Just another BRVO?

21 05 2013

A 39 year-old male of South Asian decent reported to the clinic reporting blurry vision in his right eye starting 3-4 days previous.  Vision measured OD 20/50 OS 20/20 (uncorrected – this patients was previously 20/20 OD and OS).  Patient history revealed self reported ‘mild’ hypertension which was not medically managed nor had it been indicated in previous visits with his primary care physician.   IOP was 17 mmHg OD/OS and pupils were normal.  Flurescein angiography study showed no ischemia, however a conservative approach was taken to monitor the macula edema for resolve rather then consider anti-VEGF or therapeutic laser options at the time.

Fundus photo and OCT are shown below OD as well as contrast sensitivity testing.

ODBRVOwMEThe BRVO and to a lesser extent the macular edema is obvious on fundus examination.  On closer inspection though another area off inferiorly and nasal to the disc shows vascular retinopathy in the form of a cotton wool spot and nerve fibre hemorrhages.  This is not associated with the BRVO and signals the chronicity of his systemic hypertension which resulted in an interesting turn of events for this otherwise carefree individual.

Macular edema2ndBRVO

The OCT of the macula  clearly shows the cystic edema associated with this inferior BRVO.  Because of its inferior location this fluid will likely drain away from the macula and be reabsorbed in natural course.

Notice the difference in CS vs. SF curve.  This test was done for monitoring purposes only – it was not a diagnostic test.  It was needed to monitor the quality of his vision in this case as the fluid reduced at his macula.  The retinal surgeon and myself  will rely on this in addition to his objective findings downstream to help in guiding treatment options in the event of poor resolution of edema.

ContrastSensitivityBRVO

Follow up and Discussion:

From a bird’s eye view, I would say this case is worthy of follow up but not a unique set of findings.  What followed was however very interesting.  I examined this patient on a Thursday.  I called his family doctor but was unable to speak to her.  I sent a report and advised to follow up on his hypertension at next visit which turned out to be the next day.   This patient was very proactive and I would argue, his proactive nature helped to save his own life.   Serial BP testing demonstrated an avg BP of 180/160 and the final measurement of the day climbed past 200/180 sending this patient to the emergency room at the local hospital.  He was admitted to CCU over the next 3 days in an  attempt to urgently reduce his risk of stroking out and to steer this patient away from certain death.  After an intense 3 days his BP had come down to 130/85 in response to his medical therapy and it was maintaining.  The patient reported  that his multiple daily headaches had stopped and his quality of sleep was markedly improved.

I am following him regularly until complete resolution, however I believe there is a lesson learned here.

Better communication – For years, this  man was told he was ‘fine’ but had mild hypertension.  His cultural background supported a holistic approach to managing one’s body.  Through mind and inward discipline he was confident that he was in good health.   He hadn’t followed up regarding the ‘mild’ hypertension for at least 2 years because it wasn’t a concern for his doctor so why should it be a concern for him?   In fairness, there was no way to predict that he would suffer from hypertensive crisis years later so the ‘see your doctor when there’s a problem’ approach seemed prudent here.

My communication as his eye doctor to his family doctor was difficult and I haven’t yet received a report on this potentially critical patient whom I referred for urgent care.    To be clear I don’t believe this to be a problem with this doctor specifically but with the system at large.  This is what I believe needs to change.  How we relay information to each other; whether it is two teenagers tweeting their breakup because of broken communication or a doctor to her or his patient or physicians reporting over the care of a patient we are all too busy, too slavish to outdated protocol, too pre-occupied with all about us to listen.

For this lucky young man, I suspect he is listening to his body more than ever.  He told me he and his wife are finally going to take their honeymoon which is years overdue and will slow things down a little at work.  For the record I am biased to the sense of sight,  but I think we could all do a little better to listen to the world around and within us.

In good health,

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca

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