IGNACIO, Richelle Angelika E. Dr.

Sheila Jimenez
2017-0116 Ophthalmology

[March 2, 2020 8:00-10:00 AM]

IDENTIFYING DATA
Patient. H.G. is a 55-year-old married female who works as a dog breeder currently residing in Calatagan, Batangas.
Referral. SLMC-OPD.
Source & Reliability. Information acquired from the patient. She was consistent and reliable.

CHIEF COMPLAINT
Referral to Ophthalmology for assessment of Systemic Lupus Erythematosus (SLE) retinopathy

HISTORY OF PRESENT ILLNESS

Two years prior to consult, patient was diagnosed with Systemic Lupus Erythematosus (SLE) and was referred to the
Ophthalmology department for screening of SLE retinopathy. She also presents with blurring of vision especially seeing near
objects. Patient underwent perimetry, fluorescein angiogram, and fundus photography; results were unrecalled. No medical
intervention given except for prescription of reading glasses, grade unrecalled, which provided relief of blurring of vision. Patient
was advised to come for regular follow-up every 6 months. In the interim, patient reports that her blurring of vision did not
progress. No tunnel vision, excessive tearing, redness, double vision, and visual disturbances were reported. Seven days prior to
consult, patient repeated the three tests. On the day of consult, results from the latest tests are still pending and patient did not
present with any significant symptoms.

PAST MEDICAL HISTORY

Childhood Illnesses. History of chickenpox and mumps noted. No measles and asthma.
Adult illnesses.
Systemic Lupus Erythematosus (2018). Patient was brought to the ER due to a febrile seizure and was admitted at the
ICU for 2 days. Laboratory tests revealed increased creatinine and (+) ANA; renal biopsy warranted but was not allowed
due to low platelet count. Patient was initially prescribed Prednisone for a few months. Currently managed with
Plaquenil (Hydroxychloroquine) 200mg OD.
Antiphospholipid Syndrome (2018). Patient was brought to the ER due to edema of the right leg diagnosed to be deep
vein thrombosis. Patient was prescribed Coumadin 5mg OD on weekdays and 7mg OD on weekends.
Hypertension (2018). Upon consult, initial blood pressure was 180/100 mmHg. Patient was prescribed with Amlodipine
10mg OD.
Surgeries. Cesarean section of 4th child (5-month-old abortus); no complications during and post-delivery.
OB/Gyn. G4P4 (2-0-2-2); G1 and G2 delivered term; G3: 6-month-old stillbirth delivered NSD; G4: 5-month-old stillbirth
delivered cesarean. No complications on all deliveries. Menarche at 12 years old. Menopause at 53 years old.
Accidents. None.
Allergies. None.
Immunization. Not elicited.
Screening. CBC, INR, creatinine, urinalysis, liver function tests, and lipid profile were done. Latest results were normal.

FAMILY HISTORY
Father died of a lung disease due to chronic smoking. Mother died of a cardiovascular disease due to hypertension. History of
hypertension and diabetes noted in both sides of the family. No history of liver and kidney diseases. No history of
ophthalmologic disease and eye abnormalities. No history of SLE.

PERSONAL AND SOCIAL HISTORY

H.G. works as a dog breeder and lives with her husband, who is an electrician. She does not smoke nor drink. She eats twice a
day with her diet consisting of fish, rice, and a few vegetables. She drinks 1 cup of coffee every day. No preference towards salty,
sweet, and fatty food. She does 1 hour of Zumba thrice a week as her form of exercise. Patient reports that having SLE does not
affect her ADLs. Aside from her maintenance medications, she also takes Caltrate as supplement.
 REVIEW OF SYSTEMS
Patient is well; no significant health complaints for the past two weeks.

