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Visual loss
Dr Amani Badawi
ASSISTANT PROFESSOR
OPHTHALMOLOGY
Amani Badawi
5/3/2017
Acute Visual Loss
Acute visual loss
History
• Age
• POH & PMH
• Onset
• Duration
• Severity of visual loss compared
to baseline
• Monocular vs. binocular ?
• Any associated symptoms
Examination
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Visual acuity assessment
Visual fields
Pupillary reactions
Penlight or slit lamp examination
Intraocular pressure
Ophthalomoscopy
- red reflex
- assessment of clarity of
media
- direct inspection of the fundus
1-Central Retinal Artery Occlusion
(CRAO)
• True ophthalmic emergency!
• Sudden painless and often severe visual
loss
• Permanent damage to the ganglion
cells caused by prolonged interruption
of retinal arterial blood flow
• Characteristic “ cherry-red spot ”
• Months later, pale disc (optic atrophy)
due to death of ganglion cells and their
axons
1-Central Retinal Artery Occlusion (CRAO)
treatment
• As before +
• Ocular massage:
-To dislodge a small embolus in CRA and restore circulation
-Pressing firmly for 10 seconds and then releasing for 10 seconds
over a period of ~ 5 minutes
• Ocular hypotensives, vasodilators, paracentesis of anterior
chamber
•
2-Branch Retinal Artery Occlusion (BRAO)
• Sector of the retina is opacified and
vision is partially lost
• Most often due to
embolus
• Treat as CRAO
3-Central Retinal Vein Occlusion
(CRVO)
• Acute loss of vision
• Disc swelling, venous
engorgement, cotton-wool spots
and diffuse retinal hemorrhage.
• Needs medical evaluation
• Long term complication:
neovascular glaucoma, and
macular edema so periodic
ophthalmic follow up
4-Optic Nerve Disease
• Non-Arteritic Ischemic Optic
Neuropathy (NAION)
- vascular disorder
 pale, swollen disc +/- splinter
hemorrhage
 loss of VA , VF ( often
altitudinal )
- Treatment : systemic steroids
4-Optic Nerve Disease
• Optic neuritis
- idiopathic or associated with multiple sclerosis
- young adults
- Unilateral decreased visual acuity and colour
vision
-RAPD
-pain with ocular movement
-bulbar (disc swelling) or retrobulbar (normal
disc)
5-Retinal Detachment
• Retinal detachment
- flashes, floaters, shade over
vision
- elevated retina +/- folds
• Macular disease
- decrease central vision
- metamorphopsia
Separation of sensory retina from RPE by subretinal fluid (SRF)
Rhegmatogenous - caused by a Non-rhegmatogenous retinal break
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tractional or exudative
6-Trauma
Trauma
Hyphema
Ruptured globe
• Open globe should be suspected
in any patient who has a history of
trauma to the eye, especially with a
laceration or puncture wound that
extends through the eyelid,
followed by pain and decreased
visual acuity &hyptony.
Anterior segment complications of blunt
trauma
Hyphaema
Sphincter tear
Cataract
Lens subluxation
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Iridodialysis
Angle recession
Vossius ring
Rupture of globe
Posterior segment complications of blunt trauma
Commotio retinae
RD
Choroidal rupture and
haemorrhage
Avulsion of vitreous base
and retinal dialysis
Macular hole
Optic neuropathy
Complications of penetrating trauma
Flat anterior chamber
Uveal prolapse
Damage to lens and iris
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Vitreous haemorrhage Tractional retinal detachment
Endophthalmitis
7-Media Opacities
• Corneal edema:
- ground glass appearance
- as in acute congestive glaucoma
• Corneal abrasion &ulcer
• Vitreous hemorrhage
- traumatic
- retinal neovascularization
8-Endophthalmitis
Background: Bacterial endophthalmitis is an inflammatory
reaction of the intraocular fluids or tissues caused by
microbial organisms.
History
Classification is based on routes of entry.
•Exogenous
•Endogenous
Physical
General findings
•Visual acuity decreased below the level expected
•Lid edema
•Conjunctival hyperemia
•Corneal edema
•Anterior chamber cells and flare &Hypopyon
•Vitritis
•Loss of red reflex
•Retinal periphlebitis if view of fundus possible
9-Visual Pathway Disorders
Hemianopia
- Causes: vascular or tumors
-Types
Cortical Blindness
- Extensive bilateral damage to cerebral
pathways
- Normal pupillary reactions and fundi
Chronic Visual Loss
Case 1
• A 75 year old woman is seen for an annual
physical examination and complains of mild
difficulty in reading and seeing street
signs
• Vision is especially worse at night
• PHx: HTN, T2DM diet controlled
• O/E: VA R 6/18 and L 6/12
Case 1
• What is the likely diagnosis?
