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SUDDEN VISUAL LOSS

Dr.Mohd. Mustafizur Rahman


Pakar Mata
Ophthalmology department
Queen Elizabeth Hospital

Objectives
Have a clear DDx for causes of acute
vision loss

Have a clear understanding of

immediate management steps to be


taken by the primary care provider

Acute loss of vision


Loss of vision
painful

Painless
Fleeting

Prolonged

Prolonged

ACG

embolic

ION

Optic Neuritis

migrain

CRAO

GCA

Raised ICP

CRVO

Orbital cellulitis

VIT.HGE

Endopthal

Ret. Detach

Common causes of sudden


visual loss:
Transient (< 24 hrs)
Few seconds (usually bilateral):
Papilloedema
Few minutes: Amaurosis fugax (TIA)
(unilateral), vertebrobasilar artery
insufficiency (bilateral)10-60 minutes:
Migraine (with or without headache)

Visual loss (> 24 hrs)


Painless:
Retinal artery or vein occlusion,
Retinal detachment,
Ischaemic optic neuropathy
Giant cell arteritis,
Vitreous haemorrhage,

Painful: Acute angle-closure glaucoma,


optic neuritis

History
Transient visual loss (suggestive of amaurosis fugax)
sudden onset floaters and flashing light (Retinal

detachment)
History of poorly controlled diabetes mellitus and laser
treatment to the retina (vitreous haemorrhage)
Headache +/- jaw claudication (pain in the jaw on
eating) in the elderly (giant cell arteritis)
Pain on eye movement in young patients (optic neuritis)

Examination
Visual acuity
Visual field by confrontation
pupil reaction for afferent pupillary
defect
Retinal examination.

Retinal Artery Occlusion: Hx


Central (CRAO) or branched (BRAO)
May have macular sparing (cilioretinal
artery)

Sudden, painless, unilateral

Loss: central vision + one/more fields


CRAO
Loss: one (horiz) field loss BRAO
Transient loss, esp curtain descending
amaurosis fugax = impending RAO

Retinal artery occlusion


Causes
Arteriosclerotic changes,
Embolus (from heart or carotid artery)
Inflammation (rare) periarteritis, SLE
Haematological disorders Protein c, s
deficiency, anti- thrombin 3 deficiency and
antiphospholipid antibody syndrome

Retinal Artery Occlusion: Signs


Marcus-Gunn pupil (relative afferent

pupillary defect)
Retinal edema (after 1st few hrs)
The retinal arteries are narrow or collapsed
Embolus may be seen at O.N. (CRAO)
or branch point (BRAO)
Cherry red spot = ischemia & edema
of posterior retina
w/in several hrs of occlusion

CRAO

BRAO

Retinal Artery Occlusion:


Etiology
Carotid disease
Valvular disease
Giant Cell arteritis
Jaw claudication, scalp tenderness, tongue
pain, PMR, H/A

Thrombosis: hypercoagulable states


Pregnancy, OCPs, lupus anticoag, factor V
Leiden, antithrombin III, ptn C/S deficiency

Retinal Artery Occlusion:


Etiology
IV drug use (talc retinopathy)
Lipid emboli from trauma
DIC
Sickle cell
Polyarteritis nodosa
Retinal migraine

Retinal Artery Occlusion: W/U


Heart, Carotid exam
TA tenderness
Neuro exam
Va, visual fields, pupil and retinal
exam
Carotid u/s
ECHO

Retinal Artery Occlusion: W/U


Labs:
ESR/CRP
CBC w/ diff
Coags
Consider hypercoag w/u

Retinal Artery Occlusion: Mgmt


EMERGENCY OPTHO REFERRAL!!
Dislodge embolus to move embolus

downstream (decr IOP, dilate vessels)


Ocular massage: firm digital pr on globe x 10-15 sec,
followed by rapid release of pr (may repeat 2-3x)
Diamox 500mg IV or PO
Topical beta blocker (timolol 0.5%)
NTG sl

Antiocoagulation once w/u confirms embolism


Hyperbaric O2 within 24hr

Retinal Vein Occlusion


Central (CRVO) or branched (BRVO)
CRVO: involves all 4 retinal quadrants
BRVO: involves one quadrant in arcuate
pattern

Fairly common in elderly


As with RAOs, may only be noticed with

unaffected eye closed


Impedes flow of blood from retinal
circulation

Retinal Vein Occlusion: Sx


Sudden or gradual, painless blurry Va
or vision loss
Unilateral (horiz) visual field loss
(BRVO)
Rare: unilateral pain and redness w/
loss of vision (neovascular
glaucoma assoc w/ RVO)

Retinal Vein Occlusion: Signs


Marcus-Gunn pupil
blood and thunder fundus
Dilated & tortuous veins
Flame-shaped hemorrhage
Cotton-wool spots
Macular edema
Exudates

