Instructions
You are a medical student on placement in general practice in Narrogin. Francesca Caruso, 67, woke three days ago with blurred vision in her right eye. She has not seen a GP for years. Her BP today is 172/98. Her optometrist's letter and photographs, and today's finger-prick tests, are below.
Interpret the fundus photographs and results provided
Outline to the examiner:
- Your findings
- Your most likely diagnosis and differentials
- Next steps in management, including relevant investigations
- You do not need to take a history or examine the patient
Optometrist's letter and fundus photographs (yesterday)
| Item | Value | Reference range |
|---|---|---|
| Visual acuity, right eye | 6/36, no better with pinhole | 6/6 |
| Visual acuity, left eye | 6/9, 6/6 with pinhole | 6/6 |
| Pupils | Equal; both react briskly to light; no relative afferent pupillary defect | Equal and reactive |
| Tonometry, right eye | 26 mmHg | 10-21 mmHg |
| Tonometry, left eye | 22 mmHg | 10-21 mmHg |
| Front of both eyes | White and quiet; clear corneas; angles open; early lens opacities both sides | Normal |
| Right eye: red reflex | Present | Present |
| Right eye: disc | Pinker than the left and swollen; margins indistinct all round; cup not visible | Pink, flat, clear margins; cup-disc ratio up to 0.5 |
| Right eye: vessels | Veins dark, widened and winding in all four quadrants; arteries a little narrow | Artery to vein width about 2:3; no winding |
| Right eye: macula | Looks thickened and dull; no foveal reflex; small red haemorrhages reach the fovea | Clear foveal reflex |
| Right eye: retina and periphery | Some streaky, feather-shaped red haemorrhages around the disc and along the veins, and rounder dark red blots, in all four quadrants out to the periphery; three small fluffy white patches | No haemorrhages or white patches |
| Left eye: red reflex | Present | Present |
| Left eye: disc | Pink and flat; clear margins; cup-disc ratio 0.4 | Pink, flat, clear margins; cup-disc ratio up to 0.5 |
| Left eye: vessels | Arteries narrow, with a bright light streak along them; veins look pinched where the arteries cross them | Artery to vein width about 2:3; no nipping |
| Left eye: macula | Clear foveal reflex | Clear foveal reflex |
| Left eye: retina and periphery | No haemorrhages, white patches or yellow deposits | No haemorrhages or white patches |
Optometrist's note: "Mrs Caruso woke 3 days ago with painless blurring of the right eye. Both eyes photographed through dilated pupils. Please see her today."
Finger-prick tests by the practice nurse (today, non-fasting)
| Item | Value | Reference range |
|---|---|---|
| Random glucose | 6.1 mmol/L | 3.0-7.7 mmol/L |
| HbA1c | 5.7% (39 mmol/mol) | 4.0-6.0 % |
| Total cholesterol | 6.4 mmol/L | <5.5 mmol/L |
| LDL cholesterol | 4.3 mmol/L | <3.5 mmol/L |
| HDL cholesterol | 1.3 mmol/L | 1.0-2.5 mmol/L |
| Triglycerides | 1.8 mmol/L | <2.0 mmol/L |