Download Sudden Painless Loss of Vision I

Sudden Painless Loss of Vision
Maj
Ahsan Mukhtar
FCPS, FRCS (Ophth)
Classified Eye Specialist
Registrar VR Surgery
AFIO
Objectives
• Know Imp points in History and Exam
• Enumerate common Causes
• Know the clinical appearance of various
diseases
History
• True sudden vision loss OR sudden realisation
of visual loss?
• One eye or both eyes?
• Onset and progression
• Associated visual symptoms
– flashes suggest retinal traction (but can be cortical
e.g. CVA, migraine)
– floaters suggest vitreous debris
History
• Past ocular history
– trauma and myopia are risk factors for retinal
detachment
• Systems review
– in elderly patients, ask about headache and
polmyalgia (temporal arteritis)
– history of diabetes
– cardiovascular disease, TIA symptoms suggest
emboli
Examination
•
•
•
•
•
•
•
•
•
External ocular appearance
Visual acuity
Colour vision assessment
Pupil Examination
Visual field assessment
Fundoscopy
Palpation of temporal arteries
Cardiovascular examination
Neurological examination
RAPD
• Darken the room
• Have the patient fix on
a distant target (e.g.
the top letter on a
Snellen chart)
• Alternate a bright light
rapidly (<1 second)
between the two eyes,
spending 2 seconds on
each eye
CAUSES
• Media opacity (No RAPD)
– corneal edema
– hyphema
– vitreous hemorrhage
• Retinal disease (RAPD)
– retinal detachment
– macular disease (e.g.,
macular degeneration);
– retinal vascular occlusions
• Optic nerve disease (RAPD)
– optic neuritis, retrobulbar
neuritis, and papillitis
– papilledema
– glaucoma
– ischemic optic neuropathy
•
•
•
•
– giant cell arteritis
Hypoxia
– shock
– g-LOC (an aviation related
problem)
– simply standing up suddenly,
especially if sick or otherwise
infirm
Visual pathway disorder
– homonymous hemianopia
– cortical blindness
Trauma
Functional disorder
• Media opacity (No RAPD)
– corneal edema
– hyphema
– vitreous hemorrhage
• Retinal disease (RAPD)
– retinal detachment
– macular disease (e.g.,
macular degeneration);
– retinal vascular occlusions
• Optic nerve disease (RAPD)
– optic neuritis, retrobulbar
neuritis, and papillitis
– papilledema
– glaucoma
– ischemic optic neuropathy
•
•
•
•
– giant cell arteritis
Hypoxia
– shock
– g-LOC (an aviation related
problem)
– simply standing up suddenly,
especially if sick or otherwise
infirm
Visual pathway disorder
– homonymous hemianopia
– cortical blindness
Trauma
Functional disorder
• Media opacity (No RAPD)
– corneal edema
– hyphema
– vitreous hemorrhage
• Retinal disease (RAPD)
– retinal detachment
– macular disease (e.g.,
macular degeneration);
– retinal vascular occlusions
• Optic nerve disease (RAPD)
– optic neuritis, retrobulbar
neuritis, and papillitis
– papilledema
– glaucoma
– ischemic optic neuropathy
•
•
•
•
– giant cell arteritis
Hypoxia
– shock
– g-LOC (an aviation related
problem)
– simply standing up suddenly,
especially if sick or otherwise
infirm
Visual pathway disorder
– homonymous hemianopia
– cortical blindness
Trauma
Functional disorder
• Media opacity (No RAPD)
– corneal edema
– hyphema
– vitreous hemorrhage
• Retinal disease (RAPD)
– retinal detachment
– macular disease (e.g.,
macular degeneration);
– retinal vascular occlusions
• Optic nerve disease (RAPD)
– optic neuritis, retrobulbar
neuritis, and papillitis
– papilledema
– glaucoma
– ischemic optic neuropathy
•
•
•
•
– giant cell arteritis
Hypoxia
– shock
– g-LOC (an aviation related
problem)
– simply standing up suddenly,
especially if sick or otherwise
infirm
Visual pathway disorder
– homonymous hemianopia
– cortical blindness
Trauma
Functional disorder
Methyl alcohol metabolized very slowly,
stay longer period
Oxidised in to formic acid & formaldehyde
oedema
Degenaration of ganglion cell of retina
Complete blindness
• Media opacity (No RAPD)
– corneal edema
– hyphema
– vitreous hemorrhage
• Retinal disease (RAPD)
– retinal detachment
– macular disease (e.g.,
macular degeneration);
– retinal vascular occlusions
• Optic nerve disease (RAPD)
– optic neuritis, retrobulbar
neuritis, and papillitis
– papilledema
– glaucoma
– ischemic optic neuropathy
•
•
•
•
– giant cell arteritis
Hypoxia
– shock
– g-LOC (an aviation related
problem)
– simply standing up suddenly,
especially if sick or otherwise
infirm
Visual pathway disorder
– Visual field defects
– homonymous hemianopia
– cortical blindness
Trauma
Functional disorder
• Media opacity (No RAPD)
– corneal edema
– hyphema
– vitreous hemorrhage
• Retinal disease (RAPD)
– retinal detachment
– macular disease (e.g.,
macular degeneration);
– retinal vascular occlusions
• Optic nerve disease (RAPD)
– optic neuritis, retrobulbar
neuritis, and papillitis
– papilledema
– glaucoma
– ischemic optic neuropathy
•
•
•
•
– giant cell arteritis
Hypoxia
– shock
– g-LOC (an aviation related
problem)
– simply standing up suddenly,
especially if sick or otherwise
infirm
Visual pathway disorder
– homonymous hemianopia
– cortical blindness
Trauma
Functional disorder
THANK YOU
Sudden Painless Visual Loss
• Alarming to both the patient and clinician
alike
• Requires careful history and examination to
determine underlying cause
• Visual Obscuration may range from
– a symptom of dry eye
– or it may herald the onset of irreversible visual
loss or stroke
Aims
• Focused history to identify the anatomic site of
the pathology
• Focused examination
• Know the causes
• Understand the importance of Simple
examination techniques such as
–
–
–
–
visual acuity measurement
confrontational visual field testing
pupil assessment
fundoscopy
Retinal Detachment
• Patients may notice an enlarging shadow in
peripheral vision(not just a floater)
• Sudden loss of central vision occurs when the
macula detaches
• Flashes and floaters are common associated
symptoms
• Ocular history of trauma, surgery and myopia.
