The management of macular degeneration in everyday practice is an essential part of an optometrist’s professional service. Here is a case that was referred to hospital for further assessment and management. Think about how you would manage this case in practice, what any hospital intervention might be, and what you think the visual prognosis might be.
Case study
A Caucasian 86-year-old woman attended for an eye examination. She was complaining of reduced vision and distortion in the left eye of six weeks’ duration. She had no history of ocular surgery, strabismus or amblyopia and had never needed to attend the HES. Her first spectacles were prescribed for reading at the age of 45 and distance glasses had been recommended five years later. She was a smoker and a diagnosed hypertensive. The hypertension was controlled with medication and regularly monitored by her GP. She had no allergies. She was a driver but had not felt safe driving since the onset of her visual symptoms.
The following prescription was found:
R +1.75/-0.50 x 90 (6/7.5)
Add 3.00 N5
L +3.00/-1.00 x 78 (6/38)
Add 3.25 N24 (text appeared distorted with some words missing).
Amsler: performed monocularly using her reading prescription. Appeared normal when viewed with the right eye but showed a small region of central ‘blurring’ with distortion when viewed with the left eye.
Pupil reactions: PERLA no RAPD: BE.
Cover test with distance and reading prescription: appeared normal at distance and near but the target appeared more blurred with the left eye.
Humphrey field test: SITA 24-2 fast: normal with RE; relative central scotoma with LE, though fixation errors were significant.
A fundus photograph of her right eye was unremarkable. The image of her left eye is shown (Figure 1) confirming slit-lamp ophthalmoscopy findings.
[CaptionComponent="1067"]Results
OCT is available at the practice and the following were found: The fundus photograph shows a greyish white elevation of the macula seen stereoscopically with slit-lamp indirect ophthalmoscopy (using a +90D volk lens following dilation with tropicamide 1per cent – it was determined beforehand that the patient was not driving). The OCT scan shows sub-retinal fluid and changes highly indicative of a choroidal neovascular membrane (CNVM)
In the hospital setting, fundus fluorescein angiography (FFA) was undertaken to confirm diagnosis. Early FFA and late FFA pictures showed a typical lacy pattern of hyperfluorescence that leaks profusely, suggestive of classic CNVM supporting the above diagnosis (Figure 3).
[CaptionComponent="1068"][CaptionComponent="1069"]Points to consider
- What would your referral of this case be if it presented to you practice?
- What management might be considered?
In a few weeks’ time we will be publishing a discussion of these points and an interactive CET exercise related to the case and the preceding macular disease series.
Louise Stainer is a hospital optometrist at Optegra Eye Hospital, Birmingham where Salman Mirza is a consultant ophthalmologist