Download Acute visual loss

Acute visual loss: Emergency
room perspective
Dr.Ehud Zamir
Acute visual loss
Unilateral
RETINAL
ARTERIAL
OCCLUSIONS
AION
VITREORETINAL
Bilateral
OPTIC
NEURITIS
Hemorrhagic
AMD
TOXIC
ISCHEMIC
OR OTHER
CORTICAL
DAMAGE
Acute visual loss: history
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How acute?:
seconds/minutes?
Hours?
Is it really acute?
ACUTE
VISUAL
LOSS
UNILATERAL
RETINAL
ARTERIAL
OCCLUSIONS
AION
VITREORETINAL
BILATERAL
OPTIC
NEURITIS
Hemorrhagic
AMD
TOXIC
ISCHEMIC
OR OTHER
CORTICAL
DAMAGE
History
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Associated symptoms
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Underlying risk factors
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Flashing lights, floaters, shadow/curtain
Jaw claudication, scalp tenderness , temple pain, loss of weight
Diplopia , other neurological symptoms
Peripheral vascular disease, hypertension, diabetes, cholesterol
Known embolic sources
Risk factors for retinal detachment: myopia, family history
Complete ophthalmic, systemic, family and drug history
Acute unilateral visual loss
Retinal vascular occlusions
Central Retinal Artery Occlusion
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Abrupt onset
Usually profound
visual loss
If branch: field defect
Retinal pallor
“Cherry red spot”
Visible emboli
Usually embolic (carotid)
Young pts: consider valve
Old: consider GCA
BRAO
Variable VF defect
Or central visual loss
• Embolic
• Vasculitic
• Other autoimmuune
• Hematological
Examination
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Generally very poor vision
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RAPD
Retinal whitening and pallor
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typically less than counting fingers vision
severe visual field constriction
Compare with the other eye
Carotid bruit / murmurs?
Temporal artery tenderness
Treatment
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No treatment proven consistently to be of value
Theoretically should be given ASAP
Irreversible ischaemic damage probably after 90 minutes
Modalities:
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AC paracenthesis
Ocular massage
Diamox
CO2 enriched oxygen (carbogen)
Hyperbaric oxygen
Selective ophthalmic artery catheterisation, TPA
Always consider GCA: Hx, ESR, CRP
Acute optic neuropathies
Diagnosis:
 Acute visual loss or visual
field loss
 RAPD (must be present)
 Normal examination or
abnormal nerve only
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retina and media usually OK
Acute
optic neuropathy
(schematic approach)
Old:
AION
Sick:
GCA (arteritic)
Young:
Optic neuritis
Well:
Non arteritic
(crowded disk)
Acute
optic neuropathy
Young:
Optic neuritis
Optic neuritis
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20-50 years old, more in females
Preceded/accompanied by pain on eye movements
Dyschromatopsia:
red desaturation test
RAPD
Reduced brightness
VF defect
VA: ANY
Disc: 2/3 are normal (hence retrobulbar ON)
or disc swelling. Haemorrhage is atypical.
Optic neuritis
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Diagnosed clinically
Most commonly due to demyelination
DD: vasculitis, neoplasia, syphilis
MRI of prognostic value re: MS
Treatment with high dose I.V
methylprednisolone has some early benefit
1 gram I.V. per day for 3d, then pred 1mg/kg/day for 11d then 4d taper
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Oral prednisolone (previously standard Rx) associated
with more attacks!
Treatment only hastens recovery; has no influence
over long-term visual outcome
Usually untreated; even after treatment some
deficit often remains
Acute
optic neuropathy
(schematic approach)
Old:
AION
10%
Sick, older (>80):
GCA (arteritic)
90%
Well:
Non arteritic
Non arteritic AION
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Diagnosis of exclusion: must exclude GCA
Painless
Acute onset, usually when waking up
Altitudinal field loss
RAPD
Pallid swelling of disc
(may be sectoral)
Crowded disc (see other eye)
Vascular risk factors
(DM, HTN, hypotension)
No effective therapy
Arteritic AION
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Should always be considered in AION
Constitutional symptoms
Combined ESR and CRP very sensitive and
specific (97% for ESR>47, CRP>2.45)
If suspected: admission for IV steroids
and early temporal artery biopsy.
Contralateral involvement in 50-90% of
untreated patients!
Vitreoretinal
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Vitreous haemorrhage:
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Retinal tear / detachment
Proliferative diabetic retinopathy
Retinal vein occlusion
Retinal macroaneurysms (hypertension)
Posterior vitreous detachment
Vitreous haemorrhage
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The retina has to be evaluated through
dilated fundoscopy
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Ultrasound B-scan if no fundal view
If retinal detachment: urgent surgical
repair may be required (macula on RD)
Otherwise: later treatment or surgery
(vitrectomy) depending on aetiology of
the vitreous haemorrhage
Retinal detachment
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Typically causing visual loss over days
Starts as a dark curtain over part of field
Often preceded by photopsias
Family history, myopia, trauma, intraocular
surgery may be risk factors
Requires surgical repair
The longer the delay in surgery the less chance
the retina will return to function normally
Acute retinal detachment caused by a retinal tear
Macula still attached (on)
RD
“Macula-on” detachment
Chronic, total RD
with proliferative
vitreoretinopathy
Age related macular degeneration
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Most common reason for
blindness in Western world
Wet form: neovascular
membrane bleeds/leaks, thus
affecting macular function
Treatment with intravitreal
anti-VEGF injections
Prognosis guarded
Monitor for distortion (metamorphopsia)
Questions?