# Clinical Cases: Ophthalmology ## Case 1: Acute Angle-Closure Glaucoma ### Patient Presentation **Demographics:** 62-year-old female retired schoolteacher **Chief Complaint:** "My right eye suddenly became very painful and my vision went blurry about three hours ago." **History of Present Illness:** The patient presents to the emergency department with acute onset of severe right eye pain, blurred vision, and seeing halos around lights that began approximately three hours ago while she was watching television in a dimly lit room. She describes the pain as a deep, aching sensation radiating to her right forehead and temple. She has experienced one episode of nausea and vomiting since symptom onset. She denies any recent trauma to the eye, history of similar episodes, or recent eye surgery. She notes that she was prescribed new reading glasses six months ago and has noticed gradual difficulty with peripheral vision in both eyes over the past year. She took acetaminophen 1000 mg at home without relief. She was recently started on a new medication by her primary care physician for urinary incontinence (oxybutynin), which she began taking five days ago. She has not had any recent ophthalmologic examination beyond her optometry visit for glasses. **Past Medical History:** - Hypertension, well controlled - Overactive bladder syndrome - Hyperopia (farsightedness) since age 40 - Osteoarthritis of the knees **Medications:** - Lisinopril 10 mg daily - Oxybutynin 5 mg twice daily (started 5 days ago) - Acetaminophen 500 mg as needed for joint pain - Calcium with vitamin D supplement daily **Social History:** - Non-smoker - Occasional glass of wine with dinner - Lives with her husband, independent in all activities - No occupational chemical or UV exposure **Family History:** - Mother had glaucoma diagnosed at age 70 - Father had type 2 diabetes and cataracts - No family history of retinal detachment ### Physical Examination - **Vital Signs:** BP 158/94 mmHg, HR 92 bpm, RR 18/min, Temp 36.8°C, SpO2 98% on room air - **General:** Alert, anxious-appearing woman in moderate distress, holding right side of her face - **Right Eye:** - Visual acuity: 20/200 (baseline 20/30 with correction) - Conjunctival injection with ciliary flush - Cornea: diffuse edema with microcystic changes, hazy appearance - Anterior chamber: very shallow, Grade 0-1 by Van Herick technique - Pupil: mid-dilated (6 mm), fixed, non-reactive to light, no afferent pupillary defect - Iris: bowing forward (iris bombé configuration) - Lens: mild nuclear sclerotic cataract - Fundoscopy: limited due to corneal edema; optic disc difficult to visualize - Intraocular pressure (IOP) by Goldmann applanation tonometry: 58 mmHg - **Left Eye:** - Visual acuity: 20/30 with correction - Anterior chamber: shallow, Grade 1-2 by Van Herick technique - Pupil: 3 mm, reactive - IOP: 16 mmHg - Fundoscopy: cup-to-disc ratio 0.4, healthy neuroretinal rim - **Gonioscopy (left eye):** Narrow angles, Shaffer Grade 1-2 in all quadrants ### Workup and Results **Laboratory Studies:** | Test | Result | Reference Range | |------|--------|-----------------| | Glucose (random) | 112 mg/dL | 70-140 mg/dL | | BUN | 18 mg/dL | 7-20 mg/dL | | Creatinine | 0.9 mg/dL | 0.6-1.2 mg/dL | | Potassium | 4.1 mEq/L | 3.5-5.0 mEq/L | | Sodium | 141 mEq/L | 136-145 mEq/L | | CBC | Within normal limits | -- | **Imaging/Additional Studies:** - **Anterior segment OCT (left eye):** Confirmed narrow iridocorneal angle with anterior lens position - **Ultrasound biomicroscopy (when available):** Plateau iris configuration suspected - **B-scan ultrasonography (right eye):** No retinal detachment, no posterior segment mass; lens in normal position, axial length 21.2 mm (short, consistent with hyperopia) ### Clinical Image ![Acute angle-closure glaucoma diagram showing elevated IOP, shallow anterior chamber, and mid-dilated pupil](case_01_image.jpg) *Diagram illustrating the pathophysiology of acute angle-closure glaucoma with pupillary block. Source: Educational illustration.