Approach to Chronic Blurring of
Vision: A case Presentation
Mareeya Rowena M. Rizon
Objectives
[Link] briefly present a case of chronic
blurring of vision its Diagnosis,
Diagnostics and appropriate
Management
Identifying data:
57/M
Resides in Aklan, Married
CHIEF COMPLAINT
Blurring of vision, left eye for 7
years
History of Present Illness
Patient was hit by a tree branch on his L eye
7
+ tearing, redness, pain, glare OS
years
Sought consult and was prescribed with
unrecalled antibiotic eyedrops instilled 3x/day
with good compliance
History of Present Illness
There was progression of symptoms
+tearing of left eye, redness, whitish
discharge, glare persisted, also noted blurring of
Interim
vision. No repeat consult done.
Other symptoms gradually resolved. Persistence
of blurring of vision prompted consultation.
PAST OCULAR HISTORY
+ocular trauma (2016)
- no previous ocular surgeries
- no chronic use of ophthalmic medications
PAST MEDICAL HISTORY
(-) Hypertension
(-) Diabetes Mellitus
Physical Exam
OD OS
15/200 VA Good light perception
(-) matting (-) discharges External (-) matting (-) discharges
(-) hyperemia (-) hyperemia
Full extraocular motility EOM Full extraocular motility
2-3 mm reactive to Pupils 2-3 mm reactive to light,
light, (-) RAPD
(-) RAPD Max dilation 9mm
Max dilation 9mm
+ phacodonesis and
zonulysis at 1-5 o’clock,
Clear cornea, Clear cornea, deep
deep anterior anterior chamber
chamber Slit exam
+ lens opacity + lens opacity
NC4NO2PSC3 - dense nucleus floating
freely in liquefied cortex
VH4 no cells and VH4 no cells and
flare flare
IOP – 12 mmHg Tonometry IOP – 12 mmHg
Gonioscopy – Ciliary body Gonioscopy – Ciliary body
all angles, not widened all angles, not widened
IO: clear media, yellow Fundus IO: no view
orange discs, CDR 0.3,
distinct disc borders,
AVR: 2:3, no exudates, no
hemorrhage, dull foveal
reflex
Clinical Approach to Blurring of Vision
Acute Chronic
Vascular occlusions of retinal,
Optic discs, Cerebral vessels Prechiasmal pathology Chiasmal, Retrochiasmal,
Retinal detachment Intracranial pathologies
Subacute: Inflammatory
Central vision Peripheral vision Homonymous Bitemporal
Visual acuity reduced Visual acuity not reduced defect defect
Retina
Pinhole testing VA not improved Pinhole testing VA improved
Post chiasmal Chiasmal
Refraction defect
+ RAPD - RAPD errors
Abnormal retinal appearance Normal retinal appearance Hazy, opaque humor or lens
Severe Optic
Retinal Pathologies Nerve Media
Opacity
Macula
DIFFERENTIALS
Ruled In Ruled Out
+ ocular trauma - stellate or rosette shaped
+ pain, OS posterior axial opacity, or
1. TRAUMATIC + redness
+glare
total cortical opacity
CATARACT + blurring of vision
PE:
Lens opacity
+advanced age Cannot totally rule out
+glare
+ blurring of vision
2. SENILE PE:
Lens opacity
CATARACT
Chronic blurring of vision
differentials
2. Lens induced Glaucoma
(Phacolytic, Lens particle, Phacoantigenic, Phacomorphic,)
Ruled In Ruled out
+ blurring of vision
+ pain, OS
PE: VH4 no cells and flare
Lens opacity (mature IOP – 12 mmHG (normal)
cataract, OS) Phacomorphic (closed
angle) – ciliary body seen all
angles
Phacoantigenic glaucoma –
absence of keratic
precipitates
Key Findings
Advanced Age
Progressive blurring of vision
+ Glare
OD OS
decreased VA: 15/200 decreased VA: Light perception
+ Lens opacity + Lens opacity
+ lens opacity NC4NO2PSC3 + Phacodonesis and zonulysis at 1-5 o clock
- Dense nucleus floating freely in the liquefied c
cortex
+ Ciliary body VH4
IMPRESSION
Morgagnian Senile cataract, OS
Immature Senile cataract, OD
DIAGNOSTI
1. B scan ultrasonography
CS
Patient Indications:
- Determines axial length K1, K2 for determining IOL diopter determination
- Most useful for our patient since Indirect Ophthalmoscopy of left eye difficult to assess due to the
severity of the opacity of the lens
- Guides in determining treatment choices and prognosis of visual functional capacity of patient
Post treatment
2. Optical coherence tomography
Patient Indications:
- Assess the presence of retinal and optic nerve layer pathologies that can contribute or is the
major cause of the symptoms of patient particularly blurring of vision
3. Specular Microscopy
Patient Indications:
- determines condition of
corneal endothelium
Cell count: 1500-3500
Cell variation: <0.40
Cell size <0.50
- Phacoemulsification may
risk cornea for decompensation if
already with depleted and damaged
corneal endothelium.
4. Systemic Workup
Poorly controlled comorbidities such as diabetes are
associated with higher risk of postoperative complications.
PLAN
1. Morgagnian Cataract, Ectopia Lentis OS
- Phacoemulsifaction is the preferred technique for cataract
surgery over MSICS because of faster visual improvement and lower
risk of adverse events or complications (PAO Journal, 2017)
2. For the problem of senile cataract, OD, since VA is 15/200
Delayed Sequential Bilateral Cataract Surgery is preferred
over Immediate Sequential Bilateral Cataract Surgery (ISBCS) in the
same sitting for patients with bilateral senile cataracts (PAO Journal,
2017)
Possible Complications
1. Endophthalmitis – aqueous and vitreous infection
Preoperative prevention
– treatment of coexisting eyelid disorders
Operative prevention
– sterilization of Fornix with 5% Povidone Iodine solution
- intracameral Moxifloxacin
Post operative prevention
- use of antibiotic ophthalmic drops
Post – operative Care
1. Ophthalmic antibiotic drops
- Fluoroquinolones (Moxifloxacin,
Gatifloxacin)
2. Ophthalmic corticosteroids
- Decreases risk of inflammation
3. Dry eye therapy
REFERENCES
• American Academy of Ophthalmology volume 11: Lens and Cataract 2023
• [Link]
• Kanski Clinical Ophthalmology 9th Ed
THANK YOU
