Maria is a 68-year-old female who follows up after obtaining her Humphrey visual
field. Recall that she was initially seen by me on May 23, 2008 for anterior
ischemic optic neuropathy in her left eye due to giant cell arteritis diagnosed
in April 2004. Recall that she had last seen Dr. James Ahn in November 2006.
She obtains her care both at Kaiser Fremont and has come back to see
Ophthalmology at Palo Alto Medical Foundation at Fremont.
In terms of her Humphrey visual field today, her Humphrey visual field in her
right eye shows a superior arcuate vs. a superior defect. The Humphrey visual
field in the left eye is unreliable given her false negative and this is
unreliable because of her count finger vision which has been stable the last
several years.
Incidentally, I note that her laboratory tests obtained during her last visit
showed a CRP dated May 23, 2008 that was normal at 7.0. Her ESR was slightly
elevated at 62 mm/hr.
Dr. David Fischer, her rheumatologist, spoke to the patient regarding these
findings and has her currently taking prednisone 5 mg per day as well as
methotrexate 17.5 mg per week. She was also on low-dose aspirin.
Dr. Fischer spoke to the patient and offered that her temporal artery biopsy be
repeated, however, the patient is currently not interested. He also mentions to
her that increasing the steroid dose could be hazardous and the patient is
reluctant to increase that dose. He also mentioned that her ESR is higher than
normal, but her therapy is normal. He will see her in follow-up on June 10,
2008.
EXAMINATION: On examination in clinic today, her visual acuity with correction
is 20/40 +2 in her right eye, and her left eye is count finger at 1'.
Her external examination shows an MRD1 of 1.0 mm in both eyes.
function is normal at 15.0 mm in both eyes.
Her levator
Her slit lamp examination shows bilateral upper lid ptosis. Her conjunctivae and
sclerae are white and quiet. Her corneas are clear. Anterior chambers deep and
quiet. Irides round and reactive, and lenses show 1+ nuclear sclerosis in both
eyes.
Dilated fundus examination which was performed on May 23, 2007 showed a cup-todisk ratio of 0.3 in the right eye with no optic nerve edema or focal notching.
A cup-to-disk ratio in the left eye is 0.4 with pallor. Macular examination
shows epiretinal membrane in the right eye, and left eye shows mild RPE mottling.
Her vessels are within normal limits and peripheral examination shows in the
right eye drusen superonasally and left eye a few scattered drusen in the left
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eye.
Her OCT today also showed average of retinal nerve fiber layer of 120.3 microns
in the right eye, and 50.45 microns in the left eye.
Her central macular thickness on her right eye is 391 microns showing increased
macular thickness, however, with foveal depression she may have minimal, however,
not significant macro edema in the right eye. Her left eye shows 177 microns.
IMPRESSION AND PLAN:
1. Anterior ischemic optic neuropathy in the left eye noted on April 2004 due to
giant cell arteritis, currently treated with methotrexate and low-dose prednisone
and monitored routinely by Dr. Fischer. Dr. Fischer recently spoke to the
patient and will see her in follow-up on June 10, 2008 regarding her recent
increase in ESR after normal CRP.
2. Her Humphrey visual field today shows in her left eye which is the area of
the anterior ischemic optic neuropathy, and this is reliable giving her decreased
vision. We will consider performing Goldman visual field. In the right eye, she
does show superior arcuate versus superior defect. Given the ocular optic nerve
appeared to be normal and her intraocular pressure is normal, I suspect that the
visual field defects are more likely due to her latest activity.
As a result, I have asked the patient to return and have the Humphrey visual
field of her right eye redone with her lids picked up to remove the lid artifact
effect.
3. Mild cataracts in both eyes.
4. Epiretinal membrane in her right eye with foveal thinning which has been seen
and evaluated by Dr. Gaynon in June 2005. Her central macular thickness does
appear to be increased compared to her central macular thickness in June of 2005.
I will discuss this with the patient. At this point we may consider empiric
treatment with nonsteroidal antiinflammatory drops. Given the fact that she is
monocular, would be cautious in recommending further surgical treatment such as
epiretinal membrane peel.
5. Proceed with vitreous attachment in both eyes without evidence of retinal
detachment.
6. Dry eye syndrome in both eyes. Recommend using artificial tears p.r.n.
I look forward to seeing the patient back with her repeat Humphrey visual fields
with her lids picked up to reevaluate for any evidence of visual field defects.
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