72 year-old man with decreased vision
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A 72 year-old man comes to the office after awakening yesterday morning with decreased vision on the
right. He has been feeling fine recently, with no headache or eye pain. He is taking the same
medications for the past several years: ACE inhibitor for longstanding hypertension, a statin for
hypercholesterolemia, and aspirin 81mg daily. He receives regular primary care and a recent fasting
blood sugar was normal. Corrected acuity is 20/20 on the left and 20/30 on the right. Visual field to
finger counting is full on the left; on the right, there is a defect in the lower fields, especially nasally.
Funduscopic exam reveals a normal disk with mild A-V nicking on the left and a swollen, slightly pale
disk on the right. There is a right afferent papillary defect. EOMs and the rest of the neurologic exam are
normal.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you
obtain? What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?
Case 21
A 72 year-old man comes to the office after awakening yesterday morning with decreased vision on the
right. He has been feeling fine recently, with no headache or eye pain. He is taking the same
medications for the past several years: ACE inhibitor for longstanding hypertension, a statin for
hypercholesterolemia, and aspirin 81mg daily. He receives regular primary care and a recent fasting
blood sugar was normal. Corrected acuity is 20/20 on the left and 20/30 on the right. Visual field to
finger counting is full on the left; on the right, there is a defect in the lower fields, especially nasally.
Funduscopic exam reveals a normal disk with mild A-V nicking on the left and a swollen, slightly pale
disk on the right. There is a right afferent papillary defect. EOMs and the rest of the neurologic exam are
normal.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you
obtain? What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?( click for homework help)