A 65-year-old man comes to the emergency department due to a sudden loss of vision in his right eye. He has had diabetes, and has been treated with metformin and glyburide for the past 10 years. Visual acuity is reduced to light perception in his right eye, and normal in his left. His vital signs are normal. Ophthalmoscopy reveals loss of fundus details, floating debris and a dark red glow. What is the most likely diagnosis?

Question

A 65-year-old man comes to the emergency department due to a sudden loss of vision in his right eye.  He has had diabetes, and has been treated with metformin and glyburide for the past 10 years.  Visual acuity is reduced to light perception in his right eye, and normal in his left.  His vital signs are normal.  Ophthalmoscopy reveals loss of fundus details, floating debris and a dark red glow.  What is the most likely diagnosis?

Quizplus · Accepted Answer

Vitreous hemorrhage typically presents as a sudden loss of vision and onset of floaters. The most common cause is diabetic retinopathy. An important diagnostic clue is that the fundus is hard to visualize, and even if it is visualized, details may be obscured. Immediate ophthalmologic consultation is required. For patients with underlying medical conditions, conservative treatment (i.e., upright position during sleep, which enhances settling of the hemorrhage) is recommended. (Choice A) Retinal detachment refers to the separation of the inner layers of the retina. It may be associated with metabolic disorders (e.g., diabetes mellitus), trauma (including ocular surgery), vascular disease, myopia, or degeneration. Patients typically complain of vision loss, photopsia with showers of floaters. Fundoscopy typically demonstrates an elevated retina with folds and/or a tear. (Choice B) Diabetic retinopathy patients are usually asymptomatic, even though changes in fundoscopy are seen. Vitreous hemorrhage frequently occurs in patients with proliferative diabetic retinopathy. Once a diabetic patient presents with a sudden onset of visual loss with numerous floaters, a vitreous hemorrhage is most likely to have occurred. (Choice D) Central retinal vein occlusion presents as a sudden, painless, unilateral loss of vision. It is also noted in patients with a history of hypertension. Ophthalmoscopic signs are disk swelling, venous dilation and tortuosity, retinal hemorrhages, and cotton wool spots. (Choice E) Patients with macular degeneration typically present with painless progressive blurring of central vision, which can be acute or insidious. It occurs bilaterally. Educational objective: Vitreous hemorrhage typically presents as a sudden loss of vision and onset of floaters. Vitreous hemorrhage occurs in patients with diabetic retinopathy.

A 65-Year-Old Man Comes to the Emergency Department Due to a Sudden