A 65-year-old woman comes to the emergency department due to seeing a sudden burst of flashing lights and blurred vision in her left eye. These symptoms started this morning. She now sees small spots in her field of vision. She felt "like a curtain came down" over her eye. She had a successful cataract extraction in her left eye 4 months ago. Her vital signs are stable. Examination shows a sluggish left pupil. Ophthalmoscopy reveals retinal tears and a grayish-appearing retina. What is the most likely diagnosis?

Question

A 65-year-old woman comes to the emergency department due to seeing a sudden burst of flashing lights and blurred vision in her left eye.  These symptoms started this morning.  She now sees small spots in her field of vision.  She felt "like a curtain came down" over her eye.  She had a successful cataract extraction in her left eye 4 months ago.  Her vital signs are stable.  Examination shows a sluggish left pupil.  Ophthalmoscopy reveals retinal tears and a grayish-appearing retina.  What is the most likely diagnosis?

Quizplus · Accepted Answer

Retinal detachment refers to the separation of the layers of the retina. It usually occurs in people age 40-70 years. A typical presentation includes photopsia (flashes of light) and floaters (spots in the visual field). Some patients describe "a curtain coming down over my eyes," similar to other causes of transient vision loss (eg, amaurosis fugax). Usually, the inciting event occurs months before retinal detachment. Myopia or trauma can cause retinal breaks, through which fluid seeps in and separates the retinal layers. In this patient, ocular trauma most likely occurred due to her cataract surgery. Ophthalmoscopic examination reveals a grey, elevated retina. Laser therapy and cryotherapy are done to create permanent adhesions between the neurosensory retina, retinal pigment epithelium, and choroid. (Choice A) Choroidal rupture occurs due to blunt ocular trauma. Examination reveals central scotoma, retinal edema, hemorrhagic detachment of the macula, subretinal hemorrhage, and crescent-shaped streak concentric to the optic nerve. The usual complaint is blurred vision following blunt trauma. (Choice C) Central retinal artery occlusion (CRAO) is also characterized by a sudden painless loss of vision in one eye, but its funduscopic findings differ. Ophthalmoscopy of patients with CRAO reveals pallor of the optic disc, cherry red fovea, and boxcar segmentation of blood in the retinal veins. (Choice D) Proliferative diabetic retinopathy in the initial stage is asymptomatic. Patients may later complain of decreased visual acuity. Neovascularization is the hallmark of proliferative diabetic retinopathy. The other findings are vitreous hemorrhage and macular edema. These changes may lead to retinal detachment. (Choice E) Exudative ("wet") macular degeneration can cause central vision loss; straight line distortion is one of the earliest changes. Testing reveals central scotoma. Ophthalmoscopy reveals growth of abnormal vessels in the retinal space. Sudden visual loss may occur if it is complicated by retinal detachment. Educational objective: Retinal detachment usually presents with a sudden onset of photopsia and floaters.

A 65-Year-Old Woman Comes to the Emergency Department Due to Seeing