Examination: Retinal Detachment

Casebank Combined
1

Where you are:
You are an F2 in A&E.

Who the patient is:
Harlow, aged 60, came with complaint of sudden vision loss.

What you must do:
Please take a history, perform a relevant examination and discuss management with the patient…

Background

  • Elderly patient.
  • History of cataract surgery 3 weeks ago. Or short sighted wearing glasses.
  • Sudden vision loss like a curtain falling down
  • Flashing of light and floaters.
  • No eye pain.

Data Gathering

Chief complaint: Can’t see on my side (Don’t think Bitemporal Hemianopia)

Nature of vision loss

  • Onset: Did it came on suddenly or gradually?
    • Is it blurring of vision?
    • Are you able to see?
    • Is it one eye or both?
    • How did it happen?
  • Duration: When did it happen?
  • Can you describe it for me how it happened? Do you feel like a curtain came down suddenly and blocked your vision? (Amaurosis Fugax)
  • Any flashing of light?
  • Are you seeing any dots or insects in your vision?

Differential Diagnosis for acute visual loss

  • Optic Neuritis: Sudden, difficult to differentiate colours, Family Hx of Multiple Sclerosis, eye/pain
  • Retinal Detachment: Sudden onset, like a curtain falling down
  • Myopia: (short sightedness)
  • Previous cataract surgery
  • Diabetic Retinopathy
  • GCA: Temporal teAderness, headache, shoulders & hip pains, tiredness
  • Acute Glaucoma: Sudden onset, eye pain, redness of eye, headache, nausea and vomiting,
    Family history
  • TIA/stroke: Dysphagia, weakness-face, arm, speech disturbances
  • Migraine: Headache associated with nausea and vomiting, Aura
  • Amaurosis Fugax: Sudden, curtain falling down (temporary loss of vision U/L or B/L due to lack of blood flow to retina)

Complete the History

  • ICE
  • PMAFTOSA - H/o HTN
  • Effects of symptoms
  • Summarise

Examination Findings

Visual acuity:

  • Right eye: 36/6
  • Left eye: 6/6

Visual Fields:
• Loss of nasal visual fields on the right side

Fundoscopy

2048×1753 261 KB

Diagnosis

Retinal detachment
• Separation of back chamber of eye from its position

Management

  • Immediate referral to ophthalmology specialist.
  • They will do a surgery to fix the detachment.
  • Advice not to drive

Reference

4

History

  • O: sudden unilateral visual loss
  • D: hours
  • I: nil
  • P: nil
  • A: nil
  • R: nil
  • A: nil
  • Additional history: trauma, diabetes, myopia, recent eye surgery, neurological
    symptoms

Management:

  1. Start by summarising the positive findings in the history and examination:
    “Thank you Mr. X for letting me examine you. You have told me that you have experienced sudden Right/Left visual loss. On my examination, I can see that the layer supplying oxygen and nutrients to your eye is damaged. This raises the suspicion that you have a condition called retinal
    detachment”.
  2. Specialist advice: “I will refer you immediately to ophthalmology for further management”.
  3. Safety netting: “Please try to lie back until you reach the hospital. If you experience any pain or symptoms in the other eye then please let us know. Please be mindful that you won’t be able to drive currently and you should check with the DVLA once your symptoms improve”.
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