Question

A 60-year-old lady comes to see you with complaints of dimness of her vision.
How will you approach this lady with reduced vision?

Hint:

Always perform fundoscopy in patients with reduced vision to assess for retinal pathology, such as diabetic retinopathy or macular degeneration. Tonometry is essential for detecting glaucoma.

Answer 1

Step 1: History Taking.
- Duration of Vision Problems: Ask when the patient first noticed the dimness of vision and if it was gradual or sudden. Gradual loss suggests cataracts or macular degeneration, while sudden loss may point to retinal or optic nerve issues.
- Associated Symptoms: Inquire about associated symptoms such as glare, difficulty reading, loss of peripheral vision, floaters, or flashes of light.
- Medical History: Ask about a history of diabetes, hypertension, or glaucoma, which are common risk factors for retinal conditions.
- Family History: A family history of cataracts, macular degeneration, or glaucoma may be relevant.
- Lifestyle and Medications: Ask about smoking, alcohol use, and any medications (e.g., steroids) that could contribute to visual changes.

Step 2: Visual Acuity Testing.
- Perform a Snellen chart test to assess the patient's visual acuity. This will help determine the severity of vision loss and monitor progress.

Step 3: Ocular Examination.
- Inspection: Examine the external eye for signs of infection, redness, or abnormalities.
- Pupillary Reactions: Test for direct and consensual pupillary light reflexes, as afferent pupillary defects may suggest optic nerve problems.
- Fundoscopy: Examine the retina and optic nerve for signs of diabetic retinopathy, macular degeneration, cataracts, or glaucoma. Look for abnormalities such as retinal hemorrhages, exudates, or disc swelling.
- Tonometry: Measure intraocular pressure (IOP) to check for glaucoma. Elevated IOP is a key sign of glaucoma.
- Slit Lamp Examination: Evaluate the anterior segment of the eye for cataracts, corneal abnormalities, or other lesions.

Step 4: Additional Investigations.
- If indicated, refer for further imaging (e.g., OCT for macular degeneration, fluorescein angiography for diabetic retinopathy, or OCT angiography for retinal vein occlusion).
- If suspected, an ultrasound or MRI of the brain may be needed if there are concerns about neurological causes.

Step 5: Conclusion.
A thorough history, visual acuity testing, and detailed ocular examination are essential in determining the cause of reduced vision. Further investigations may be required based on initial findings.