* ### Diagnosis **Acute Primary Angle-Closure Glaucoma (Right Eye) with Narrow Angles (Left Eye)** **Key Diagnostic Criteria:** - Acutely elevated IOP (58 mmHg) with symptoms of pain, blurred vision, halos, nausea/vomiting - Shallow anterior chamber with closed angle on examination - Mid-dilated, fixed pupil - Corneal edema and conjunctival injection - Precipitating factor: anticholinergic medication (oxybutynin) - Anatomic predisposition: hyperopia, short axial length, shallow anterior chamber bilaterally ### Treatment Plan 1. **Immediate IOP-lowering therapy:** - Timolol 0.5% one drop to the right eye - Apraclonidine 1% one drop to the right eye - Pilocarpine 2% one drop to the right eye every 15 minutes x 2 doses (once IOP begins to fall below 40 mmHg and sphincter ischemia resolves) - Acetazolamide 500 mg IV stat, followed by 250 mg PO every 6 hours - Mannitol 1-2 g/kg IV over 45 minutes if IOP remains refractory 2. **Topical prednisolone acetate 1%** one drop every hour to reduce intraocular inflammation 3. **Antiemetic:** Ondansetron 4 mg IV for nausea 4. **Discontinue oxybutynin** immediately and notify prescribing physician 5. **Definitive treatment:** Laser peripheral iridotomy (LPI) to the right eye once corneal edema clears and IOP is controlled 6. **Prophylactic LPI to the left eye** given narrow angles and high risk of similar attack 7. **Follow-up:** Reassess IOP in 1 hour; ophthalmology admission if IOP uncontrolled; outpatient follow-up within 1 week post-LPI ### Key Learning Points - Anticholinergic medications (oxybutynin, antihistamines, tricyclic antidepressants, inhaled ipratropium) can precipitate acute angle-closure in anatomically predisposed eyes by causing pupillary dilation. - Hyperopic (farsighted) patients have shorter axial lengths and shallower anterior chambers, placing them at higher risk for angle-closure glaucoma. - The contralateral eye should always be examined and treated prophylactically with laser peripheral iridotomy, as the risk of a similar attack is approximately 50% within 5 years. - Pilocarpine may be ineffective if the IOP is extremely high (>50 mmHg) because iris sphincter ischemia prevents miosis; it should be applied after initial IOP reduction with other agents. - Acute angle-closure glaucoma is an ophthalmologic emergency; delay in treatment can result in permanent optic nerve damage and vision loss within hours. --- ## Case 2: Diabetic Retinopathy Screening ### Patient Presentation **Demographics:** 54-year-old male long-haul truck driver **Chief Complaint:** "My doctor sent me for an eye check. I think my vision has gotten a little blurry recently, but I figured it was just my age." **History of Present Illness:** The patient is referred by his primary care physician for diabetic retinopathy screening. He was diagnosed with type 2 diabetes mellitus eight years ago but admits to poor adherence with his medications and follow-up appointments due to his work schedule. He has not had a dilated fundus examination in over four years. He reports mild blurring of his vision bilaterally over the past several months, particularly when reading road signs at a distance, but attributes this to aging. He denies flashes of light, floaters, sudden vision loss, or eye pain. He has noticed increased difficulty driving at night. His most recent HbA1c, obtained two weeks ago, was 9.8%. He reports frequent polyuria and polydipsia. He checks his blood glucose at home "once or twice a week" with fasting readings typically in the 180-250 mg/dL range. He has a 15-pack-year smoking history but quit smoking 3 years ago. He was told he has "borderline high" blood pressure and cholesterol at his last physical examination. **Past Medical History:** - Type 2 diabetes mellitus (8 years), poorly controlled - Hypertension, suboptimally treated - Hyperlipidemia - Obesity (BMI 34.2) - Peripheral neuropathy in both feet (diagnosed 2 years ago) - Microalbuminuria noted on last urinalysis **Medications:** - Metformin 1000 mg twice daily (admits to missing doses frequently) - Glipizide 10 mg twice daily - Lisinopril 20 mg daily - Atorvastatin 40 mg daily - Aspirin 81 mg daily **Social History:** - Former smoker (quit 3 years ago, 15-pack-year history) - Drinks 2-3 beers on weekends - Long-haul truck driver, sedentary lifestyle - Diet high in processed and fast food - Divorced, lives alone **Family History:** - Father: type 2 diabetes, died of myocardial infarction at age 63 - Mother: type 2 diabetes, hypertension, alive at age 78 - Brother: type 2 diabetes diagnosed at age 45 ### Physical Examination - **Vital Signs:** BP 148/92 mmHg, HR 78 bpm, RR 16/min, Temp 36.7°C, BMI 34.2 kg/m² - **Right Eye:** - Visual acuity: 20/50 (pinhole improvement to 20/40) - Anterior segment: unremarkable, no neovascularization of the iris (NVI) - IOP: 17 mmHg - Dilated fundus examination: - Multiple dot-and-blot hemorrhages in all four quadrants - Hard exudates forming a circinate ring