1. Grand Rounds The Blurry Vision Consult: Something or Nothing?
Frederick Blodi, DO
9/28/18
Department of Ophthalmology and Visual Sciences

2. Patient Presentation CC HPI “Blurry Vision”
48 yo WM, who was recently hospitalized for a right below the knee amputation (R BKA) due to gas gangrene after he stepped on a piece of wood. On the day of discharge, the patient fell while getting out of the car. His foot tangled in the wheelchair and he was readmitted for stump dehiscence. The patient underwent washout and revision of the R BKA. After that procedure, he had an episode of light-headedness and dyspnea. A CTA revealed extensive bilateral pulmonary emboli. Vision has been "hazy and blurry" since then (about 2 weeks). He has difficulty describing his vision but he "just has trouble seeing."

3. History (Hx) Past Ocular Hx: None
Past Medical Hx: Morbid obesity, HTN, DM, R BKA
Fam Hx: non-contributory
Meds: Hydrocodone, amlodipine, lovenox bridge until therapeutic on warfarin, lantus, humalog, metoprolol, among others
Allergies: NKDA
Social Hx: Non-smoker, non-drinker, no illicits

4. External Exam OD OS VA N CC 20/20 -1 Pupils 4→2mm No rAPD IOP 17 mmHg
EOM
full

5. External Exam OD OS VA* 20/20 -1 Pupils 4→2mm No rAPD IOP 17 mmHg
EOM
full

6. External Exam
Visual Fields by confrontation

7. Anterior Segment Exam PLE OD OS External/Lids WNL Conj/Sclera White
Cornea
Clear
Ant Chamber
Formed
Iris
Flat
Lens

8. Posterior Segment Exam
Fundus OD OS
Optic Nerve
Pink and sharp
Macula
WNL
Vessels
Periphery

9. Assessment
40 yo M with vague complaints of blurry vision, VA is 20/20 OU, however pt has left superior homonymous quadrantanopia. Exam otherwise normal.
Differential Diagnosis
Stroke
Intracranial hemorrhage secondary to head trauma
Space occupying lesion
Demyelination

10. Plan Consult stroke team
“I fear that he may have suffered a stroke in his right temporal lobe in his optic radiations thus causing his vision problems”
Recommend neuroimaging including CT Head, MRI.

11. CT Head WO contrast

12. CT Head WO contrast

15. Discussion - Retrochiasmal lesions
Homonymous VF defects respecting midline
Most common causes in adults:
Stroke 60%.
Trauma ~10%
Hemorrhage ~10%
Children: trauma and tumors

16. Discussion - Temporal lobe
Lesions become more congruous more posteriorly
Associated with seizure activity, including olfactory seizures and visual hallucinations

17. Discussion - Driving with VF defects
States treat hemianopia as any other restricted peripheral field
Hemianopia pts ~90° of horizontal vision
Federal gov’t requires field of 70° horizontally but most states are more stringent (avg around 110°)
Only KY and UT have vertical VF requirements (25°)
United Kingdom: driving explicitly prohibited with hemianopia

18. Discussion - Driving with VF defects

19. Discussion - Driving with VF defects

20. Discussion - Driving with VF defects

21. Hospital Course MRI unable to be performed due to body habitus
TEE: patent foramen ovale
Discharged on aspirin, lipitor, and warfarin (for PE)
To follow up in clinic

22. Conclusions Something or nothing?
Ophthalmology can be on the front line
History is key
Small clues can be valuable
Lesions in temporal lobe become more congruous posteriorly and can be associated with seizures and visual hallucinations
Driving should be considered on an individual basis

23. References American Journal of Occupational Therapy
BCSC Neuro-ophthalmology
Hemianopsia.net
Ophthalmology Secrets
Clinical Neuro-ophthalmology: The Essentials
“Visual field requirements in the USA.” E Peli, Harvard
Thank you to Dr. Piri for your help!