Case Reports

Sudden gross visual deterioration – Importance of examining the whole eye

Case Report Details

First Author: N.Iqbal UK

Co Author(s):    S. Downes   S. De Silva                 

Abstract Details

Purpose:

We present a case of sudden severe sequential visual loss in a 75 year-old female caucasian patient with advanced diabetic eye disease, long-term poorly controlled diabetes and hypertension. We show that although the original diagnosis of bilateral sequential anterior ischaemic optic neuropathy (AION) easily explained the visual loss, the importance of a further comprehensive examination identified the actual remediable cause.

Setting:

Outpatient clinic.

Report of Case:

A 75 year-old white Caucasian was seen urgently as her vision had suddenly deteriorated from 6/9 right to counting fingers in her right eye. A diagnosis of AION was made. Four months later, she re-presented with sudden loss of vision in her second (left) eye, which had deteriorated from 6/12 to counting fingers only. Her past ocular history was notable for referral by her Optometrist 15 years previously at the age of 60 for management of diabetic macular oedema. At that time and over the following 4 years she underwent 6 focal laser treatments to her left eye, and 3 to the right eye. She then developed proliferative diabetic retinopathy (PDR) aged 64 requiring multiple applications of pan retinal photocoagulation (PRP). Despite this, she developed bilateral rubeosis iridis. At 65 years old she underwent bilateral vitrectomies and endolaser. She developed bilateral cataracts over the next 18 months and underwent successful bilateral phacoemulsification with posterior chamber intraocular lens implant surgery aged 66, followed by YAG capsulotomies. Visual acuities post operatively were 6/9 bilaterally and remained so for the ensuing years. Her past medical history included poorly controlled type I diabetes and hypertension as well as hypothyroidism and peripheral neuropathy with a right Charcot’s foot. At age 75 she presented with sudden right visual loss. The features were consistent with non arteritic AION. No symptoms of giant cell arteritis were present and her erythrocyte sedimentation rate was 12mm/hr. Pupil responses were difficult to check due to autonomic pupil dysfunction, and both discs were pale. She then re-presented 4 months later with the same sudden history of visual loss in her other eye. It was presumed from the history that she had developed AION in her second eye. Visual acuities were counting fingers bilaterally. However, a review of the peripheral retinas revealed bilateral dislocated intraocular lenses draped in their capsular bags located in the inferior retina. (Fig 1a and b). Refraction resulted in visual acuities of 6/9 right and left with +11.50/-1.00 x 75 right and +11.50/-1.00 x 65 aphakic correction and CF acuity without. The patient later underwent secondary IOL implantation.

Conclusion/Take Home Message:

In this patient with a history of visual obscurations, pale discs, significant vascular risk factors, and uncontrolled blood pressure and poorly controlled diabetes, the diagnosis of AION seemed clear-cut. However, a full peripheral retinal examination revealed the real cause of the visual loss. Without this the patient would have been left with severely compromised vision with a really significant impact on her quality of life. We would like to reiterate the importance of careful examination and keeping all potential diagnoses in mind, when examining patients with unexplained visual loss.

Financial Disclosure:

None