1-Cataract
• Symptoms gradual over years
• 1. Reduction in visual acuity
• Worsening of existing myopia
• Correction of hyperopia “second sight of the
aged”
• 2. Loss of contrast sensitivity in low light
• 3. Glare in bright light :Forward scatter of
light
Case 2
• A 76 year old man has noted visual distortion
over the
past week
• Straight lines viewed through his right eye dipped down
in the centre
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Round plates seem to have “edges”
O/E: VA R 6/18 and L 6/6
What is the likely diagnosis?
What test are you going to do?
Case 2
Case 2
Case 2
2-Macular degeneration
• Loss of central vision
• Reading, recognizing faces impaired
• Leading cause of legal blindness in developed
world
• Multifactorial
• Age
• Smoking, vascular disease, UV light, diet, FHx, …
• Atrophic (dry) or exudative (wet)
Geographic atrophy –
dry AMD
Choroidal neovascularisation – wet AMD
Macular scarring – wet AMD
Management – dry AMD
• Lifestyle
• Stop smoking, reduce UV exposure, Zinc &
antioxidants
• Low vision aids
• Legal blindness and driving
• Monitoring with Amsler chart
Management – wet AMD =CNV
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Observation
Laser photocoagulation
Photodynamic therapy (PDT)
Intra-vitreal injection of Anti-VEGF
Anti-VEGF therapies
• VEGF-A stimulates angiogenesis and vascular
permeability
• Intravitreal injection of monoclonal antibodies
• Ranibizumab (Lucentis)
• Off-label Bevacizumab (Avastin)
Case 3
• A 68 year old man was referred from his
optometrist for visual field testing
• He has not reported any problems with
vision, but the test report shows a reduction
in peripheral vision in the Right eye
Case 3
• What is your
likely diagnosis?
• What further
examination are
you going to
do?
Case 3
LE
RE
3-Glaucoma
• 1. Optic nerve damage (optic disc cupping)
• Increased Cup:disc ratio
• Loss of neuroretinal rim
• 2. Increased IOP
• 3. Peripheral visual defects
The trick of IOP
• Only 10% with IOP>21 have glaucoma
• The rest have ocular hypertension
• Only 50% of glaucoma patients have
IOP>21
• The rest have normal tension glaucoma
Glaucoma
• Types
• Primary
• Open angle (90%)
• Closed angle
• Secondary
• Congenital
Primary open angle glaucoma
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“The silent thief of sight”
Asymptomatic
Usually detected on routine examination
Risk factors: IOP, age, FHx, DM, myopia
Impaired drainage of aqueous humor through
trabecular meshwork
• Due to age-related morphological changes
Primary open angle glaucoma
Management
• Aim to stop progress
• Medical – reduction of aqueous secretion
• Beta-blockers (Timolol)
• Alpha-agonists (Brimonidine)
• Prostaglandin analogues (Latanoprost)
• Parasympathomimetics (Pilocarpine)
• Carbonic anhydrase inhibitors (Brinzolamide)
Management
• Surgical
• Argon and selective laser trabeculoplasty
• Filtering surgery
• Trabeculectomy
• Laser peripheral iridotomy : Yag laser
Case 4
• A 13 year old girl is seen for physical examination at
school. She admits to difficulty in reading the
blackboard, but not in reading textbooks. She does
not wear glasses.
• O/E: VA R 6/36 ph 6/6 and L 6/36 ph 6/6
• What is your diagnosis?
4-Refractive error
• Corrects with pinhole
• Management: glasses, contact lenses, refractive
surgery
Case 5 – spot diagnosis
5-Retinitis pigmentosa
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Genetically inherited
Progressive retinal dystrophy
Night blindness, tunnel vision, legal blindness
Bony spicules from mottling of RPE
Incurable
Future: gene therapy, bionic eye, …?
6 – diabetic retinopathy
• Microvascular retinal changes
• Blindness is progressive, but preventable
• Annual retinal examination
• Tight T2DM control HbA1c 6-7%
• laser treatment
• Pre-proliferative retinopathy
• Proliferative retinopathy
• Also predisposes to cataract & glaucoma
Diabetic retinopathy
Diabetic retinopathy
Diabetic retinopathy
Diabetic retinopathy
Diabetic retinopathy
Diabetic retinopathy
Diabetic retinopathy
Diabetic retinopathy
Diabetic retinopathy
Summary
Causes of chronic visual loss
• Cataract
• Glaucoma
• Age-related macular degeneration
• Refractive error
• Retinitis pigmentosa
• Diabetic retinopathy
Thank you