PHYSICAL EXAMINATION
General Survey. Patient appears healthy and well-groomed. She is conscious, coherent, and cooperative. No noted body or
breath odors.
Vital Signs. Height and weight not taken. Blood pressure (left arm) 120/80 mmHg. Heart rate 70 bpm; regular. Respiratory rate
16 bpm. Body temperature (temporal) not taken.
Eyes.
Visual Acuity. 20/20 OU; Jaeger 6.
Gross Eye Exam. Eyes symmetric; no scars, lesions, and discolorations; sclera white, conjunctiva pink. No palpable mass.
Pupils. Both eyes dilated; patient was under mydriatic upon consult.
Confrontation Visual Fields. Both eyes positive for visual field defect prominent in the superior part of the field of
vision; more prominent in the right eye.
EOMs. Intact range of motion for both eyes.
Digital Tonometry. Firm upon gentle pressing.
Fundoscopy. Full ROR on both eyes. AV Ratio 2:3. Clear media. Optic nerve approximately 0.6-0.7mm in both eyes. Disc
margins sharp. No hemorrhages or exudates.

SALIENT FEATURES
This is a case of a middle-aged female, known case of Systemic Lupus Erythematosus (SLE) managed with Plaquenil, coming in
for assessment of SLE retinopathy. Patient is asymptomatic upon presentation but reports farsightedness. No tunnel vision,
excessive tearing, redness, double vision, and visual disturbances were reported. Patient underwent perimetry, fluorescein
angiogram, and fundus photography wherein results were unrecalled. No medical intervention given except for prescription of
reading glasses, which alleviated blurring of vision. Repeat of previous tests done; results pending. Patient was diagnosed with
antiphospholipid antibody syndrome and hypertension and controlled with Coumadin and Amlodipine, respectively. Physical
examination shows a well patient with stable vital signs. Reduced visual acuity on near vision. Visual field defect noted on
superior field of vision in both eyes; more prominent in the right eye. Normal IOP. Optic nerve approximately 0.6-0.7mm; optic
disc cupping observed with sharp disc margins. No redness, itchiness, and excessive tearing noted. Other findings are
unremarkable.

DIFFERENTIAL DIAGNOSES
Upon history taking, patient reports blurring of vision upon seeing near objects, which could be attributed to an error of
refraction. This happens due to a change in the shape if the eyeball or the curve of the retina. However, given the patient’s age
and the recent onset of BOV, it is more likely that this condition is presbyopia, which is a physiologic change that happens as
aging occurs when the lens loses its accommodating power and can no longer focus on objects viewed at a near proximity.
Another possibility for this symptom is cataract, which is the clouding of the normally clear lens. Given that the patient is in her
middle age years, having a cataract is likely since it is prevalent as aging occurs. However, further tests (i.e. slit lamp exam,
retinal exam) are needed in order to rule out this diagnosis.

Besides the patient’s blurring of vision, patient was also found to have optic disc cupping and visual field defects in both eyes.
One of the differentials for these symptoms is compressive optic neuropathy (CON) caused by injury to the optic nerve by an
extrinsic lesion. Although the patient presents with similar symptoms with CON (i.e. asymptomatic at presentation, optic disc
cupping, and reduced VA), this diagnosis can be ruled out since there is no known extrinsic lesion that may compress the
patient’s optic disc. Moreover, this condition is associated with dyschromatopsia, propoptosis, and ocular motility abnormalities
which the patient does not manifest with. Another possible diagnosis is optic neuritis characterized as the inflammation of the
optic nerve. It presents with the same symptoms and is predominant among females, which puts the patient at a higher risk of
acquiring it. However, optic neuritis is usually preceded by a viral illness and is associated with multiple sclerosis and
neuromyelitis optica, which the patient does not present with. Moreover, this condition occurs at young age, unlikely for the
middle-aged patient. Also, common symptoms of this condition such as subacute vision loss associated with pain on eye
movement, retro-orbital or ocular pain, and dyschromatopsia, are not reported by the patient, hence, this is unlikely the
diagnosis. Ischemic optic neuropathy (ION) secondary to blockage due to inflammation of the arteries may also be considered
given that the patient is hypertensive and presents with painless vision loss alongside the other symptoms. However, in this
condition, visual loss is monocular, whereas in the patient, it is binocular. Peripapillary hemorrhage should also be present. In
addition, patient’s hypertension is well-controlled, which makes it less likely to trigger the development of this condition, hence,
it is unlikely. Given the patient’s overall symptoms, glaucoma described to be the optic nerve damage due to increased IOP, is
highly considered because, aside from the symptoms, risk factors in acquiring glaucoma is also present in the patient, such as
high blood pressure, age 40 and older, and having poor short-distance vision.

