A 75-year-old man comes to the clinic due to a gradual onset of blurred vision in both eyes and difficulty reading over the past 2 months. He also has difficulty driving at night and reports seeing halos around bright lights. Medical history is notable for longstanding diabetes and hypertension. The patient has a 40 pack-year smoking history. Vital signs are normal. Corrected vision is OD (right eye) 20/80 and OS (left eye) 20/100 with normal findings on visual field testing. Which of the following is the most likely diagnosis in this patient?

Question

A 75-year-old man comes to the clinic due to a gradual onset of blurred vision in both eyes and difficulty reading over the past 2 months.  He also has difficulty driving at night and reports seeing halos around bright lights.  Medical history is notable for longstanding diabetes and hypertension.  The patient has a 40 pack-year smoking history.  Vital signs are normal.  Corrected vision is OD (right eye) 20/80 and OS (left eye) 20/100 with normal findings on visual field testing.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d822_8364_bc81_4119227227ae_MD0003_00 This patient has progressive, bilateral blurring of vision, suggesting cataracts. A cataract is a vision-impairing opacification of the lens, most commonly related to oxidative damage of the lens with aging. Other risk factors for cataract include diabetes, smoking, chronic sunlight exposure, and glucocorticoid use. Cataracts are usually bilateral, but patients may become symptomatic in one eye before the other. Patients usually report painless blurring of vision, bothersome glare, and often halos around lights at night due to scattering of light in the lens. Ocular examination in early cataract formation may show a normal red reflex with clear visualization of the retina; as the cataract progresses, the red reflex is lost and retinal detail may not be visible. red reflex Cataracts typically follow a slowly progressive course, and treatment is indicated when loss of vision impairs activities of daily living. Definitive treatment is lens extraction with artificial lens implantation. (Choice B) Diabetic retinopathy is characterized by vascular proliferation with or without vitreous hemorrhage. Symptoms are a late finding and may include floaters, decreased visual acuity, focal visual field defects, and acute monocular vision loss. Gradually progressive blurring with glare and halos is more consistent with cataracts. (Choice C) Hypertension can cause progressive arteriolar changes in the retina. Most patients with hypertensive retinopathy are asymptomatic; symptoms can occur due to retinal hemorrhage but typically present acutely with monocular vision loss. (Choice D) Macular degeneration causes decreased acuity of central vision. It occurs in 2 primary forms: atrophic (dry), which causes slowly progressive, vision loss that involves one or both eyes and is usually associated with scotoma (ie, blind spot); and exudative/neovascular (wet), which causes unilateral, aggressive vision loss, often starting with straight line distortion. However, difficulty with night driving, typically due to glare, and halos are more suggestive of cataracts. (Choice E) Open-angle glaucoma presents with insidious, gradual loss of peripheral vision. This may lead to near-miss motor vehicle collisions, but night driving is not preferentially affected. Open-angle glaucoma also does not cause halos around bright lights; these are sometimes seen with acute angle-closure glaucoma, which classically presents with severe eye pain, conjunctival redness, and a poorly reactive mid-dilated pupil. Educational objective: A cataract is a vision-impairing opacification of the lens. Patients usually have painless blurred vision, glare, and often halos around lights. Treatment with lens extraction and artificial lens implantation is indicated when loss of vision impairs activities of daily living. References: Cataracts. (http://www.ncbi.nlm.nih.gov/pubmed/26319346)

A 75-Year-Old Man Comes to the Clinic Due to a Gradual