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monocular vision loss- loss of vision on one side of the eye cause the person to rely on the other eye

caucasian- europian white people (pale skin)

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27-year-old Caucasian female- high risk to get multiple sclerosis, pcos,

painful monocular vision loss- occur by lesion anterior to optic chiasm, issued like cornea ulcer, retinal detachment

developed over the last two days- acute process (due to infection)

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HOPI- how & when the vision loss begin to indicate acute or chronic, associated symptoms, started from two eyes or just one eyes, is it affect peripheral vision?,

site-started from two eyes or just one eyes

onset- when the vision loss begin

characteristics- vision loss black, white or grey, vision loss affect far away or close up, have blurred vission or not, pain (dull, stabbing),shadows, dark spot, flashes of light

radiation- does the range of visual field affected, does the pain spread at head, temple, face

associated symptom- change in colour vision, headache, nausea, photophobia, diplopia, balancing problem, eye redness, trauma

time- how long does the symptoms last, intermittent or consistent

exacerbating factor- painful when move the eye, ask anything that make the pain worse, medication that could relieve the pain, does bright light worse the pain

severity- scale (0-10)

past medical history- hs of the eye disease, any ocular problem, eye surgery or trauma, head trauma, CVS, other diseases, diabetes

social history- smoking or drug, alcohol, use contact lens, diet hs

family history- any family member have same Sx, any family member have autoimmune ds

medications- take any drug that related to vision loss, any OTC medication

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limb paraesthesia - abnormal sensation of limb such as tingling and prickling

multiple sclerosis (MS) - autoimmune disorder that long lasting chronic disease of cns due to damage in myelin causing scar indicates sclerosis, early symptom - limb paraesthesia

fleeting episodes - a short life occurance of symptoms or sensation that resolve quickly

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-Initially she developed discomfort in the left eye which became worse with

eye movements followed by progressive blurring of left eye vision- pain due to inflammation of the optic nerve(if damage can cause loss of vision) of the eye or it contents

-in particular, coloured objects appeared pale or washed out compared with

their appearance through her right eye - inflammation of optic nerve or optic neuritis cause varius visual disturbance including reduce colour perception and contrast sensitivity, dyschromatopsia

-There were no right eye symptoms. - unilateral

-There was no previous ocular history. - no preexisting conditions

-While giving a detailed history, she recalled fleeting episodes of limb paraesthesia several times in the past year lasting minutes - problem in sending nerve signal, compression of the nerve or demyelination of neuronal axon

-with no other history of transient neurological symptoms.

-Past history of asthma but took no regular medications. - common in patient with MS

-The patient was not on prescription or OTC medication. - not medication related disease

-No history of head/eye trauma or surgical procedures - not due to external factors

-She had a cousin with multiple sclerosis (MS) and she was very

concerned about her own risk of developing the condition. - Has high risk of getting MS

-There was no history of alcohol abuse or illicit drug use - not due to drug

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General Examination:

Vital sign - bp, pulse rate, temp, breathing rate

Physical appearance - body weight

Systemic Examination:

Visual acuity test- snellen chart

Colour vision test - ishihara colour blind test

Visual field test - evaluate field of vision

Fundoscopy -

Cranial nerve assessment - Swinging flashlight test

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optic neuritis

Multiple Sclerosis

Thromboembolic from internal carotid artery

glaucoma

orbital tumor

cornea ulcer

iritis

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Visual fields were full to confrontation - normal vision

left eye red desaturation - ability of left eye to perceive colour red is reduced, abnormalities in red cones

left relative afferent pupillary defect - condition where there is abnormal response of pupil to light

looking to the extremes of gaze - moving eye as far as possible without tilting head

gait examination - observe how person walk

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Vital signs were normal - BP in normal range - loss of vision not due to HTN, temperature normal no infection

On examination, eyes and orbit appeared normal, Visual fields were full to confrontation. - normal vision

Visual acuity was 20/20 on the right eye and 20/40 on the left. - right eye normal , left eye defect vision

There was left eye red desaturation and abnormal colour vision on Ishihara plate testing. - patient left eye has reduced perception to red colour so difficult to distinguish red and green colour

Her pupils were equal in size. - normal pupillary function

A left relative afferent pupillary defect was noted. - RAPD, person noted RAPD associated with acute unilateral optic neuritis

On ophthalmoscopy, the cornea, anterior chamber, lens and

vitreous humor appeared normal in both eyes, as did both optic discs. - anterior part of eye not affected, rule out corneal ulcer

There were no hemorrhages or other abnormal retinal findings. - no defect in eye blood circulation

Eye movements were normal, but she found looking to the extremes of gaze painful in the left eye. - muscle strain and inflammation in optic nerve of left eye

No other abnormal neurological findings were detected. - no neurological disorder causing vision loss e.g stroke

The remainder of the cranial nerve examination was normal. - no abnormalities detect in cranial nerve

Strength, coordination, and sensation were normal, as was a gait examination. - all work normally

A systemic examination was unremarkable. - no related to other systems

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optic neuritis

Multiple Sclerosis

Thromboembolic from internal carotid artery

glaucoma

orbital tumor

cornea ulcer

iritis

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FBC (CRP) - for inflammation

Tonometry

CT scan / MRI

Lumbar puncture - CSF

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1. anatomy of orbit and eye

2. causes of vision loss (explain disease that can cause vision loss)

3. discus hereditary vs acquired

4. discuss type of paresthesia (transient vs chronic)(everything) (peripheral nerve impairment)

5. discuss visual pathway (with RAPD -definition ,test ,finding)

6. discuss image formation

7. discuss mechanism of colour vision (relate with colour blindness &Ishihara plating test)

8. discuss optic neuritis ( definition , risk factor, causes, pathophysiology, sign and symptom, investigation (relate with trigger 4), complication, management, follow up and prognosis)

9. discuss multiple sclerosis ( definition , risk factor, causes, pathophysiology, sign and symptom, investigation (relate with trigger 4), complication, management, follow up and prognosis)

10. discuss cranial nerve assessment that relate with eye