WORKING IMPRESSION
Presbyopia and glaucoma; rule out SLE retinopathy

CLINICAL ASSESSMENT
Given that the patient is a known case of systemic lupus erythematosus (SLE), assessment for ocular pathologies is warranted
because they are one of the most common complications of this condition. Anterior segment findings include
keratoconjunctivitis sicca, conjunctivitis, episcleritis, anterior scleritis, keratitis and iritis. However, posterior segment disease is
more important to identify since it is a significant cause of morbidity among patients with SLE. Retinopathy associated with SLE
is one of the most common vision-threatening complications of SLE and is an accurate marker of the presence of active systemic
disease activity. Patients with this condition commonly presents with blurring of vision, and, when left untreated, may cause
complete blindness. It manifests as microangiopathy similarly seen in diabetic and hypertensive retinopathy. Earliest findings
include small intraretinal hemorrhages and cotton wool spots, which may be attributed to deposition of immune complexes in
the vessel wall and microemboli. Other manifestations include microaneurysms, vascular tortuosity, arteriolar narrowing, retinal
edema or exudates. Frank phlebitis and arteritis may also occur and may cause venous or arteriolar occlusion, which is most
likely to happen in the patient since she also has APAS. However, based on the current clinical findings from the patient, no signs
and symptoms of SLE retinopathy were observed but further tests should be done to rule out this diagnosis. Furthermore,
continuous monitoring for this condition is warranted to prevent long-term complications.

In this case, blurring of vision is most probably due to presbyopia. This condition manifests at age 40 and above, which increases
the risk of our patient given that she is 55 years old. As the patient ages, the crystalline lens loses its elasticity and its ability to
become more rounded when the zonular fibers loosen their grip, consequently leading to the inability to focus on objects at a
reading distance, explaining the farsightedness that the patient is complaining of for which she was given prescription glasses.

Other pertinent findings found in the patient such as visual field defects and optic disc cupping points to a diagnosis of
glaucoma. Glaucoma is an eye condition caused by raised intraocular pressure, which compresses and damages the optic nerve.
Once it is damaged, its function to carry visual information to the brain is impaired, resulting to loss of vision. In the patient’s
case, this loss of vision is not yet that apparent, however, a visual field defect in the superior field of vision is evident, which may
be explained by the fact that the first artery affected in the development of glaucoma is the superior arcuate artery. Alongside
these signs and symptoms, patient also presents with certain risk factors such as her high blood pressure, 55 years of age, and
having poor short-distance vision, all of which generally increasing her chances of acquiring glaucoma. In assessing for glaucoma,
three important symptoms should be watched out for—glaucomatous cupping, intraocular pressure (IOP), and visual field (VF)
defect. Presence of these symptoms, alongside the risk factors, help in evaluating if the patient is a glaucoma suspect or a
definite case. First, glaucomatous cupping occurs due to increased IOP which impedes blood flow to the distal part of the optic
nerve, causing retinal fibers in that area to die and atrophy, causing the cup to become larger. In the patient’s case, her optic
disc is approximately 0.6-0.7mm (Normal optic disc: 0.33mm). Second, intraocular pressure should also be checked given that
glaucoma is often caused by fluid buildup due to impaired drainage of the aqueous fluid. Most glaucoma cases are diagnosed
with an IOP of >20 mmHg, however, this is not always the case, as IOP can remain normal but manifest with other symptoms of
glaucoma. In the patient’s case, her IOP is normal. Lastly, visual field defects should be evaluated as these indicate loss of vision
when blood flow going to the optic disc is inadequate. Evaluation of VF defect is the most important as this can tell the severity
of the patient’s condition and may be used to monitor progression of loss of vision in the patient. In the patient’s case, she
manifest with superior arcuate defect. Basing from these findings, at this point, patient is not just a glaucoma suspect
considering that she has more than one risk factor and presents with visual defects and optic nerve damage. At best, patient
most probably have an early glaucoma. However, further diagnostic tests done only in clinical setting can confirm this diagnosis.
Moreover, diagnosis of glaucoma is done over time as symptoms take time to manifest.
Contrary to the usual cause of glaucoma known to be raised IOP, that is not always the case, as in the patient because she
manifests with normal IOP. Hence, it can be assumed that the patient has normal-tension glaucoma, which is characterized by
the presence of visual field defects and optic disc cupping but a normal IOP. Other major types of glaucoma are open-angle
glaucoma and angle-closure glaucoma. The former is the most common type which presents as a pattern of progressive
peripheral visual field loss followed by central field loss and is most often associated with increased IOP due to impaired
drainage of the aqueous fluid. It usually manifests as the classic optic disc cupping. On the other hand, angle-closure glaucoma is
characterized by the narrowing or closure of the anterior chamber angel leading to inadequate drainage of the aqueous fluid,
thereby increasing IOP and damaging the optic nerve. An acute case of this condition is associated with anatomical
predisposition, presents with a painful red eye, and must be treated within 24 hours to prevent permanent blindness.

