GP Ophthalmology Note

Date of Consultation: 1 November 2024 58y/o female, now with sudden onset blurred vision in her right eye. Medical History: 58y/o female # Type 2 Diabetes Mellitus: Well-controlled with Metformin 500mg BD. No known complications. HbA1c 6.5% (latest blood results). # Hypertension: Managed with Amlodipine 5mg OD. No known complications. BP 128/78 mmHg (latest reading). # Allergies: Penicillin - causes rash. Presenting Complaint: Patient now presents with sudden onset blurred vision in her right eye, ongoing for approximately 3 days. She reports a sensation of a 'curtain coming down' over her vision. No associated pain, redness, or discharge. She denies any flashes or floaters. Vision is worse in dim light. No alleviating or exacerbating factors noted. Social History: Lives with husband. Non-smoker. Occasional alcohol use. Works as a retired teacher. No recent foreign travel or sick contacts. Physical Examination: 1. Visual Acuity Assessment: - Distance Visual Acuity: Right eye 6/36, Left eye 6/9 - Near Visual Acuity: Right eye N18, Left eye N6 2. Colour Vision Assessment: Ishihara plates: Right eye impaired, Left eye normal 3. Visual Field Assessment: - Peripheral Visual Fields: Right eye constricted inferiorly, Left eye full to confrontation - Blind Spot Assessment: Right eye enlarged, Left eye normal 4. External Eye Examination: - General Inspection: No obvious swelling or erythema. - Eyelid Assessment: Normal position, no ptosis or lagophthalmos. - Conjunctival Assessment: Clear and white, no injection or discharge. - Corneal Assessment: Clear, no opacities or abrasions. - Anterior Chamber: Deep and clear. 5. Pupillary Assessment: - Pupil Size and Symmetry: Pupils are equal and round, 3mm in diameter. - Pupil Shape and Colour: Round, black. 6. Pupillary Reflexes: - Direct Light Reflex: Right eye sluggish, Left eye brisk. - Consensual Light Reflex: Right eye sluggish, Left eye brisk. - Swinging Light Test: Right eye reveals a relative afferent pupillary defect (RAPD). 7. Ocular Motility Assessment: - Strabismus Assessment: No strabismus noted. - Eye Movement Testing: Full range of extraocular movements, no pain or diplopia. - Nystagmus: No nystagmus present. 8. Fundoscopy: - Fundal Reflex: Right eye dull, Left eye bright. - Optic Disc Assessment: Right eye optic disc appears pale and swollen, cup-to-disc ratio obscured. Left eye optic disc sharp margins, C/D 0.3. - Retinal Assessment: Right eye exhibits retinal haemorrhages and exudates, particularly in the superior temporal quadrant. Left eye retina appears healthy. - Macular Assessment: Right eye macular oedema present. Left eye macula appears healthy. 9. Fluorescent Staining: No corneal staining noted in either eye. Clinical Impression: Acute vision loss in the right eye, likely due to central retinal vein occlusion given the sudden onset, 'curtain' sensation, reduced visual acuity, RAPD, optic disc oedema, and retinal haemorrhages/exudates. Management: Treatment initiated: - Advice to keep head elevated to reduce intraocular pressure (acute). Further referrals or investigations: Urgent referral to Ophthalmology for further assessment and management. Consider urgent blood tests including FBC, ESR, CRP, and a fasting lipid profile to investigate underlying causes.