Grand Rounds Conference
Juan P. Fernandez de Castro, MD
University of Louisville
Department of Ophthalmology and Visual Sciences
June 05, 2015
Subjective
CC: Refraction re-check
HPI: 76 yo M presents to clinic because of poor
vision even with his new glasses; refracted six
weeks ago.
Previous visit he complained of right sided
intermittent headache with associated flashes.
No changes in vision.
History

Past Medical History
DM, newly diagnosed. HbA1C 5.9
 Hyperlipidemia



Meds: Oral DM meds, statin
NKDA
History

Past Ocular History
Cataracts OU, not visually significant
 Glaucoma suspect

C/D: 0.65 / 0.4
 Tmax: 20mmHg / 20mmHg
 Central Corneal Thickness: 578 / 550μ
 Neg Family Hx


Migraine with ocular aura
Objective


VAcc
M Rx
OD
20/20
OS
20/20-2
+1.00+0.75x008
+1.50+0.75x165
20/20
20/20
+1.25+0.75x007
+1.25+0.75x169
Objective

Pupils
OD
5→2mm
OS
5→2mm
NO rAPD


IOP
EOM
15mmHg
Full
16mmHg
Full
Objective







External/Lids
Conj/Sclera
Cornea
Ant Chamber
Iris
Lens
Vitreous
WNL OU
White OU
Clear OU
Deep and Quiet OU
WNL
+1 NS OU
Clear
Objective

DFE

OD: C/D 0.65 Sharp, No pallor
Macula WNL
Vessels WNL
Periphery WNL

OS: C/D 0.4 Sharp, No pallor
Macula WNL
Vessels WNL
Periphery WNL
Upon further questioning…

“While driving I have missed a bridge in my
property twice in the past month. It has never
happened in 30 years”

CVF
OS
OD
Neurologic Exam





Mental status: Alert and oriented x3
Fluid, appropriate speech
No cranial nerve deficit
No limb weakness or numbness
No gait abnormalities
Humphrey Visual Fields 24-2
OS
OD
Assessment


76 year old white male who presents with a
bilateral homonymous visual field deficit.
Differential Diagnosis
Occipital lobe ischemic event, unknown timing
 Occipital lobe tumor


Plan: Emergency Department for CNS imaging
and neurology evaluation
CT Head
CT Head



Hemorrhagic mass surrounded with large edema
or acute ischemic injury with a foci of
parenchymal heme located mainly in the right
temporal and parietal lobe.
Recommend MRI
Pt transferred to UofL Hospital for further
evaluation and treatment
MRI Brain

Heterogeneously-enhancing right occipital lobe
mass measures up to 3.1 cm in maximal
diameter, with extensive peritumoral infiltration
into the subcortical and periventricular white
matter of the right occipital, parietal, temporal,
and to a lesser extent, frontal lobes.
Brain tumor resection

Pre-op
Post-op
Pathology

Right Occipital Dural Base Tumor Biopsy:
Metastatic carcinoma, consistent with renal
cell carcinoma
Postoperative CT Head

Postoperative changes from posterior occipital
craniotomy are noted with resection of the
previously noted enhancing right cuneus mass
with no residual enhancement noted to suggest
residual enhancing tumor, consistent with
gross total resection.
CT Abdomen

Large heterogeneously enhancing lesion arising
from the upper pole of the right kidney,
consistent with renal cell carcinoma.
BONE SCINTIGRAPHY

No convincing
scintigraphic evidence of
underlying osseous
metastatic disease
Injection site
Bladder
Nephrectomy

1 month later, patient undergoes
Right laparoscopic radical nephrectomy


4.3 x 4.7 x 5.3 cm mass
No complications
Current Treatment

Brain: Stereotactic Radiotherapy x1 completed

Kidney: adjuvant chemotherapy (Pazonib)
Follow up with ophthalmology

Follow up 2 months

VA 20/20 OU

Vision is subjectively better
HVF 24-2 Improvement
7 ways to do Confrontational
Visual Fields







Description of examiner’s face
Finger counting
Finger comparison
Red comparison
Static finger wiggle
Kinetic finger wiggle
Kinetic red target
Description of examiner’s face
Patients to examiner
distance 30 cm
(test 20 degrees)
 Are any parts missing
OR distorted

20cm
Finger counting
20°
60cm


90cm
22cm
Use 1 or 2 fingers
20 °eccentric
Finger comparison

20°20°
22cm
22cm
Are both fingers
equally sharp?
Red comparison

20°20°


22cm
22cm
Use atropine bottle
caps
Aprox 20mm
Are both caps equally
red?
Static finger wiggle


20°20°
22cm
22cm

Wiggle 1 finger
Less than 5°oscillation
Ask which finger is
wiggling
Kinetic finger wiggle

When is the finger
first visible?
Kinetic red target
5mm
5mm
5mm
5mm

When is the red target
first visible?
-6
Best 5 Combinations
Conclusion



Detection of field loss may be the first sign of
sight-threatening or potentially life-threatening
disease.
CVF has limited sensitivity compared with
Goldmann or Humphrey VF
Even the best combination of CVF tests will fail
to detect more than 20% of lesions, so it is
important to use an appropriate technique to
maximize sensitivity.
References




Kerr NM, Chew SS, Eady EK, Gamble GD, Danesh-Meyer HV. Diagnostic
accuracy of confrontation visual field tests. Neurology. 2010 Apr13; 74(15):
1184-90
Elliott DB, North I, Flanagan J. Confrontation visual field tests. Ophthalmic
Physiol Opt 1997;17 suppl 2:S17–S24.
Pandit RJ, Gales K, Griffiths PG. Effectiveness of testing visual fields by
confrontation. Lancet 2001;358:1339 –1340.
Johnson LN, Baloh FG. The accuracy of confrontation visual field test in
comparison with automated perimetry. J Natl Med Assoc 1991;83:895– 898.