Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 68-year-old woman with difficulty seeing out of her left eye

mksap
Conditions
July 7, 2010
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 68-year-old woman is evaluated in the emergency department for difficulty seeing out of her left eye.

mksap 15The symptoms were first present upon awakening 45 minutes earlier. She describes her vision as “looking through a dark veil.” Her right eye is unaffected. There is no associated pain, headache, muscle aching, or difficulty chewing, and no trauma or history of a similar episode. She has hypertension, hypercholesterolemia, and chronic open-angle glaucoma. Current medications are ramipril, hydrochlorothiazide, atorvastatin, aspirin, and timolol ophthalmic solution.

Vital signs are normal. Visual acuity in the right eye is 20/30, corrected for glasses; in the left eye, visual acuity is restricted to finger counting. Both globes are nontender to palpation. There is no conjunctival injection. Ophthalmoscopic examination of the right eye is normal. Findings in the left eye are shown.

Test Yourself MKSAP image © 2010, American College of Physicians, Medical Knowledge Self-Assessment Program (MKSAP® 15)
Test Yourself MKSAP image © 2010, American College of Physicians, Medical Knowledge Self-Assessment Program (MKSAP® 15)

Venous pulsations are noted. Pupils are equal. The right pupil reacts to direct and consensual light stimulus. The left pupil has sluggish response to direct light, but normal consensual response. Cardiac and neurologic examinations and electrocardiogram are normal.

Which of the following is the most likely diagnosis?

A) Acute angle-closure glaucoma
B) Acute occipital stroke
C) Central retinal artery occlusion
D) Central retinal vein occlusion
E) Retinal detachment

Answer and Critique

The correct answer is C) Central retinal artery occlusion.

This patient presents with the acute onset of painless visual loss, which should immediately raise concern for an ischemic vascular event, in this case a central retinal artery occlusion (CRAO). CRAO classically presents in a 50- to 70-year-old patient, often in the early morning hours, with an abrupt but painless loss of vision. Risk factors include atherosclerosis, diabetes mellitus, hypertension, hypercholesterolemia, hypercoagulable states, and migraine. This patient has notable physical examination findings typical of CRAO: markedly diminished visual acuity; an afferent pupillary defect; and a pale fundus, with a “cherry red spot” near the fovea. Central visual acuity may be preserved if the retina is perfused by the cilioretinal artery.

CRAO represents a “stroke to the eye.” Interventions to restore perfusion are essential, as permanent visual loss may result within 90 to 100 minutes from symptom onset, although the most effective intervention is not known. Immediate consultation with an ophthalmologist is essential. Ocular massage for 15 minutes, agents to lower the intraocular pressure, and lying the patient flat may help the plaque or clot to migrate and can be initiated immediately.

Acute angle-closure glaucoma can result in acute visual loss that is typically painful, in contrast to this patient’s presentation. Additionally, patients present with headache, seeing halos around lights, conjunctival injection, a pupil that is mid-dilated and sluggish or fixed in reaction to light, and sometimes a clouded cornea.

An acute stroke may cause loss of vision. Neurologic findings in this patient are absent, other than for monocular visual loss, which would be unusual as the sole presenting feature of an occipital stroke. Furthermore, the funduscopic findings are typical of CRAO and would not be seen in an ischemic event to the occipital lobes.

ADVERTISEMENT

Central retinal vein occlusion (CRVO) may also present with the abrupt onset of painless, monocular visual loss. In contrast to CRAO, however, the retina is notable for hemorrhages, “cotton wool” spots, or the classic “blood and thunder” appearance of extensive edema and hemorrhages.

Symptoms of retinal detachment include the relatively sudden and painless onset of floaters. The peripheral vision is usually affected first, and then symptoms may progress over days or weeks to involve the central vision. The abrupt onset of near complete monocular visual loss and the appearance of the retina in this patient make retinal detachment unlikely.

Key Point

* The acute onset of painless visual loss suggests the possibility of a central retinal artery occlusion, which is a medical emergency.

Learn more about ACP’s MKSAP 15.

This content is excerpted from MKSAP 15 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 15 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

Treatment decisions under migraine headache influence

July 7, 2010 Kevin 3
…
Next

Combo pills do not save patients money

July 7, 2010 Kevin 5
…

Tagged as: Patients, Specialist

Post navigation

< Previous Post
Treatment decisions under migraine headache influence
Next Post >
Combo pills do not save patients money

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

More in Conditions

  • Inside the final hours of a failed lung transplant

    Jonathan Friedman, RN
  • Why South Asians in the U.S. face a silent heart disease crisis

    Monzur Morshed, MD and Kaysan Morshed
  • Why chronic pain patients and doctors are both under attack

    Richard A. Lawhern, PhD
  • The quiet work of dying: a hospice nurse’s reflection

    Christopher M. Smith, RN
  • Medicaid lags behind on Alzheimer’s blood test coverage

    Amanda Matter
  • Why transgender health care needs urgent reform and inclusive practices

    Angela Rodriguez, MD
  • Most Popular

  • Past Week

    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • What street medicine taught me about healing

      Alina Kang | Education
    • Are we repeating the statin playbook with lipoprotein(a)?

      Larry Kaskel, MD | Conditions
    • The silent cost of choosing personalization over privacy in health care

      Dr. Giriraj Tosh Purohit | Tech
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Past 6 Months

    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Confessions of a lipidologist in recovery: the infection we’ve ignored for 40 years

      Larry Kaskel, MD | Conditions
    • A physician employment agreement term that often tricks physicians

      Dennis Hursh, Esq | Finance
    • Why taxing remittances harms families and global health care

      Dalia Saha, MD | Finance
  • Recent Posts

    • Inside the final hours of a failed lung transplant

      Jonathan Friedman, RN | Conditions
    • Why South Asians in the U.S. face a silent heart disease crisis

      Monzur Morshed, MD and Kaysan Morshed | Conditions
    • Why chronic pain patients and doctors are both under attack

      Richard A. Lawhern, PhD | Conditions
    • The overlooked power of billing in primary care

      Jerina Gani, MD, MPH | Physician
    • The quiet work of dying: a hospice nurse’s reflection

      Christopher M. Smith, RN | Conditions
    • A systemic plan for health worker well-being [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • What street medicine taught me about healing

      Alina Kang | Education
    • Are we repeating the statin playbook with lipoprotein(a)?

      Larry Kaskel, MD | Conditions
    • The silent cost of choosing personalization over privacy in health care

      Dr. Giriraj Tosh Purohit | Tech
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Past 6 Months

    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Confessions of a lipidologist in recovery: the infection we’ve ignored for 40 years

      Larry Kaskel, MD | Conditions
    • A physician employment agreement term that often tricks physicians

      Dennis Hursh, Esq | Finance
    • Why taxing remittances harms families and global health care

      Dalia Saha, MD | Finance
  • Recent Posts

    • Inside the final hours of a failed lung transplant

      Jonathan Friedman, RN | Conditions
    • Why South Asians in the U.S. face a silent heart disease crisis

      Monzur Morshed, MD and Kaysan Morshed | Conditions
    • Why chronic pain patients and doctors are both under attack

      Richard A. Lawhern, PhD | Conditions
    • The overlooked power of billing in primary care

      Jerina Gani, MD, MPH | Physician
    • The quiet work of dying: a hospice nurse’s reflection

      Christopher M. Smith, RN | Conditions
    • A systemic plan for health worker well-being [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

MKSAP: 68-year-old woman with difficulty seeing out of her left eye
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...