A 58-Year-Old Man Comes to the Office with Reports of Visual

question 894

Multiple Choice

A 58-year-old man comes to the office with reports of visual disturbances over the past several weeks.  He describes multiple episodes of bluish tinting of his vision and a sensation of "lights becoming too bright," which last a few hours and improve spontaneously.  He has had no headache, eye pain, loss of vision, tunnel vision, focal weakness, or numbness.  The patient has a history of type 2 diabetes mellitus, hypertension, stage 3 chronic kidney disease, and erectile dysfunction.  His medications include lisinopril, amlodipine, furosemide, insulin detemir, and as-needed sildenafil.  He does not use tobacco, alcohol, or recreational drugs.
Blood pressure is 120/70 mm Hg and pulse is 76/min.  The patient's pupils are equal and reactive, and visual acuity and field of vision are normal.  Funduscopy shows few microaneurysms and dot-blot hemorrhages but is otherwise unremarkable.  Neurological examination demonstrates decreased pain sensation over both feet and bilateral absence of ankle reflexes but is otherwise unremarkable.
Which of the following is the most likely cause of this patient's current visual symptoms?

• A)Diabetic retinopathy
• B)Macular degeneration
• C)Medication side effects
• D)Open-angle glaucoma
• E)Transient ischemic attacks