Case Challenge – April 2019

An 84-year-old African-American man with a history of glaucoma presented for consultation and care. Review of past records indicated that he had also been diagnosed the previous year with dry age-related macular degeneration (AMD) OD and wet AMD OS with a circinate ring of exudates temporal to the left macula. He reported never following through with a retinal consultation for the AMD. On today’s visit, he reported a reduction of vision in his right eye for the past week. He was 20/50 in each eye. Dilated fundus examination revealed an extensive hemi-retinal vein occlusion in the right eye, advanced glaucomatous disc damage OU, scattered retinal drusen OU, asteroid hyalosis OS, disc collaterals OS and curiously a circinate ring of exudates OS nearly identical to the description from the previous record. Macular degeneration in a patient of African descent is a very uncommon occurrence.

The unchanging ring of exudates would not be consistent with wet AMD. Careful inspection revealed a saccular dilatation within the circinate exudates consistent with a retinal arterial microaneurysm (RAM). Retinal arterial macroaneurysms are acquired saccular or fusiform dilatations of the large arterioles of the retina. They are usually observed within the first three orders of bifurcation. Patients who develop RAM are typically in the 50-80 year-old age range. In many cases, un-ruptured lesions remain asymptomatic until discovered during routine dilated exams. Even without loss of function, by the time the patient presents, there has often been significant leakage into surrounding areas manifesting as visible exudates with variable presentations of pre-, intra-, and/or sub-retinal hemorrhage.

These balloon-like formations are caused by a break in the internal elastic lamina of the arteriole wall, through which serum, lipids and blood exude into the surrounding retina. The lesions seem to have an affinity for the bifurcations of vessels where structural integrity is weakest.

The natural course of RAM typically involves spontaneous sclerosis and thrombosis, particularly after hemorrhaging. For this reason, so long as there is no increased threat of macular hemorrhage, periodic observation is indicated. Asymptomatic non-leaking RAM may be monitored at 4-6 month intervals. If there is leakage in the form of exudation and/or hemorrhage that does not threaten the macula, then monitoring at 1-3 month intervals is indicated. If hemorrhage threatens or involves the macula or if there is persistent macular edema reducing vision or creating visual field loss, then direct photocoagulation of the RAM may speed resolution. The visual prognosis for eyes with ruptured or leaking RAM depends on the degree and type of macular involvement. In most cases, there is gradual and spontaneous involution concurrent with hemorrhage resorption. Intravitreal bevacizumab has shown promise as an effective therapy for complicated RAM and cases with submacular exudation.


Click on the toggles below to read previous case challenges.

Case Challenge 08 – March 2019

A 53 year old man who had been treated for advanced glaucoma presented with slowly progressive, painless vision loss in his right eye. He had missed his visits for the past year, though he had been obtaining medication refills through his pharmacy. His...

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Case Challenge 07 – January 2019

A 25 year old woman was involved in a minor automobile accident where she was hit by another driver. The accident was reportedly minor, with no initial injury to either driver, and both cars were able to be driven away. She felt that she experienced only a...

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Case Challenge 06 – November 2018

Optometric Education Consultants Clinical Case Challenge A 21 year old male plumber called in requesting an urgent appointment. He was working on a job and trying to dislodge a drain coupling by hammering it with the blunt end of a screw driver. He missed,...

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Case Challenge 05, Explained – October 2018

  A 47-year-old man presented complaining of gradually decreasing vision and monocular diplopia in his right eye for approximately the past 18 months. He had undergone LASIK vision correction over 13 years earlier with an excellent emmetropic...

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Case Challenge 05 – September 2018

A 65 year old woman previously diagnosed with primary open angle glaucoma presented for ongoing care. She was using latanoprost in each eye and had bilateral selective laser trabeculoplasty performed two years earlier. Her medical history was significant for hypertension, elevated cholesterol, and arthritis.  Her vision was 20/20 OD and 20/25 OS. She had an inferior retinal nerve fiber layer defect in the right eye and significant superior rim damage in the left eye. Threshold perimetry showed the above corresponding visual field defects.

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Case Challenge 04 – August 2018

The first patient is a 16 year old male whose vision has been fluctuating for 6 weeks. He also complains about headaches. His primary care physician feels it’s a normal growth spurt and Mom feels it’s migraines as there is a strong family history, but she still wants eyes checked. His vision is 20/20 OD/OS uncorrected and he has bilateral optic disc edema.

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Case Challenge 03 – July 2018

A 35 year old man presents wanting another opinion due to “blood on my right eye”. He says that everything happened 3 days ago after violently vomiting, reportedly due to food poisoning from chicken Caesar salad. He still feels a little nauseated and somewhat “not himself”. He saw another practitioner 3 days ago, was told he had a ‘bruise’ on his eye and it should go away in 1-2 weeks. From the outward appearance, he seems to simply have just a subconjunctival hemorrhage…or does he?

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Case Challenge 02 – June 2018

A 13 year old female was referred for painless reduced vision (20/40) in her left eye with a concurrent abnormal screening visual field, reportedly elevated intraocular pressure (IOP), and an afferent pupillary defect. Her previous exam was 3 weeks earlier and she had been previously referred to an ophthalmologist over a year earlier by another optometrist, but her mother did not know why and did not take her. When presented with painless vision loss in a young patient with these findings, there are numerous diagnostic possibilities.

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Case Challenge 01 – June 2018

A 27 year old woman presents urgently complaining of painful vision loss in her right eye. She has no known medical history and this has never occurred before. She has an edematous optic nerve with hemorrhaging, an afferent pupil defect, superior arcuate scotoma, pain when she moves her eye, and 20/70 visual acuity. A clear-cut case of optic neuritis possibly as the first manifestation of multiple sclerosis? Perhaps…perhaps not.

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