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Ask Dr. Rick Your Own Question

Dr. Rick
Dr. Rick, Board Certified MD
Category: Eye
Satisfied Customers: 7364
Experience:  Ophthalmology since 1994 with Retina sub-specialty interest
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Need a dx assortment 1. sudden painless reduced vision, one eye from 20/30 to 20/

Customer Question

Need a dx assortment:

1. sudden painless reduced vision, one eye
from 20/30 to 20/80 with correction in place.
2. Pt noticed brown color to all areas seen with that eye since onset.

3. Visual field uniformly depressed on that eye, first field done on this pt.

4. Pt is 23 years old with no health probs and no meds

5. affected eye is strabismic but has been for years, with consistent 20/30 vision.

Dilated fundus exam optic nerve head normal, no retinal bleeds or tears, macula flat and good color.

Non-affected eye had perfect visual field and 20/20 corrected vision.
Submitted: 2 years ago.
Category: Eye
Expert:  Dr. Rick replied 2 years ago.

Dr. Rick :

Hi. I'm online and happy to answer your question today.

Dr. Rick :

Are you treating her? What is your training?

Dr. Rick :

How is the color vision in the affected eye?

Customer :

Hi- just wanted another pair of eyes on this unusual case. I am an optometrist She is my patient.

Dr. Rick :

Any RAPD?

Customer :

No- pupils were normally reactive

Dr. Rick :

So. To review. Healthy, young female, no significant PMHx, No drug use, no trauma, no other physical findings/complaints, with completely normal eye exam. She has a history of mild amblyopia but there is a sudden decrease in vision as well as a global decrease in HVF indices ( what program did you use, 30-2?). Do I have it correct so far?

Customer :

Yes the 30-2, I was careful in history she insists no trauma or drug use, and looks healthy

Dr. Rick :

Did you check color vision? Perhaps with Ishihara plates?

Customer :

No this was not done

Dr. Rick :

Ok. Red/green is not the best test in these cases anyway.....

Dr. Rick :

The first thing that comes to mind is retrobulbar optic neuropathy. This could also be caused by MS.

Customer :

I do have the old farnsworth d-15

Dr. Rick :

That would good.....

Dr. Rick :

Other things in the DDx are toxic optic neuritis, posterior scleritis, rare rod/cone or cone/rod dystrophies, functional vision loss and then we get into just plain guessing.....

Customer :

But that would be a reschedule- Curious about what options come to mind- Considering referral to neuroophthalmologist

Customer :

Well we have no pain, sign of inflammation, monocular onset, etc, which makes it tough

Dr. Rick :

I would consider an MRI with contrast of the brain and orbits and referral to an ophthalmologist. Neuro ophthalmologist is a good idea but it wouldn't hurt to get a second pair of eyes on the issue before trying to get into a busy neuro opth guy.....

Dr. Rick :

There may be a mild RAPD present....they amblyopia alone should have caused at least one log unit of a defect.....

Customer :

Possible, of course. We are in a small town, no ophthalmologist, and a XXX XXXX XXXXX to one- either general or neuro-

Dr. Rick :

I'm a retina doc so I get a lot of optic nerve stuff.....I like to think of myself as the "poor man's neuro-ophthalmologist :o)

Customer :

With the brown vision- does that make you think of anything particular

Dr. Rick :

I'm the only retina guy for an hour in any direction....so I know all about small towns ;)

Dr. Rick :

Makes me think of optic nerve problems......

Customer :

Well, since it appears pre-chiasmal, the options aren't that great for someone her age

Dr. Rick :

I'd try to get a MRI and then take it from there. A FA would may also be of some help, although it likely will come back normal in this case.

Customer :

Ok- makes since. Thanks

Dr. Rick :

And stigmata of neurofibromatosis?

Customer :

Sense

Customer :

Nope

Dr. Rick :

ok....just a thought.

Customer :

The sudden onset has me worried, of course,

Dr. Rick :

Sorry I couldn't be of more help in this very interesting case. If you have a chance drop me a note and let me know what you find.

Customer :

I would like that- how would I do that?

Dr. Rick :

Ya, me too. Try to get her in for another look see ASAP.

Dr. Rick :

Just post to this thread, or if it has closed, just "ask" for me on the main page. There is no need to pay again to get back to me.

Dr. Rick :

And, now, the obligatory word from our sponsors: :o)

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Customer :

Thanks

Dr. Rick :

What State are you in? I'm in Wisconsin

Dr. Rick :

My pleasure.

Customer :

California

Dr. Rick :

My sister lives in Santa Barbara.....

Customer :

Pleasant there, I hear- I'm in the middle of the desert, nearest town palm springs

Dr. Rick :

sounds hot.....take care. The lady is lucky to be treated by a concerned Optometrist like you :o)

Expert:  Dr. Rick replied 2 years ago.
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Expert:  Dr. Rick replied 2 years ago.
Let me know if there is anything else I can do to help you with your patient. Good luck.

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