It occurs bilaterally.