Additional Subjective Data to Gather
In this case study, a 79-year-old male presents to a primary care clinic with chief complaints of a gradual decrease in visual acuity and bothersome glare. The patient has not had an eye examination because he knows no ophthalmologist in Florida. The patient states that gradual visual loss has made reading and watching television difficult, and glare has become bothersome as it has made him triple over objects on the floor.
Additional Subjective Data to Gather
The additional subjective data that would be included in the medical history, social and pertinent family history involve asking the patient if he is using any corticosteroids and anticholinesterase inhibitors or if he has been exposed to traumatic trauma such as electric shock, blunt trauma, ultraviolet radiation, or chemical injuries (Ahmad et al., 2022). The patient should also be asked if he has had a past medical history of systematic diseases such as myotonic dystrophy and atopic dermatitis and endocrine disorders such as diabetes mellitus and hypoparathyroidism. Social history includes asking the patient if he smokes, drinks alcohol, and the type of diet he consumes. Particular attention should be paid to a diet deficient in vitamins and antioxidants. A pertinent family history should include asking the patient if any family members have cataracts, glaucoma, or age-related macular degeneration (Ahmad et al., 2022)
Additional Objective Data to Assess
After thorough history taking, a comprehensive ocular examination should be performed to determine the patient’s visual acuity for far and near distances in a brightly lit room, and contrast sensitivity should be assessed (Ahmad et al., 2022). The ocular and intraocular structures should also be examined as they may explain the gradual visual loss. A funduscopy should also be performed to determine whether vision acuity is decreased or normal. Lastly, a swinging flashlight test should detect relative afferent pupillary defects or Marcus Gunn’s pupil, which suggests optic nerve lesions.
Differential Diagnosis
Based on the physical findings and clinical manifestations, differential diagnoses to consider are age-related cataracts, nonexudative age-related macular degeneration, and presbyopia (Lin et al., 2019). Age-related cataract is a gradual progressive eye disorder characterized by clouding and thickening of the lens. The rationale for this diagnosis is that the patient remarks that gradual progressive visual deterioration has resulted in reduced visual acuity, disabling glare, and myopic shift, which makes him unable to recognize people at some distance. Age is a significant risk factor supporting this diagnosis because the patient is entering his eighth decade. Another critical diagnosis is non-exudative age-related macular degeneration, a progressive chronic disorder of the central retina. The rationale for this diagnosis in the patient is that clinical manifestations are marked by gradual progressive visual loss, difficulty reading and watching television, and age, risk factors as the disease usually occurs in people older than 50 (Lin et al., 2019). The third diagnosis is presbyopia, an eye disease characterized by gradual visual loss that affects the ability to see nearby objects. The rationale for this diagnosis is the presentation of symptoms such as blurred vision and old age as a risk factor.
Laboratory Tests to Rule out Some of the Differential Diagnoses
Laboratory tests that can be performed to rule out differential diagnoses include macular function tests such as blue-light endoscopy, photo stress recovery test, and Maddox rod test to detect a macular problem (Hashemi et al., 2021). Other tests are intraocular pressure, which should be performed to rule out glaucoma and fundoscopy to rule out retinal or vitreous pathology.
Radiological Examinations or Additional Diagnostic Studies
Radiological examinations that should be ordered include computed tomography (CT) scan and magnetic resonance imaging when the clinician identifies that premature or extremely dense cataracts clog an adequate view of the back of the eye or suspects posterior pole pathology (Hashemi et al., 2021). An ultrasound scan should also be ordered so the clinician can view vitreous pathology or retinal detachment.Treatment and Specific Information about the Prescription
The most definitive treatment is surgical intervention, where lenses are extracted and different extraction methods are considered. These methods include intracapsular cataract extraction, extracapsular cataract extraction, and phacoemulsification (Chen, 2020).
Potential Complications
Potential complications of these surgical interventions occur after surgery. Complications during the surgical intervention include expulsive hemorrhage, posterior capsular rupture, corneal burn, and hyphaema. Post-surgery complications include growth-related refractive changes, uveitis, retinal detachment (retina moving out of place), glaucoma, and posterior capsular thickening (Chen, 2020). The risk of these surgery-related complications is higher if there are underlying eye diseases such as macular degeneration and glaucoma.
Additional Laboratory Tests
More laboratory tests, such as blood glucose levels, echocardiography, and electrocardiography, should be performed to establish systematic diseases. Before surgery, baseline tests, such as a bleeding profile, renal function test, and complete blood count, should be ordered to develop underlying conditions that could increase surgery-related complications.
Additional Patient Teaching and Consultations
Since the patient has not had surgery, he should be advised only to delay surgery once the cataract has matured and is hard, increasing the likelihood of postoperative complications. Moreover, the patient should be educated about possible complications, surgery, and follow-up care. Lastly, a comprehensive preoperative assessment would be performed before recommending surgical intervention to determine if the patient is psychologically, medically, and financially ready (Hashemi et al., 2021). A periodic consultation with the ophthalmologist would also be performed to evaluate the progress of the cataract.
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