68-year-old woman with diabetes and tobacco use and 3-year w | Figure 1
68-year-old woman with diabetes and tobacco use and 3-year worsening vision
What is the role of the primary care or emergency medicine physician?
If cataracts are suspected, nonurgent referral to an ophthalmologist for cataract evaluation is warranted.
What is the role of the ophthalmologist?
- Perform cataract evaluation with a complete dilated eye examination, including a slit-lamp examination to determine the cataract type and extent.
- Assess for best-corrected visual acuity and perform glare testing.
- Order testing to help determine the intraocular lens needed.
- Perform cataract extraction and placement of an intraocular lens.
Review the full case on the Academy website for more details, including links to educational resources on key topics related to the case.
Diagnosis
The image is consistent with a diagnosis of cataract, a clouding of the crystalline lens of the eye, leading to progressive vision loss. Patients may report poor night vision, glare, and increased nearsightedness. Early in the formation of a cataract, patients can experience a temporary improvement in vision, especially near vision. The 3 most common types are nuclear sclerotic, cortical, and posterior subcapsular. Treatment includes extraction of the cataract & placement of an intraocular lens.
More about this case
ResolvedVerified literatureCommon presentationTrending
Why you should join Figure 1
- Share your knowledge with our global community of healthcare professionals
- Get help from experts in your field
- Learn from our library of real-world cases and quizzes
Similar cases
What is the role of the primary care or emergency medicine physician?
- Check the child's visual acuity in each eye in an age-appropriate manner.
- Refer the patient to a pediatric ophthalmologist if you suspect vision is decreased in 1 or both eyes, or if you suspect 1 of the risk factors for amblyopia is present:
- refractive error
- strabismus
- deprivation (eg, ptosis, cataract, corneal scar)
What is the role of the ophthalmologist?
- Check visual acuity in each eye.
- Check the refraction in each eye.
- Perform an external, anterior segment, and posterior segment exam, looking for any risk factors for amblyopia.
What is the treatment?
Patching or atropine eyedrops are used to block (patching) or blur (atropine) the better-seeing eye to strengthen neural connections to the weaker eye. The underlying causes of the child's amblyopia should also be treated as appropriate:
- glasses for refractive amblyopia
- strabismus surgery for strabismic amblyopia
- treatment of the condition blocking vision in deprivation amblyopia (eg, cataract surgery, ptosis repair)
Review the full case on the Academy website for more details, including links to educational resources on key topics related to the case.
What is the role of the primary care or emergency medicine physician?
- Refer glaucoma suspects (ie, cup-disc ratio >0.5 or IOP >21 mm Hg) nonurgently to ophthalmology.
- Consider glaucoma screening for high-risk patients such as African Americans, Hispanics, people with diabetes, and those with a family history of glaucoma. Screening is not recommended for asymptomatic adults.
- Suggest that patients at age 40 get a baseline ocular examination by an ophthalmologist.
What is the role of the ophthalmologist?
The ophthalmologist will evaluate the cup-disc ratio (normal, <0.5) for signs of optic nerve damage, use Goldmann applanation tonometry to measure IOP (normal, ≤21 mm Hg), and use gonioscopy to evaluate the anterior chamber angle.
What is the treatment?
The goal of therapy is to lower IOP via reduced aqueous humor production or increased outflow. Treatment options include the following:
- topical: alpha agonists (eg, brimonidine), beta-blockers (eg, timolol), miotics (eg, pilocarpine), carbonic anhydrase inhibitors (eg, dorzolamide), and prostaglandins (eg, latanoprost)
- systemic: carbonic anhydrase inhibitors (eg, acetazolamide)
- surgical: laser trabeculoplasty, trabeculectomy, glaucoma drainage devices, minimally invasive glaucoma surgery, and cyclodestructive procedures
Review the full case on the Academy website for more details, including links to educational resources on key topics related to the case.
What is the role of the primary care or emergency medicine physician?
- Perform visual screening exams in infancy and periodically throughout childhood at well-child visits.
- If esotropia is noted by caregivers or a primary care physician, refer the patient to an ophthalmologist due to concern of amblyopia development and permanent vision loss.
- If a deficit in abduction (moving the eye outward), nystagmus, or an abnormal red reflex is seen, referral is urgent.
What is the role of the ophthalmologist?
The role of the ophthalmologist. includes the following:
- determining visual acuity
- assessing for motility defects in the primary gaze and 6 cardinal positions
- assessing eye alignment measurements at near, distance, and cardinal positions of gaze
What is the treatment?
- Nonsurgical treatments include correction of refractive error (especially hyperopia). Patching or pharmacologic penalization of the sound eye can be used to treat amblyopia.
- Surgical treatment may be performed on the extraocular muscles in an attempt to restore ocular alignment.
Review the full case on the Academy website for more details, including links to educational resources on key topics related to the case.
What is the role of the primary care or emergency medicine physician?
- Most often, provide reassurance that this is a common, minor occurrence.
- If the patient has a history of ocular trauma, refer urgently to ophthalmology to evaluate for other ocular injuries.
- If the patient presents with significant subconjunctival hemorrhage extending 360 degrees around the cornea, refer emergently to ophthalmology to evaluate for an open globe, which requires emergent surgical repair.
- If the condition is recurrent, the primary care physician may perform a workup for an underlying bleeding disorder.
What is the role of the ophthalmologist?
- Perform a slit-lamp examination.
- If ocular trauma occurred, evaluate for other eye injuries.
- Most often, reassure the patient that the condition is benign and will resolve.
What is the treatment?
No treatment is required if there are no other associated eye injuries. The condition will heal on its own in days to weeks. However, artificial tears may be used to relieve irritation.
Review the full case on the Academy website for more details, including links to educational resources on key topics related to the case.