Young, Patricia Marie G.

CASE 1

1. What is your probable diagnosis and the likely cause?

Muscae volitantes or “Floaters”. With time, the vitreous gel liquefies and eventually pulls
away or separates from the back of the eye where it is attached to the retina. This process is
called Posterior Vitreous Detachment (PVD) and is a normal event occurring in most people
somewhere between the ages of 40-70 years.

Any opacity in the vitreous, which comes in the line of vision is perceived as Floaters. Even
normal vitreous may contain some opacities which are perceived as floaters. During PVD, the
debris generated in the vitreous may lead to sudden increase in floaters. Also sometimes,
during the separation a blood vessel of the retina may rupture with or without retinal tear and
can cause vitreous hemorrhage (bleeding in the vitreous) which is perceived as shower of
floaters. Large hemorrhages can cause large dark blobs in the visual field or an overall
decrease in vision.

2. What additional examination would you do to verify your diagnosis?

Floaters are often readily observed by an ophthalmologist or an optometrist with the use of an
ophthalmoscope or slit lamp. However, if the floater is near the retina, it may not be visible to
the observer even if it appears large to the sufferer.

Increasing background illumination or using a pinhole to effectively decrease pupil diameter

may allow a person to obtain a better view of his or her own floaters. The head may be tilted
in such a way that one of the floaters drifts towards the central axis of the eye. In the
sharpened image the fibrous elements are more conspicuous.

3. What is your plan of management?

Most commonly, there is no treatment recommended.
• Vitrectomy may be successful in treating more severe cases; however, the procedure
is typically not warranted in those with lesser symptoms due to the potential for
complications to include cataracts, retinal detachment, and severe infection. The
technique usually involves making three openings through the sclera known as the
pars plana. Of these small gauge instruments, one is an infusion port to resupply a
saline solution and maintain the pressure of the eye, the second is a fiber optic light
source, and the third is a vitrector. The vitrector has a reciprocating cutting tip
attached to a suction device. This design reduces traction on the retina via the
vitreous material. A variant sutureless, self-sealing technique is sometimes used.

• Laser vitreolysis: In this procedure an ophthalmic laser (usually an Yttrium

aluminium garnet "YAG" laser) is focused onto the floater and in a series of brief
bursts, the laser vaporizes and lyses (cuts) the collagen strands of the floater. Laser
treatment is not widely practiced and is only performed by very few specialists in the
world. It is an outpatient process, which is much less invasive to the eye than a
vitrectomy, with potentially fewer side effects.

CASE 2

1. What is your diagnosis and proper management?

Central Retinal Artery Occlusion.
Medical Care
• Immediate lowering of intraocular pressure includes acetazolamide 500 mg IV or 500
mg PO once.
• Topical medications are used to lower intraocular pressure.
• Further treatments
o Carbogen therapy (5% CO2, 95% O2): CO2 dilates retinal arterioles, and O2
increases oxygen delivery to ischemic tissues. Perform for 10 minutes every
2 hours for 48 hours.
o Hyperbaric oxygen therapy (HBOT) may be beneficial if begun within 2-12
hours of symptom onset. Institute treatment with other interventions first, as
transport to a chamber may usurp precious time.
Consultations
• Hyperbaric medicine
o Early treatment (<2 h from onset of symptoms) with HBOT may be
associated with increased visual recovery, but HBOT can be considered if the
duration of visual loss is less than 12 hours.
o Inhalation of 100% oxygen at 2 atmospheric absolute provides an arterial pO2
of 1000-1200 mm Hg, resulting in a 3-fold increase in oxygen diffusion
distance through ischemic retinal tissues. Some studies show a 40%
improvement of 2 or more levels of visual acuity.