temporal to the macula - Cotton-wool spots (4 total across both hemifields) - Venous beading in two quadrants - Intraretinal microvascular abnormalities (IRMA) noted superior-temporal - No neovascularization of the disc (NVD) or elsewhere (NVE) - Clinically significant macular edema suspected (retinal thickening within 500 μm of foveal center) - **Left Eye:** - Visual acuity: 20/40 (pinhole improvement to 20/30) - IOP: 16 mmHg - Dilated fundus examination: - Scattered dot-and-blot hemorrhages in two quadrants - Microaneurysms, predominantly temporal to macula - Rare hard exudates - One cotton-wool spot - No IRMA, venous beading, or neovascularization - No macular edema ### Workup and Results **Laboratory Studies:** | Test | Result | Reference Range | |------|--------|-----------------| | HbA1c | 9.8% | <7.0% (diabetic goal) | | Fasting glucose | 228 mg/dL | 70-100 mg/dL | | Creatinine | 1.3 mg/dL | 0.7-1.3 mg/dL | | eGFR | 62 mL/min/1.73m² | >90 mL/min/1.73m² | | Urine albumin-to-creatinine ratio | 180 mg/g | <30 mg/g | | Total cholesterol | 242 mg/dL | <200 mg/dL | | LDL cholesterol | 148 mg/dL | <100 mg/dL (diabetic goal) | | HDL cholesterol | 36 mg/dL | >40 mg/dL | | Triglycerides | 290 mg/dL | <150 mg/dL | | CBC | Within normal limits | -- | **Imaging/Additional Studies:** - **Optical coherence tomography (OCT) right eye:** Central macular thickness 412 μm (normal <300 μm), intraretinal cystic spaces and subretinal fluid consistent with center-involving diabetic macular edema (DME) - **OCT left eye:** Central macular thickness 278 μm, no intraretinal fluid - **Fundus fluorescein angiography (FFA):** Right eye shows extensive capillary non-perfusion in the mid-periphery, macular leakage, and microaneurysm hyperfluorescence; left eye shows mild peripheral capillary dropout - **Ultra-widefield fundus photography:** Confirmed hemorrhages and IRMA distribution in all quadrants of the right eye ### Clinical Image ![Fundus photograph showing features of severe non-proliferative diabetic retinopathy](case_02_image.jpg) *Fundus photograph illustration demonstrating features of severe non-proliferative diabetic retinopathy including dot-blot hemorrhages, hard exudates, cotton-wool spots, and venous beading. Source: Educational illustration.* ### Diagnosis **Right Eye: Severe Non-Proliferative Diabetic Retinopathy (NPDR) with Center-Involving Diabetic Macular Edema (DME)** **Left Eye: Moderate Non-Proliferative Diabetic Retinopathy without DME** **Key Diagnostic Criteria:** - **Severe NPDR (Right Eye) — meets the "4-2-1 Rule":** hemorrhages in all 4 quadrants, venous beading in 2+ quadrants, and IRMA in 1+ quadrant (any one criterion qualifies) - **Center-involving DME:** OCT-confirmed central macular thickness >300 μm with intraretinal cystic changes - **Moderate NPDR (Left Eye):** More than mild (microaneurysms only) but does not meet severe NPDR criteria - **Systemic context:** Poorly controlled diabetes (HbA1c 9.8%), concurrent microvascular complications (nephropathy, neuropathy) ### Treatment Plan 1. **Right eye — center-involving DME:** - Intravitreal anti-VEGF therapy (aflibercept 2 mg or ranibizumab 0.3 mg) as first-line treatment - Loading phase: monthly injections for the first 5-6 months, then treat-and-extend protocol - Repeat OCT at each visit to monitor central macular thickness 2. **Right eye — severe NPDR:** - Close monitoring (every 2-3 months) for progression to proliferative diabetic retinopathy (PDR) - Consider early panretinal photocoagulation (PRP) if follow-up adherence is a concern (as per DRCR.net Protocol S, anti-VEGF is non-inferior to PRP for PDR) 3. **Left eye — moderate NPDR:** - Dilated fundus examination every 6 months - OCT monitoring for DME development 4. **Systemic optimization (coordinate with primary care/endocrinology):** - Intensify glycemic control: add basal insulin (e.g., glargine) given HbA1c 9.8%, target HbA1c <7% - Optimize blood pressure to <130/80 mmHg: increase lisinopril or add amlodipine - Intensify lipid management: increase atorvastatin to 80 mg, add fenofibrate (FIELD/ACCORD Eye studies suggest benefit in DR) 5. **Occupational counseling:** Discuss implications for commercial driving license; visual acuity and visual field requirements must be met 6. **Patient education:** Emphasize that vision loss from diabetic retinopathy is largely preventable with glycemic control and regular screening ### Key Learning Points - The "4-2-1 Rule" classifies severe NPDR: dot-blot hemorrhages in