What is the most likely finding on examination in a patient with sudden onset blurred vision in one eye, hypertension, hyperlipidemia, and diabetes mellitus?

Optic Disc Edema and Diffuse Retinal Hemorrhages on Funduscopic Exam

The most likely finding on examination is optic disc edema and diffuse retinal hemorrhages on funduscopic exam, consistent with central retinal vein occlusion (CRVO), given this patient's sudden painless monocular vision loss and multiple vascular risk factors (hypertension, hyperlipidemia, diabetes). 1

Clinical Reasoning

Why CRVO is Most Likely

• Sudden, painless monocular vision loss with profound visual acuity reduction (20/150) in a patient with hypertension, hyperlipidemia, and diabetes strongly suggests retinal vascular occlusion 1
• CRVO classically presents with optic disc edema, diffuse retinal hemorrhages ("blood and thunder" appearance), venous dilation and tortuosity, and cotton wool spots on funduscopic examination 1
• The incidence of retinal vein occlusions increases dramatically with age and in the presence of vascular risk factors including diabetes, hypertension, and hyperlipidemia 1
• Diabetic patients with retinal vein occlusion show a strikingly high prevalence of hypertension (72%) and hyperlipidemia (54%), making these the main underlying medical conditions for RVO in diabetics 2

Why Other Options Are Less Likely

Conjunctival injection and corneal clouding:

• These findings suggest acute angle-closure glaucoma, which presents with severe eye pain, headache, nausea, and vomiting—symptoms this patient explicitly denies 1
• Acute glaucoma causes rapid vision loss but is accompanied by a red, painful eye with a mid-dilated, non-reactive pupil 1

Loss of red perception on exam:

• This finding is more characteristic of optic neuritis, which typically affects younger patients (20-40 years) and is associated with multiple sclerosis 1
• Optic neuritis often presents with pain on eye movement and may have a more gradual onset over days 1
• The patient's age and vascular risk factor profile make a vascular etiology far more likely 1

Temporal tenderness to palpation:

• This finding suggests giant cell arteritis (GCA), which should be considered in all patients over 50 years with sudden vision loss 1, 3
• However, GCA typically presents with additional symptoms including jaw claudication (most specific), scalp tenderness, headaches, malaise, and constitutional symptoms 1, 3
• The patient denies headaches and other systemic symptoms, making GCA less likely 1
• ESR >60 mm/h has high likelihood ratio for GCA diagnosis, and this should still be checked in any patient over 50 with sudden vision loss 3

Critical Examination Findings in CRVO

The initial examination should document: 1

• Visual acuity (already documented as 20/150 OS)
• Pupillary assessment for relative afferent pupillary defect (RAPD), which corresponds to the level of ischemia and predicts risk for neovascularization 1
• Intraocular pressure measurement 1
• Gonioscopy prior to dilation to evaluate for iris neovascularization, especially important in ischemic CRVO when IOP is elevated 1
• Dilated funduscopic examination revealing optic disc edema, diffuse retinal hemorrhages, venous dilation and tortuosity, and cotton wool spots 1

Immediate Management Priorities

Systemic evaluation is mandatory: 1

• An internist should be involved in management because of associated systemic risk factors including diabetes, hypertension, and hyperlipidemia 1
• Optimal control of blood pressure, diabetes and blood glucose, and other risk factors through direct communication with the patient's primary care physician 1

Ophthalmologic monitoring: 1

• Optical coherence tomography (OCT) to detect and monitor macular edema 1
• Fluorescein angiography to assess degree of ischemia and areas of retinal non-perfusion 1
• Serial examinations to detect neovascularization complications, which can develop in ischemic CRVO 1

Treatment considerations: 1

• Initial treatment for macular edema in CRVO uses anti-VEGF agents (ranibizumab and aflibercept are FDA-approved) 1
• Secondary treatments include intravitreal corticosteroids 1
• If iris neovascularization develops, extensive peripheral panretinal photocoagulation is indicated 1

Common Pitfalls to Avoid

• Do not dismiss the possibility of concurrent stroke: Up to 25% of patients with retinal artery occlusions have concurrent silent brain infarction on MRI, though this is more common with arterial rather than venous occlusions 3
• Do not forget to check ESR and CRP in all patients over 50 years to assess for giant cell arteritis, regardless of whether classic symptoms are present 3
• Do not delay ophthalmologic referral: Close monitoring is essential to detect and treat neovascular complications that can lead to further vision loss 1