A 65-year-old man comes to the physician because of floaters in his right eye for the past 2 days. He also experienced some brief flashes of light as well as poor vision in the same eye 1 day ago. He has always been nearsighted and has worn glasses since he was a teenager. He has no eye pain or trauma. There is no history of diabetes mellitus.
No obvious abnormalities are detected on funduscopic examination, but an extensive right-sided visual field defect is confirmed by confrontation.
Which of the following is the most likely diagnosis?

Question

A 65-year-old man comes to the physician because of floaters in his right eye for the past 2 days.  He also experienced some brief flashes of light as well as poor vision in the same eye 1 day ago.  He has always been nearsighted and has worn glasses since he was a teenager.  He has no eye pain or trauma.  There is no history of diabetes mellitus.
No obvious abnormalities are detected on funduscopic examination, but an extensive right-sided visual field defect is confirmed by confrontation.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's history and examination findings are most compatible with a retinal detachment, which is a separation of the multilayer neurosensory retina from the underlying retinal pigment and choroid. This detachment can occur passively due to fluid accumulation or actively due to vitreous traction on the retina. Rhegmatogenous detachment (break in the retina with a full thickness hole or tear) is the most common detachment and usually presents as a posterior vitreous detachment. Risk factors for non-traumatic retinal detachment include myopia and age >50. Non-rhegmatogenous detachments usually occur in patients with proliferative diabetic retinopathy. retina Patients typically present with a new onset of floaters, flashing lights, or loss of vision. Direct funduscopy has low sensitivity for retinal detachment and may be normal; clinical detection often depends on identification of visual field defects. Patients with vision loss should see a retinal specialist within 24 hours. All other patients may see the ophthalmologist more electively, especially if flashes and floaters are the only symptoms. Symptomatic detachments usually require surgical therapy to preserve vision. Patients who have retinal detachment without retinal breaks or tears may be treated conservatively. loss of vision (Choice A) Central retinal artery occlusion is usually preceded by amaurosis fugax and is associated with marked vision loss. Funduscopic examination usually shows a pale fundus with a cherry-red spot in the macula, which is not present in this patient. cherry-red spot (Choice B) Dry macular degeneration usually presents as gradual vision loss with drusen (areas of retinal depigmentation). Wet macular degeneration usually presents as acute vision loss with subretinal fluid and/or hemorrhage on funduscopic examination. This patient's normal funduscopic examination makes both diagnoses unlikely. drusen (Choice C) Optic neuritis usually presents as vision loss in younger individuals. It may accompany multiple sclerosis and is associated with pain on eye movement. (Choice E) Temporal (giant cell) arteritis with loss of vision is often preceded by symptoms of polymyalgia rheumatica and/or scalp and temporal pain. Visual symptoms in temporal arteritis most often include amaurosis, scotomata, diplopia, and blurred vision. Educational objective: Retinal detachment most commonly presents as a posterior vitreous detachment with floaters, flashing lights, and occasional vision loss. Patients with retinal detachment and vision loss require urgent referral to an ophthalmologist. __________ References: Acute-onset floaters and flashes: is this patient at risk for retinal detachment? (http://www.ncbi.nlm.nih.gov/pubmed/19934426)

A 65-Year-Old Man Comes to the Physician Because of Floaters