Download Acute Visual Loss

Dr Shueh Wen Lim
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70yo woman presents with sudden onset loss
of vision in her right eye half hour ago
No improvement since
No previous ophthalmic history
What are your DDx?
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Retinal vessels
 Central/ branch retinal artery occlusion
 Central/ branch retinal vein occlusion
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Vitreous
 Vitreous haemorrhage (diabetic complications)
 Retinal detachment
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Macula
 ARMD – ‘wet’ ARMD
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Optic nerve
 Anterior ischemic optic neuropathy: arteritic, non-artertic
 Optic neuritis
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Cerebral cortex
 Stroke: homonymous hemianopia
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Transient vision loss – amaurosis fugax
What else would you like to know
about the patient?
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Hx
 Sudden onset while she was gardening
 Painless, no associated redness
 Hx of transient blurring of vision 2 weeks ago but
recovered
 Medhx – IHD, diabetes (on meds)
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Ex
 Visual acuity <6/60 right eye, 6/9 left eye
 RAPD
 Fundus exam
Pale oedematous retina
 Thin attenuated vessels
 Cherry red spot
 Embolus may be seen
 Optic disc not pale or swollen
After 6 weeks:
 Cherry red spot recedes
 Optic disc pallor becomes evident
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Ix
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CDV RFs – lipids, fasting BSL
ESR, CRP (r/o GCA)
Carotid US
Echocardiogram
± Thrombophilia screen
Mx
 Urgent referral to ophthal
 Ocular massage
 Lower IOP (diamox 500mg stat ± ant chamber
paracentesis)
 Long term aspirin?
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Similar hx
 65 yo p/w sudden and painless loss of vision in left
eye
 Hx of DM and HTN
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Similar ex
 6/60 left eye, 6/9 right eye
 RAPD
 Fundus exam
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Intraretinal flame-shaped haemorrhages
(visible in all four quadrants)
Optic disc swelling
Dilated, tortuous veins
Cotton wool spots
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Mx
 Check BP
 Screen for diabetes, hyperlipidemia
 Thrombophilic screen in younger pts
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2 major complications
 Macular edema
 Neovascularisation of iris and retina
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Hx
 70yo lady p/w sudden onset loss of vision in her right eye
 Generalised muscle pain and weakness (but untreated for
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past 8 months)
Been feeling poor for the past 4 weeks with a flu and fever
that she hasn’t been able to shake
Moderate severe headaches during the time
Unable to chew food properly because ‘it hurts’, lost 5kgs
Pmedhx: T2DM, smoker
Visual acuity
 Hand movements in right eye, 6/6 left eye
 RAPD in right eye
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Fundoscopy
 Pale, swollen optic disc
 Some haemorrhages, cotton wool spots
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Mx
 ESR (urgent!), CRP, plt count
 Temporal artery biopsy
 High dose systemic steroids (but always check for
RFs that may C/I or complicate Rx with steroids)
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Hx
 69yo man who p/w painless loss of vision
 Recent hx of increased number of visual floaters
and flashes
 “Dark shadow” in the visual field of left eye
 High myopia since 15yo, T2DM
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Ex
 Loss of red reflex
 RAPD
Separation of sensory retina from the retinal pigment epithelium
Risk factors
 High myopes
 Ocular trauma
 DM
 Previous eye surgery eg cataract removal
 Visual acuity will be affected only if central macula is affected
 Examination
 Abnormal red reflex
 RAPD
 ‘Tobacco dust’
 Detached retina (grey area)
 Urgent opinion from ophthalmologist- surgery?
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Questions?