Vision Changes

A patient presents with a chief complaint of a gradual onset vision change, present for the past 6 months, while denying eye pain, redness or trauma. The funduscopic exam, extraocular movements and pupillary reactions are within normal limits. When considering a diagnosis of presbyopia, which of the following best describes patient presentation? 

A. A 50-year-old who states, "I need to hold what I'm reading really far away in order to see it clearly". 

B. A 75-year-old who states,"When I look at a bright light, I see a colored halo around it".

C. An 80-year-old who states, "I have a blurry spot in the middle of my eyesight". 

D. A 17-year-old who states, "I went to get my driver’s license, but failed the distance vision exam".

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A patient presents with a chief complaint of gradual-onset vision change present for the past 6 months, while denying eye pain, redness, or trauma. The fundoscopic exam, extraocular movements, and pupillary reactions are within normal limits. When considering the diagnosis of presbyopia, which of the following best describes the patient presentation?  

A: A 50-year-old who states, "I need to hold what I'm reading really far away in order to see it clearly.” 

B: A 75-year-old who states, "When I look at a bright light, I see a colored halo around it." 

C: An 80-year-old who states, "I have a blurry spot in the middle of my eyesight." 

D: A 17-year-old who stated, "I went to get my driver's license, but I failed the distance vision exam.” 

The correct answer here is A: The 50-year-old who states, “I need to hold what I'm reading really far away in order to see it clearly.” Where should you start? First, determine what kind of a question this is. Given that the word diagnosis is held within the question, this is clearly a diagnosis question. 

First, let's take a look at some background information. You'll notice in three of the scenarios the person is 50 or more years old. Process of aging is associated with changes in all of the senses, including the patient with vision changes. Some are related to an underlying treatable condition, or with a disease where early detection and treatment can help avoid particularly permanent vision changes. 

As I've mentioned in previous Q&A podcasts, a key point in the differential diagnosis process is knowing who is at greatest risk for a given condition. That's going to help you narrow the potential differentials. Also, from an exam design viewpoint, an option with a 17-year-old really stands out when you have because all of the other patients are 50 years and older. 

You have an outlier on the test question like that, particularly in a very well-designed exam such as DNP boards. You can usually count on that not being the correct answer, but rather a powerful distractor kind of drawing the test taker in. You'll notice that you're provided with some, but certainly not all, the components of an eye exam. 

Please note what is missing. Evaluation of visual acuity, intraocular pressure, and visual field are not reported. And, you know, checking visual acuity. Remember, that's the basis of the vital signs of the eye. And these key physical exam components need are needed to arrive at the correct diagnosis. At the same time, you probably have heard this 80 to 90% of all diagnoses can be arrived at correctly by simply listening to the patient’s chief complaint or health history. 

With that is background information, let's take a look at the question. A patient presents with the chief complaint of gradual-onset vision change present for the past 6 months while denying eye pain, redness, or trauma. The fundoscopic exam, extraocular movements, and pupillary reactions are within normal limits. When considering the diagnosis of presbyopia, which of the following best describes the patient presentation? 

A 50 year old who states, “I need to hold what I'm really reading, really far away in order to see it clearly.” This is the correct answer. Presbyopia is one of the most common vision issues noted in people in their 40s and beyond, and is related to aging of the eye. Yes, even in their 40s. Age related changes are seen in many parts of the body, and with presbyopia, it's caused by stiffening of the ocular lenses, which is a normative age-related change. 

The result is inability to focus vision on closely held objects. So, a lot of times what the patient will say, if my arms were just a little bit longer, I could read this book just fine. The only abnormality in the ocular exam noted with presbyopia is the result of visual acuity. Presbyopia is usually easily treated with the use of eyeglasses or contact lenses, and it's also not associated with any other comorbidity. 

B: A 75-year-old who states, “When I look at a bright light, I can see a colored halo around it.” This clinical presentation reports one of the many vision changes commonly reported in a person with senile cataracts, sometimes just called cataracts. But those are the cataracts that are related to aging with senile cataracts, a progressive condition. There is dimming of the vision as well as new-onset distance vision problems. 

Close vision is usually retained at baseline with cataracts. In addition, the ocular exam will likely reveal lens clouding. Finding not noted in the limited physical exams reported here. Can people have cataracts when they're in their 50s? Certainly. But generally they're really faint and not very mature, and they're not causing any visual problems in a person who is in their early 50s, as our patient is. 

C: An 80-year-old who states, "I have a blurry spot in the middle of my eyesight.” Truth be told, that's a terrifying report from an older adult, because this is the visual complaint most often noted in a person with macular degeneration. This is the most common cause of new-onset blindness in older adults. 

While risk factors for macular degeneration include tobacco use, obesity, and cardiovascular disease; likely the most potent risk factor for the development of macular degeneration is simply aging. The result of the Amsler grid test would be abnormal, and treatment is available to minimize disease progression. Option D: A 17-year-old who states, “I went to get my driver's license, but I failed the distance vision exam.” 

As I mentioned, this response is a big time outlier age-wise. Everybody else is 50 and older. This is a teenager. We're given one important piece of information here. Failing the distance vision at the DMV, this teen has a condition known as myopia, caused by an alteration in corneal or eyeball shape. Vision correction versus eyeglasses or contact lens is usually the rule. 

And, again, myopia not particularly associated with other comorbidity. Key takeaway: alterations in vision are among the one of the most common patient complaints seen in primary care. And remember, you're being tested as a primary care provider. Well, a referral for further evaluation with an eye care specialist is usually the next step, we need to be able to sort out the differential diagnosis. 

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