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Probability diagnosis

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Amaurosis fugax

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Migraine

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Retinal detachment

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Acute glaucoma

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‘Wet’ macular degeneration

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Serious disorders not to be missed

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Cardiovascular:

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  • central retinal artery occlusion

  • central retinal vein occlusion

  • hypertension (complications)

  • CVA

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Neoplasia:

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  • intracranial tumour

  • intraocular tumour:

    • — primary melanoma

    • — retinoblastoma

    • — metastases

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Vitreous haemorrhage

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AIDS

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Temporal arteritis

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Acute glaucoma

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Benign intracranial hypertension

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Pitfalls (often missed)

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Acute glaucoma

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Papilloedema

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Optic neuritis

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Uveitis

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Intraocular foreign body

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Masquerades checklist

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Diabetes (diabetic retinopathy)

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Drugs (e.g. quinine, alcohol)

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Thyroid disorder (hyperthyroidism)

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Is the patient trying to tell me something?

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Consider ‘hysterical’ blindness, although it is uncommon.

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Key history

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Past medical history including risk factors for cardiovascular disease and neurology such as migraine and cerebrovascular disease. Family history and drug history.

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Key examination

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  • Visual acuity: Snellen chart

  • Ophthalmoscopic examination, tonometry

  • Cardiovascular including carotid arteries

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Key investigations

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The vast majority of patients should be referred urgently to an ophthalmological service or stroke unit. Initial tests are:

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  • FBE

  • ESR/CRP

  • blood sugar.

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Diagnostic tips

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  • The visual disturbance may be the presenting symptoms of a general medical disorder such as temporal (giant cell) arteritis, hypertension or diabetes.

  • A cherry-red spot on the macula is pathognomonic of retinal artery occlusion.

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