Retinal Detachment
•
•
•
•
Acuity normal = macula "on"
Acuity poor = macula "off'
RAPD
Visual field defect corresponding to area of
detached retina
• Fundus examination is diagnostic (but may be
difficult to pick with direct ophthalmoscope)
Vitreous Haemorrhage
• Causes
– Proliferative diabetic retinopathy (new vessels
present)
– BRVO with new vessels
– Retinal tears (tear through a retinal vessel)
Vitreous Haemorrhage
• History
– Blurred vision with floaters
– Diabetes(may be undiagnosed)
• Vision: varies with severity of haemorrhage
(6/6 to PL)
• Pupils: NO RAPD (unless retina detached as
well)
• Fundus: reduced red reflex and difficult to see
retinal detail
Central Retinal Artery Occlusion
•
•
•
•
•
•
Sudden total loss of vision
Previous episodes of amaurosis fugax
Cardiovascular disease
Vision may be NPL
Afferent pupil defect
Total field loss
Central Retinal Artery Occlusion
• Cloudy swelling of infarcted posterior retina
• Cherry red spot at fovea (where retina
thinnest)
• Segmentation of blood columm in retinal
veins (slow flow)
• Look for emboli in the retinal arteries
Central retinal vein occlusion (CRVO)
• Patients usually>50 yrs
• Strong association with hypertension and
cardiovascular disease
• Sudden painless bIur of vision
• Vision varies with severity (from 6/6 to hand
movements)
• Afferent pupil defect if severe CRVO (HM
vision)
Central retinal vein occlusion (CRVO)
• extensive retinal haemorrhages in all
quadrants
• retinal venous distension
• optic disc swelling
AION
• Elderly patients (age >65)
• Sudden and severe loss of vision in one eye
initially
• Systemic symptoms are headaches, scalp
tendemess,malaise, jaw claudication
• Vision 6/60 or worse RAPD
• Extensive visual field loss
• Pale swollen optic disc (anterior ischaemic optic
neuropathy), rarely CRAO.
AION
•
•
•
•
•
Aim to prevent loss of the other eye!
Urgent ESR (expect >60)
Prednisolone l00mg stat
Urgent referral
Temporal artery biopsy will confirm the
diagnosis
Optic Neuritis
• Typically affects one eye of young women
• Vision progressively dims over 48 hours (not
truly "sudden")
• Ache around eye at onset (worse with eye
movement)
• Reduced acuity and colour vision
• A relative afferent pupil defect (RAPD) is
present
Optic Neuritis
• Fundus may be normal (retrobulbar neuritis)
• Recovery over 6 weeks, more rapid if IV
methylprednisolone.
• Strong association with MS (MRI Brain will
help predict risk)
Alcohol Amblyopia
Acute onset
Resulting in optic atrophy & permanent blindness
Etiology• Intake of wood alcohol spirit in cheap adulterated
beverages
• Inhalation of fumes in industries
Methyl alcohol metabolized very slowly,
stay longer period
Oxidised in to formic acid & formaldehyde
oedema
Degenaration of ganglion cell of retina
Complete blindness
Methyl alcohol amblyopia
• Mild disc oedema
• Markedly narrowed blood vessels
• Bilateral optic atrophy
Eye
Pain
RAPD
Key findings
CRAO
No
Yes
Pale retina, cherry-red spot
CRVO
No
+/-
Blood and thunder / “Ketchup”
fundus
RD
No
+/-
May have localized field defect,
cloudy veil. But suspect on history
AION
No
Yes
Swollen pale disc, signs of temporal
arteritis
Optic Neuritis
Yes
Yes
Painful EOM, young female pt
Urgency
Can wait till AM? ED Treatment
CRAO
CALL
IMMEDIATELY
Only if subacute
(Many days old)
Orbital massage
Lower the IOP
CRVO
CALL when
convenient
Yes, wait
ASA
RD
CALL
IMMEDIATELY
At their
discretion
Bed rest supine
Eye shield
AION
CALL if TA, severe
sx, uncertain dx,
can wait if not TA
Yes, wait
Steroids if TA
Optic
Neuritis
CALL
Yes, for ophth
AVOID oral
steroids