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 outcome. His prior prescription was a spherical equivalent of about (-) 10.00 DS in each eye. At this point, his best acuity is 20/70 OD and 20/20 OS. He had been to several eye care practitioners in recent months with no identified reason for the vision decrease. Results of perimetry, pupil testing, macular OCT, biomicroscopic and fundus evaluation, pachymetry, and corneal topography were all reportedly normal.

The key diagnostic findings included a pinhole improvement to a crisp 20/25 acuity though he refracted no better than 20/70. Most telling was a refractive shift of (-) 4.50 diopters. Now, a careful lens evaluation revealed a dense, “milky” nuclear opalescent cataract in the right eye only.

Patients typically develop “milky” nuclear sclerotic cataracts at an earlier age than other forms of lens opacification. The onset is often unilateral or asymmetric, usually developing during middle age, often beginning in the 40s and 50s. Males are often more affected than females and patients are typically moderately to highly myopic.

Patients will often complain of declining vision which is more rapid than with other types of cataract. Monocular diplopia occurs commonly though most patients will describe it as blurred vision. Pinhole testing relieves monocular diplopia and may significantly improve vision, though the patient may not see similar improvement with subsequent refraction. Patients will commonly have a myopic shift that can be relatively dramatic, accounting for up to 1-2 diopters per year. As the myopia is refractively corrected, best visual acuity declines to a point where the patient cannot tolerate the spectacle imbalance, visual acuity, or both.

In contrast to generalized cataractogenesis, there will be a white density within the nuclear core that is best appreciated with a fine biomicroscopic slit beam (optic section) directed off the visual axis. Comparison to the fellow eye in unilateral or asymmetric cases is often helpful in making the diagnosis, which may be subtle. Also in contrast to other types of cataracts, patients can present with significantly reduced vision, yet the funduscopic view is minimally altered; that is, practitioners will have a clear view into the eye yet the patient reports poor visual acuity. When this occurs, diagnosing cataract is not intuitive and the patient may go through additional testing and referral needlessly. Ultimately, the patient successfully underwent cataract extraction with an excellent outcome.

When encountering such a clinical situation, remember the M-Rule: Myopic, Male, Middle-aged, Myopic shift, Monocular diplopia, Milky nucleus


Click on the toggles below to read previous case challenges.

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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Quebec City, Quebec, Canada
August 31-September 2, 2018