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Instructions

You are a foundation year doctor in A&E. A patient has presented with sudden complete vision loss in his right eye that started 30 minutes ago.

1. Examine the patient's eyes.

2. Explain your findings and management plan to the examiner.

Checklist

Examination

Introduction

Adheres to appropriate infection control.
Introduces themselves by name and role.
Confirms identity of patient.
Explains procedure in simple terms.
Gains consent.
Asks: "Are you in any pain at all?"
Positions patient sitting on a chair.

Visual Acuity

Assesses distance vision using Snellen chart or logMAR chart for reduced visual acuity, no perception of light.
Assesses near vision using near vision chart for hypermetropia.
Uses pinhole to differentiate refractive errors from other causes of visual impairment.

Colour Vision

Assesses colour vision using Ishihara plates for colour blindness.

Visual Fields

Uses confrontational testing to assess for central scotoma, peripheral visual field loss, homonymous hemianopia, bitemporal hemianopia, binasal hemianopia, quadrantanopia.
Assesses blind spot for enlarged blind spot.

External Eye Inspection

Inspects periorbital regions for periorbital oedema, periorbital erythema, periorbital ecchymosis.
Inspects eyelids for ptosis, entropion, ectropion, trichiasis.
Inspects conjunctiva and sclera for red eye, chemosis, pinguecula, pterygium.
Inspects cornea for corneal ulceration, corneal foreign body, corneal arcus, Kayser Fleischer rings, keratoconus, corneal opacity.
Inspects pupils for anisocoria, irregular pupil shape.
Inspects iris for iris nevus, iris melanoma.
Inspects lens for cataract, lens dislocation.
Inspects eye position for proptosis, enophthalmos.
Inspects anterior chamber for hypopyon, hyphema.

Pupillary Reflexes

Assesses direct pupillary reflex and consensual pupillary reflex for oculomotor nerve palsy.
Performs swinging light test for relative afferent pupillary defect.
Assesses accommodation reflex for argyll robertson pupil.

Eye Movements

Performs light reflex test and cover test to assess for esotropia, exotropia, hypertropia, hypotropia.
Performs H motility test for diplopia, internuclear ophthalmoplegia, nystagmus, oculomotor nerve palsy, trochlear nerve palsy, abducens nerve palsy.

Fundoscopy

Darkens the room and dilates pupils with mydriatic eye drops if necessary.
Assesses fundal reflex for absent red reflex, white pupillary reflex.
Examines optic disc for optic disc swelling, optic disc pallor, optic disc haemorrhage, increased cup to disc ratio.
Inspects retinal vessels for retinal artery narrowing, retinal vein dilation, arteriovenous nipping, vessel tortuosity.
Examines retina for pale retina, cotton wool spots, hard exudates, flame haemorrhages, dot blot haemorrhages, retinal tears, retinal pigment epithelium changes.
Assesses macula for macular oedema, drusen, macular hole, cherry red spot, macular haemorrhage.

Closing

Explains that examination is finished.
Thanks patient
Reminds about effects of mydriatic drops if used.
Adheres to appropriate infection control.

Management

Explain most likely differential diagnosis is Central Retinal Artery Occlusion.
Explain less likely and red flag differential diagnoses could be retinal detachment, giant cell arteritis, migraine with aura.
Suggest bedside investigations of visual acuity, visual fields, pupillary reflexes, fundoscopy.
Suggest laboratory investigations of ESR, CRP, platelet count, glucose, cholesterol.
Suggest imaging of carotid doppler ultrasound, ECG, echocardiogram.
Suggest interventions of immediate ophthalmology referral, hospital admission, ocular massage, anterior chamber paracentesis if within 4 hours, acetazolamide, aspirin if no contraindications, cardiovascular risk assessment.

Internally Approved

Surname/Nom (1)

Peterson

Given names/Prenoms (2)

David

Date of birth/Date de naissance (4)

05 OCT 1952 (71)

Sex/Sexe (5)

PRESENTING COMPLAINT

Sudden complete vision loss in right eye 30 minutes ago. No pain.

EXAMINATION FINDINGS

Right eye shows no perception of light. Left eye has normal visual acuity.

confrontational testing reveals right peripheral visual field loss.

relative afferent pupillary defect present in the right eye.

Fundoscopy shows pale retina with cherry red spot at macula. retinal artery narrowing noted.