DIAGNOSTICS AND ANCILLARY TESTS

To rule out SLE retinopathy, fundoscopy may be used to evaluate the common findings in this condition such as cotton wool
spots, phlebitis, and arteritis in the retinal area. Fluorescein angiogram should also be observed for retinal changes such as
hyperpermeability of arterioles and venules as well as capillary nonperfusion. These findings should be seen in a patient with
confirmed diagnosis of SLE.

Since presbyopia is considered, a basic eye exam with refraction assessment should be done to confirm this diagnosis as this
was not done during consult.

Patient’s PE findings pointing to glaucoma warrants slit lamp gonioscopy to evaluate possible fluid buildup in the anterior
chamber angle. It also determines the type of glaucoma the patient has depending on the angle where the iris meets the cornea,
whether angle-closure or open-angle. Under the slit lamp, intraocular structures are better seen which helps in ruling out
secondary causes of glaucoma (i.e. diabetes, hypertension). Perimetry should be done as it accurately detects where in the field
of vision has glaucoma affected, supporting the visual field defect found in PE. Another adjunct to diagnosing glaucoma is
pachymetry which determines the thickness of cornea because it can influence IOP readings and may help in developing a
treatment plan tailored to the patient. In addition to these, a repeat fundus photography was recently done by the patient
because it evaluates the presence of a classic glaucomatous appearance when seen by expert graders. Fluorescein angiogram
was also repeated to assess blood flow in the distal part of the optic nerve, which is important in the development of optic disc
cupping and visual field loss seen in glaucoma.

TREATMENT AND MANAGEMENT

SLE Retinopathy. If the patient eventually develops this condition, systemic immunosuppression is the mainstay of treatment.
Oral corticosteroids are the usual initial treatment, but may be preceded by IV methylprednisolone. Since the patient has APA,
she is more likely to acquire a vaso-occlusive disease which may call for anti-coagulation therapy alongside
immunosuppressants. In addition, this also helps in stabilizing the retinal disease and prevent possible vascular events.
Considering that the patient is maintained on Plaquenil for SLE, monitoring of intake of this medication should be ensured since,
although unlikely, this medication may cause retinal toxicity.

Presbyopia. Given the patient’s presbyopia, a prescription reading glasses with a grade 2.5 is warranted. Other options would
be wearing contact lenses, undergoing refractive surgery, lens implants, and corneal inlays. However, these are more invasive
and more costly.

Glaucoma. Assuming the diagnostics tests return positive for glaucoma, patient should be given anti-glaucoma medications as
this is the first-line treatment for this condition They work by either decreasing the amount of fluid (aqueous humor) in the eye
or improving its outward flow, or both. Medical advice is needed as to which specific medication best fits the patient. However,
if the patient cannot maintain pharmacologic therapy due to high cost or incompliance, she may opt for surgical laser therapy. If
visual field loss becomes severe, the latter is warranted. Concomitantly, routine glaucoma checkup, which consists of assessing
visual field defect, IOP, and optic disc cupping, should be monitored, ideally every 3-6 months, to assess progression of her
condition. Adherence to medications should also be checked.

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