all 4 quadrants, OR venous beading in 2+ quadrants, OR prominent IRMA in 1+ quadrant. Meeting any one of these criteria is sufficient. - Patients with severe NPDR have a 52% risk of progressing to proliferative diabetic retinopathy within one year without treatment, underscoring the importance of close follow-up. - Anti-VEGF intravitreal injections are the current first-line treatment for center-involving DME, replacing focal/grid laser photocoagulation. - Diabetic retinopathy screening should begin at diagnosis for type 2 diabetes and 5 years after diagnosis for type 1 diabetes, with annual dilated fundus examinations thereafter. - Systemic risk factor control (glycemia, blood pressure, lipids) is essential and synergistic with ophthalmic treatment in slowing DR progression. --- ## Case 3: Retinal Detachment ### Patient Presentation **Demographics:** 58-year-old male software engineer **Chief Complaint:** "I've been seeing flashing lights in my left eye for two days, and today I noticed a dark shadow coming across my vision from the bottom." **History of Present Illness:** The patient presents urgently to the ophthalmology clinic with a two-day history of photopsia (flashing lights) in his left eye, described as brief, arc-like white flashes in the temporal visual field, particularly noticeable in dim lighting and with eye movements. He also reports a sudden increase in floaters, describing them as "a shower of tiny black dots," beginning simultaneously with the flashing lights two days ago. This morning, he noticed a dark curtain-like shadow progressing from the inferior visual field upward in his left eye. He estimates that approximately one-third of his lower visual field is now obscured. His central vision remains relatively intact. He denies eye pain, redness, or discharge. He has a history of high myopia and underwent LASIK surgery on both eyes twelve years ago. He reports a remote history of blunt trauma to his left eye from a squash ball approximately five years ago, which was evaluated at the time and deemed to have no acute damage. He has not had a dilated eye examination in three years. **Past Medical History:** - High myopia (pre-LASIK refraction: -8.50 D OD, -9.25 D OS) - Status post bilateral LASIK (12 years ago) - Posterior vitreous detachment of the right eye (diagnosed 2 years ago, uncomplicated) - Mild essential hypertension - No history of diabetes **Medications:** - Amlodipine 5 mg daily - Multivitamin daily - Fish oil supplement **Social History:** - Non-smoker - Social alcohol use (1-2 glasses of wine per week) - Avid squash player (plays twice weekly) - Works long hours at computer screens - Married with two children **Family History:** - Father: retinal detachment repair at age 65 - Mother: glaucoma - No family history of connective tissue disorders (Marfan, Stickler syndrome) ### Physical Examination - **Vital Signs:** BP 132/82 mmHg, HR 72 bpm, RR 14/min, Temp 36.6°C - **Right Eye:** - Visual acuity: 20/20 (post-LASIK) - Anterior segment: clear cornea with LASIK flap scar, deep anterior chamber - IOP: 15 mmHg - Dilated fundus: Weiss ring noted (evidence of prior posterior vitreous detachment), no retinal breaks or detachment, lattice degeneration present at 10 o'clock position in the periphery, flat retina 360 degrees - **Left Eye:** - Visual acuity: 20/40 (decreased from baseline 20/20) - Relative afferent pupillary defect: absent - Anterior segment: clear, deep anterior chamber, trace anterior vitreous cells - IOP: 10 mmHg (lower than fellow eye, suggestive of detachment) - Dilated fundus examination: - Tobacco dust (Shafer sign/pigmented cells) present in the anterior vitreous - Vitreous: posterior vitreous detachment with collapse, mild vitreous hemorrhage - Superior retina: horseshoe (flap) tear at 1 o'clock position, approximately 1.5 disc diameters in size, with a rolled posterior edge and a visible operculum - Bullous retinal detachment extending from the superior tear, involving the superior and temporal quadrants, extending to just above the fovea - Macula: attached but threatened (detachment border within 2 disc diameters of fovea) - Subretinal fluid: moderate, shifting with positioning - No proliferative vitreoretinopathy (PVR) noted - Lattice degeneration at 9 o'clock with an atrophic hole (no associated subretinal fluid) ### Workup and Results **Laboratory Studies:** | Test | Result | Reference Range | |------|--------|-----------------| | CBC | Within normal limits | -- | | INR | 1.0 | 0.8-1.2 | | Metabolic panel | Within normal limits | -- | | Fasting glucose | 94 mg/dL | 70-100 mg/dL | **Imaging/Additional Studies:** - **B-scan ultrasonography (left eye):** Confirms superior bullous retinal detachment with the detached retina still tethered at the optic disc and ora serrata; no posterior vitreous mass or choroidal detachment; vitreous opacities consistent with mild hemorrhage and tobacco dust - **OCT macula (left eye):** Fovea remains attached but shallow subretinal fluid is present within 500 μm of the foveal center, indicating imminent macula-off status - **Widefield fundus photography (left eye):** Documents the extent of detachment involving approximately 40% of the retinal surface area (superior and supero-temporal quadrants) - **OCT macula (right eye):** Normal foveal contour, no subretinal fluid, no epiretinal membrane ### Clinical Image ![Diagram of rhegmatogenous retinal detachment showing horseshoe tear and subretinal fluid accumulation](case_03_image.jpg) *Cross-sectional diagram illustrating a rhegmatogenous retinal detachment with a horseshoe tear, vitreous traction, and subretinal fluid accumulation. Source: Educational illustration.* ### Diagnosis **Rhegmatogenous Retinal Detachment, Left Eye — Macula-Threatening (Macula-On)** **Key Diagnostic Criteria:** - Acute symptoms of photopsia, floaters, and progressive visual field loss - Horseshoe retinal tear at 1 o'clock position (causative break) - Bullous retinal detachment with subretinal fluid in the superior and temporal quadrants - Shafer sign positive (tobacco dust in vitreous — pathognomonic for retinal break) - Low IOP relative to fellow eye (10 vs 15 mmHg) - Macula currently attached but imminently threatened - Risk factors: high myopia, posterior vitreous detachment, lattice degeneration, family history, prior ocular trauma, age ### Treatment Plan 1. **Emergency surgical repair** — this is a macula-on detachment with imminent macula-off threat; surgery should be performed within 24 hours to preserve central vision 2. **Positioning:** Patient positioned with head elevated and turned to the right (detachment is superior, so face-down/right positioning helps prevent macular involvement while awaiting surgery) 3. **Surgical options (vitreoretinal surgeon decision):** - **Primary pars plana vitrectomy (PPV)** with endolaser to the retinal tear and gas tamponade (SF6 or C3F8): preferred approach for this bullous, superior detachment with a large horseshoe tear - Alternative: Scleral buckle, which may be considered given patient's age and phakic status, though PPV is more commonly performed - Combined PPV with scleral buckle if lattice degeneration with atrophic holes poses additional risk 4. **Intraoperative treatment of lattice degeneration:** Laser retinopexy to the lattice with atrophic hole at 9 o'clock and to the lattice in the fellow right eye at 10 o'clock 5. **Postoperative care:** - Face-down positioning for 5-7 days if gas tamponade used - Topical antibiotics and corticosteroids - No air travel until gas tamponade resorbs (2-6 weeks depending on gas type) - Activity restriction: no heavy lifting, straining, or racquet sports for 4-6 weeks 6. **Prophylactic laser to the right eye:** Barricade laser around the lattice degeneration at 10 o'clock to reduce risk of retinal detachment in the fellow eye 7. **Long-term follow-up:** Dilated fundus examination at 1, 3, 6, and 12 months post-surgery, then annually; counsel about symptoms of re-detachment ### Key Learning Points - The triad of new photopsia, floaters, and visual field loss should be considered a retinal detachment until proven otherwise and warrants urgent dilated fundus examination. - Shafer sign (tobacco dust/pigmented cells in the anterior vitreous) is pathognomonic for a retinal break and should be specifically sought during slit-lamp examination. - Macula-on retinal detachments are surgical emergencies (repair within 24 hours), as macular involvement dramatically worsens the visual prognosis; macula-off detachments are urgent but can typically be repaired within 24-72 hours. - High myopia (>-6.00 D) is the most common risk factor for rhegmatogenous retinal detachment, increasing the risk 5-6 fold due to peripheral retinal thinning, lattice degeneration, and earlier posterior vitreous detachment. - Fellow eye prophylaxis with laser retinopexy to lattice degeneration is important, as the lifetime risk of retinal detachment in the fellow eye of a myopic patient is 10-15%.