A 78-year-old man is brought to the office due to recurrent falls. The patient is a nursing home resident, and the nursing home staff noticed that he has a progressive decrease in vision. The patient has not had any double vision, dizziness, nausea, vomiting, headache, or vertigo. Medical problems include Alzheimer dementia, peptic ulcer disease, diverticulosis, and degenerative joint disease. Vital signs are stable. On examination, he has decreased vision in both eyes, and bilateral anterior cortical cataracts. Which of the following associated conditions is most likely contributing to his decreased vision?

Question

A 78-year-old man is brought to the office due to recurrent falls.  The patient is a nursing home resident, and the nursing home staff noticed that he has a progressive decrease in vision.  The patient has not had any double vision, dizziness, nausea, vomiting, headache, or vertigo.  Medical problems include Alzheimer dementia, peptic ulcer disease, diverticulosis, and degenerative joint disease.  Vital signs are stable.  On examination, he has decreased vision in both eyes, and bilateral anterior cortical cataracts.  Which of the following associated conditions is most likely contributing to his decreased vision?

Quizplus · Accepted Answer

Explanation: The common causes of decreased vision in elderly patients (especially age >75) are cortical cataracts and associated age-related macular degeneration (AMD). The prevalence of cataractsin this age group is almost 40%, and that of associated AMD is 20%. Cataracts represent slow, progressive opacification of the lens, progressing to painless blurry vision with generally intact visual fields. AMD refers to degeneration of the central portion of the retina (possibly due to chronic inflammation or infection), leading to loss of central vision. Early changes are often asymptomatic but can progress to difficulty reading, scotomas, or needing brighter light for visualization. Drusen (cellular debris) may be visible in early stages (dry AMD). With wet AMD (choroidal neovascularization), the presentation can be more acute. Visual loss related to AMD may be irreversible, unlike that related to cataract. scotomas Drusen Patients with cataracts should be thoroughly evaluated for the severity of AMD, as they may not benefit from cataract surgery alone (eg, lens extraction); AMD management (eg, oral eye vitamin, potential intravitreal therapy in case of wet AMD) may be warranted. Cataract surgery may also increase the risk of AMD progression (possibly because the opacified lens provided some protection from AMD); therefore, decisions about cataract surgery in patients with AMD should be based on an assessment of the potential gain from lens extraction. (Choices A and B) Although the prevalence of glaucoma increase with age, it is still <10%. In addition, closed-angle glaucoma usually causes severe eye pain and headache. (Choice C) Proliferative retinopathy is usually seen in patients with diabetes. Without a history of diabetes, this diagnosis is very unlikely. (Choice E) Retinal detachment usually presents with a sudden onset of unilateral loss of vision. Educational objective: Cataracts and associated macular degeneration are extremely common in the elderly population and often result in visual impairment. Elderly patients should be thoroughly evaluated for the severity of macular degeneration, as they may not benefit from cataract surgery.

A 78-Year-Old Man Is Brought to the Office Due to Recurrent