From the Guidelines
For a 72-year-old male with vision loss in the left eye for 3 months, I recommend an urgent comprehensive evaluation starting with a detailed history and ophthalmologic examination, as prolonged vision loss could indicate serious conditions such as age-related macular degeneration, retinal detachment, glaucoma, diabetic retinopathy, central retinal artery or vein occlusion, or giant cell arteritis, and prompt evaluation is crucial for preserving remaining vision. The history should focus on onset, progression, associated symptoms (pain, flashes, floaters), and risk factors including hypertension, diabetes, smoking, and cardiovascular disease, as suggested by 1 and 1. The examination should include visual acuity testing, pupillary responses, intraocular pressure measurement, and dilated fundoscopic examination. Immediate referral to an ophthalmologist is essential, preferably within 24-48 hours, as recommended by 1 and 1. Additional testing may include optical coherence tomography, visual field testing, fluorescein angiography, and carotid imaging, as outlined in 1 and 1. Laboratory tests should include complete blood count, erythrocyte sedimentation rate, C-reactive protein, HbA1c, and lipid profile, as suggested by 1, 1, and 1. The three-month duration is concerning, and delayed treatment for many eye conditions can lead to permanent vision loss, making prompt evaluation crucial for preserving remaining vision, as emphasized by 1, 1, 1, and 1. Key considerations in the evaluation and management of this patient include:
- Recognizing symptoms associated with giant cell arteritis (GCA), such as vision loss, headaches, scalp tenderness, malaise, fatigue, temporal tenderness, jaw claudication, weakness, fever, diplopia, and history of polymyalgia rheumatica, especially in patients over age 50, as noted in 1 and 1
- Obtaining an immediate erythrocyte sedimentation rate, C-reactive protein, and complete blood count with platelets in patients with GCA symptoms, as recommended by 1 and 1
- Referring patients with acute, symptomatic CRAO, BRAO, or OAO to a stroke center for prompt systemic evaluation, as suggested by 1 and 1
- Performing neuroimaging evaluation, noninvasive imaging of the cervicocephalic vessels, and echocardiography as part of the evaluation, as outlined in 1 and 1.
From the Research
Evaluation of the Patient
The patient, a 72-year-old male, presents with complaints of not being able to see in his left eye for 3 months. The evaluation of this patient should consist of:
- A detailed history to determine the underlying cause of the vision loss 2
- Visual acuity test to assess the patient's vision in both eyes 3, 4
- Pupil examination to check for any abnormalities in the pupil's reaction to light 3, 4
- External examination to look for any signs of trauma or infection 3
- Extraocular movements test to assess the patient's eye movements 3, 4
- Visual fields test to check for any defects in the patient's field of vision 3, 4
- Color vision test to assess the patient's ability to see colors 3
- Slit lamp examination to examine the patient's eyes in detail 3
- Direct ophthalmoscopy to examine the patient's retina and optic nerve 3
- Intraocular pressure measurement to check for any signs of glaucoma 3
Special Tests
Special tests such as:
- Plain film study
- Computed tomography (CT) scan
- Ultrasound studies of the eye and orbit
- Dilated fundus examination may be obtained when indicated to further evaluate the patient's condition 3, 4, 5
Referral to an Ophthalmologist
If the patient's condition is suspected to be an ocular emergency, such as a retinal detachment or central retinal artery occlusion, referral to an ophthalmologist should be made immediately 4, 5 If the patient's condition is suspected to be a transient ischemic attack (TIA), referral to a specialist for further evaluation and management should be made promptly 6, 2