March 29, 2014 | POSTED BY | Articles, Clinical Optometry, Retina
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Age/Sex/Race

52 year old African American male

Chief Complaint

“I am having trouble with distance so I think I need a new glasses prescription.”

Denied having flashes, floaters, pain, itching or burning.

Medical History

Diabetes, hypertension, hepatitis C

His blood sugar that morning was 87.

Ocular History

Negative

Medications

He didn’t have his medication list with him.

NKDA

Family History

Diabetes and cataracts

Social History

Smokes cigarettes every day, social drinker

Diagnosis and initial plan of action

I thought he might have a refractive error, while some diabetic retinopathy could be evident.

Applicable Testing & Results of Testing

Distance visual acuity (uncorrected):

OD: 20/60

OS: 20/60

Confrontation fields: FTFC OU

Extraocular muscles: Full OU

Pupils: PERRLA, (-) APD

Manifest Refraction:

OD: +3.75 sph, 20/20

OS: +5.50-2.00X165, 20/25

Add +2.25, 20/20 OU

Slit lamp examination:

Lids/lashes – ptosis of upper lid OD

Conjunctiva –  racial melanosis OU

Cornea – clear OU

Anterior chamber – no cells and flare

IOP – 12 mm Hg OU

Lens – trace nuclear sclerosis OU

Dilated fundus exam:

C/D: 0.4/0.4 round with distinct borders OU

OD: cotton wool spots nasal to disc

OS: cotton wool spots and flame hemorrhage along superior and inferior arcades

No CSME OU

Assessment and Plan

1) Stage 2-3 hypertensive retinopathy OU vs interferon retinopathy

– Patient mentioned upon further inquiry that he was taking interferon for hepatitis C. He was educated to return to the clinic in 6 months for a dilated fundus examination. When cotton wool spots and flame hemes were observed, hypertensive retinopathy was thought to be the tentative diagnosis. Interferon retinopathy wasn’t initially thought of as a possibility.

2) Cataracts OU: monitor yearly

3) Presbyopia OU: prescribed glasses

4) Involutional ptosis OD

It’s hard to distinguish the cause of retinal changes when a patient has multiple diseases. In order to figure out which disease is the primary reason for the retinal changes, I did some research and found few overall points:

How do you distinguish between hypertensive retinopathy and diabetic retinopathy?

Hypertensive retinopathy: more cotton wool spots are seen than exudates or hemorrhages, while more flame hemorrhages are noticed (3rd picture above, courtesy of Kanski textbook)

Diabetic retinopathy: more hemorrhages are seen, especially dot-blot hemes (2nd picture, courtesy of Kanski textbook)

Interferon associated retinopathy: 1st picture on top

Interferon associated retinopathy has similar signs as hypertensive retinopathy, such as cotton wool spots, retinal hemorrhages and cystoid macular edema. Cotton wool spots are usually around the optic nerve head in interferon associated retinopathy. Usually these signs disappear after stopping treatment. I once heard a speaker say that in some cases, even if these patients have retinal changes, they still have to continue taking interferon for their therapy.

References:

  1. Shectman, D.L. and Falco, L.A. Hypertension: more than meets the eye. Review of Optometry, September 2007. http://www.revoptom.com/content/d/retina/c/15347/dnnprintmode/true/?skinsrc=%5Bl%5Dskins/ro2009/pageprint&containersrc=%5Bl%5Dcontainers/ro2009/simple
  2. http://webeye.ophth.uiowa.edu/eyeforum/cases/116-Interferon-retinopathy.htm
  3. Kanski, Jack J. Clinical Ophthalmology: A Systemic Approach. Philadelphia 2007: pages 484-485