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Gradual deterioration in visual acuity over time

Clinical Discipline(s)/Organ System(s)
Ophthalmology, General Practice
Progress Test Topic(s)
Eyes
Description
A 75 year old, otherwise healthy Indian woman, who drives and reads avidly, notices increasing difficulty seeing road signs and reading the newspaper over six months. Five years previously she had cataract surgery to both eyes which greatly improved her vision. After the cataract operations she noted 'I could see like I was 20 years younger'. Current visual acuity is 6/12 right and 6/24 left with spectacles.
Applied Science for Medicine 
   - Anatomy of the eye with focus on the choroid and retina
   - Physiology of vision: alignment and function of photoreceptors
   - Effect of ischaemia and vascular growth factors on vascular function; effect of ultra-violet light on the eye; effect of oxidative damage to tissue
   - Pathogenesis of glaucoma
   - Effects on the eye of commonly used eye drops
   - Pharmacology of anti-VEGF (vascular endothelial growth factor) therapy - vascular endothelial growth factor inhibitors
Clinical and Communication Skills 
   - Elicit a relevant history of gradual vision loss
   - Measure visual acuity for distance and near, and record accurately
   - Assess macular function (e.g. use of Amsler grid)
   - Assess visual fields to confrontation
   - Ophthalmoscopy to identify any media opacities (e.g. cataract) and assess fundus
   - Distinguish acute from chronic vision loss; distinguish between retinal causes and other common, slowly advancing, age related causes of vision loss (e.g. cataract, glaucoma)
   - Driving standards for vision, return to work capabilities, occupational standards for vision (monocular and binocular)
   - Patient education: appropriate recommendations, advice regarding risks and appropriate referral for significant vision loss, patient self-monitoring, appropriate use of dietary supplements, cessation of smoking, treatment options
Personal and Professional Skills 
   - Team work: understanding the role of other ophthalmic and non-ophthalmic health professionals (e.g. optometrists) in identification, monitoring and referral
   - Clinical reasoning: using key signs and symptoms to establish most likely diagnosis
Hauora Māori 
   - Consideration of access to cultural / spiritual support for patient and whānau
Population Health 
   - Epidemiology of common age-related eye diseases that may profoundly affect vision: age-related macular degeneration, chronic open angle glaucoma, cataract, and diabetic retinopathy
   - Cost to individual and community of blindness and severe visual impairment
   - Cost to health boards of universal treatment for age-related macular degeneration
Conditions to be considered relating to this scenario
Common
age-related macular degeneration, senile cataract
Less common but 'important not to miss'
advanced chronic open angle glaucoma, diabetic retinopathy (maculopathy)