A 67-year-old man comes to the office due to decreased vision in his left eye. While driving 2 weeks ago, he noticed things appeared distorted or were "missing." He has also had difficulty reading despite changing his reading glasses multiple times over the last several months. The patient has had no headaches, eye pain, or double vision. He has a long-standing history of hypertension and is an ex-smoker with a 40-pack-year history.
Funduscopic findings are shown in the image below.

Which of the following is the most likely diagnosis?

Question

A 67-year-old man comes to the office due to decreased vision in his left eye.  While driving 2 weeks ago, he noticed things appeared distorted or were "missing."  He has also had difficulty reading despite changing his reading glasses multiple times over the last several months.  The patient has had no headaches, eye pain, or double vision.  He has a long-standing history of hypertension and is an ex-smoker with a 40-pack-year history.
Funduscopic findings are shown in the image below.

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient with progressive, painless, monocular vision loss has age-related macular degeneration (AMD). AMD is a major cause of blindness and visual impairment in older adults (age >50). Damage to the macula may initially be asymptomatic but eventually leads to progressive distortion and vision loss, primarily in the center of the visual field (central scotomas). (central scotomas) AMD occurs in 2 forms: "dry" and "wet." In the dry form, as in this patient, cellular debris called drusen accumulates between the retina and the choroid, sometimes leading to retinal detachment. In the wet form, which is more severe, blood vessels grow up from the choroid behind the retina, and the retina can become detached. This is often associated with retinal hemorrhage. Peripheral vision is usually spared. drusen (Choice B) Central retinal artery occlusion is characterized by acute retinal ischemia due to thrombosis or emboli in the central retinal artery (branch of ophthalmic artery). Patients develop sudden-onset, painless loss of vision in one eye, with a cherry red macula and retinal pallor on examination. Additional findings may include a relative afferent pupillary defect (Marcus Gunn pupil). Central retinal artery occlusion (Choice C) Hypertensive retinopathy can present with gradual, painless, binocular vision loss and headaches, although most patients have no visual symptoms initially. Characteristic features on funduscopic examination include "copper and silver wiring," hard exudates, flame hemorrhages, arteriovenous nicking, arteriolar narrowing, and ischemic changes ("cotton wool spots"). Hypertensive retinopathy (Choice D) Open-angle glaucoma presents with gradual, painless loss of vision. Examination shows optic nerve atrophy with increased optic cup size and cup-to-disk ratio. Tonometry usually shows elevated intraocular pressures. Open-angle glaucoma (Choice E) Retinal detachment is characterized by acute vision loss associated with flashes of light (photopsia), numerous floaters (drifting spots or strings in the visual field), and eye heaviness. Patients may describe the impression of a veil or curtain being drawn over the field of vision. Both peripheral and central vision are affected. Retinal detachment Educational objective: Age-related macular degeneration is characterized by progressive, painless central vision loss in patients age >50. Ocular findings include drusen, with or without hypervascularity and hemorrhages. __________ References: Current knowledge and trends in age-related macular degeneration: genetics, epidemiology, and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/24285245)

A 67-Year-Old Man Comes to the Office Due to Decreased