Fundoscopy Quiz
Yesterday, a consultant neurologist came to my hospital and took one of the PACES candidates for a mock.
This was what the patient had(picture above). It was Station 5 Fundoscopy.
Quiz :
1) What is your diagnosis ?
2) What else would you look for ?
3) What are the common causes ?
4) What would you look for in the other eye ?
The patient was a young lady.
What is your complete diagnosis ?
Labels: Fundus, Quiz series, Station 5
posted by Wuchereria @ 6/15/2007 02:41:00 PM
7 Comments:
Hmm...spot diagnosis.....
either right or wrong the whole thing
This is a glaucoma.
I would like to go back to the patient to take a history and perform a physical examination of the eye,including a funduscopy
Causes are genetic predisposition and steroid use.
I would look for the same pathology in the other eye.
My diagnosis is glaucoma.
OK. Not quite right.
HINTS:
Look at the optic disc again. Observe the color of the disc.
Now that you mention it.
The colour of the optic disc is rather pale rather than pink with a clear margin.
The optic disc is well circumscribed with no uneven border.
There are prominent vessels present.
Could this be a case of optic atrophy?
I will give this a go (1st time):
Optic atrophy??
As the patient is a young lady, could Multiple Sclerosis be a possibility here?
Other associated signs I would like to look for:
1. Looking for a relative afferent pupillary defect (Marcus Gunn pupil).
2. Inspect whether is color vision affected, red in particular
3. If optic neuritis, is there pain on movement of the eye?
4. Other associated sign suggestive of MS: INO, Lhermitte's sign, Upper motor neuron signs in the affected limbs, and sensory changes.
Common causes:
1.Optic neuritis, Multiple sclerosis
2.Tumor impinging optic nerve
3.Syphilis
The other eye:
Intact direct light reflex, impaired consensual?
Maybe INO
Hope I didn't go totally wrong here,
regards,
Ronald
Good work ronald :)
And well done to xiao_zhai for 2nd try as well.
Anything to add, buddy wuchereria?
This comment has been removed by the author.
Yes, very good. The answer is that the patient had optic atrophy due to recurrent optic neuritis (in fact, the lady had 8 times optic neuritis but still has not fulfilled the criteria of MS based on the Mc Donald's criteria - MRI always normal)
The other important thing is to look for central scotoma and visual field(pituitary tumour eg craniopharyngioma causing optic nerve compression is a common PACES case)
When you look in the other eye, do not forget to look for papilloedema which will be present in Foster Kennedy syndrome(favourite question from Neurologists)
Do not also forget other causes of Optic atrophy such as AION, toxic(methanol, lead, tobacco, ethambutol), B1,B12 deficiency and consecutive optic atrophy from retinitis pigmentosa.
The 5 features of nerve injury includes
1) RAPD
2)Decreased visual acuity
3) Attenuated colour vision
4) Central/paracentral scotoma
5) Optic atrophy
3 common fundus PACES questions include retinitis pigmentosa, optic atrophy and diabetic retinopathy.
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