CRVO: blood & thunder

CRVO: cotton wool spots

BRVO

Retinal Vein Occlusion: W/U

Va, visual fields, pupil and retinal exam


Systemic htn
HCG? OCPs?
h/o other thromboembolic events, fam hx
Labs
Hypercoagulable w/u as in RAO
tsh to check for thyroid eye disease
compression of CRV

Retinal Vein Occlusion: Mgmt


Optho eval w/in 48-72 hrs
Laser photocoagulation to reduce
macular edema and neovascular
complications

Retinal Detachment
Fluid separates retina from underlying

retinal pigment epithelium


Causes:

Posterior vitreous detachment retinal tear


liquefied vitreous dissects between retina
and pigment epithelium
Serous fluid under retina
Traction from scar tissue in vitreous (diabetic
retinopathy repeated vitreous hem)

Retinal Detachment: Sx
Flashing lights
Floaters
Visual field loss: curtain, shadow or
bubble
Metamorphopsia
Decreased Va
Painless

Metamorphopsia

Retinal Detachment: Signs


Marcus-Gunn
Unilateral visual field loss
Sectoral, quadrant, hemifield, total

Retinal exam w/ direct

ophthalmoscope may be unrevealing

Retinal Detachment

Retinal Detachment

Retinal Detachment:
W/U & Mgmt
Immediate Ophtho referral!!
Surgical intervention
If acute or progressive should be
referred to Ophthalmology <24h, if
chronic may be seen with 2-4 weeks

Vitreous Hemorrhage
Due to underlying vascular process
Painless, pt may complain of red

shower or spots
May be slower in onset vs RAO, RVO
or retinal detachment
Visualization of retina often
impossible
Ophthalmic u/s done by eye docs

Vitreous Hemorrhage: Etiology


Proliferative diabetic retinopathy
Posterior vitreous detachment w/ an
avulsed vessel
Retinal tear through vessel
Trauma
Retinal vascular lesion
Management: ophtho referral & tx
underlying process

Vitreous Hemorrhage

Angle Closure Glaucoma


Outflow of aqueous humor from

shallow anterior chamber is occluded


when pupil dilates
F:M = 3-4:1, high incidence in asians
Peak age: 55-70
Shorter, smaller far-sighted eyes

Normal Angle

Narrow or Closed Angle

Angle Closure Glaucoma


Precipitating factors:
Enter darkened room
Stress
Dilating drugs
Systemic rx
Anticholinergics
sympathomimetics

Angle Closure Glaucoma: Sx


Intense pain & photophobia
Blurred vision, usually unilateral
Halos around lights
Vasovagal sx (diaphoresis, n/v)

Angle Closure Glaucoma: Signs


Mid-dilated pupil
Conjunctival injection w/ lid edema
Corneal edema
Blurring of corneal light reflex

IOP markedly elevated (60-80 mm


Hg)

Angle Closure Glaucoma: Mgmt


OPHTHO EMERGENCY!!!!
Rx to lower IOP
Topical beta-blocker (timolol 0.5% 1 drop)
CA inhibitors (Diamox 500mg IV, or 250 mg PO
x2)
Osmotic agents (mannitol 1-2g/kg IV over
45min)

Laser iridectomy

Corneal Ulcer
Risk factors:
Recent trauma or contact lens wear
(may develop from corneal abrasion)
Poor lid apposition
Incr risk Gm neg bacteria (esp Pmonas)
w/ soft contact lens wear
Fungal: h/o trauma w/ vegetable matter
or chronic topical steroid use

Corneal Ulcer: Sx
Pain
Redness
Decreased Va
photophobia

Corneal Ulcer: Signs


Dense corneal infiltrate w/ overlying
epithelial defect
Hypopyon
Corneal destruction and ocular
perforation
Ulcer w/ feathery border: fungal

Corneal ulcer w/ hypopion

Corneal Ulcer: Tx
Immediate Ophtho referral
Corneal scraping for Grams stain &

Cx
Abx: gent, cefazolin
Contact lens removal
Pt will require daily f/u until healed

Uveitis
May be subacute in onset
Pain, photophobia, decreased vision
Exam:
Small, sluggish pupil
Circumlimbal flush
Cell & flare in ant chamber on SLEx

Ophtho eval before ocular steroids

Uveitis

Uveitis

Uveitis

Uveitis

Uveitis
Etiol: most idiopathic; many systemic
causes
W/U: careful H&P, looking for
systemic disease

for unilateral, first-episode disease,


unremarkable hx and exam, no w/u
needed
for bilateral, recurrent disease, systemic
w/u indicated

Uveitis
Tx:
ophtho referral w/in 24h
cycloplegia (topical homatropine 5%
bid)
topical steroid (Pred-Forte 1%) initiated

by an ophthalmologist

Optic Neuritis
15-45 y.o.
Usually subacute (several days)
Pain w/ eye movement (+/-)
May have h/o transient neurological
disturbances
Assoc w/ MS

Optic Neuritis
Signs
Optic Disc edema (unusual)
Visual field cuts, esp. central
Maracus-Gunn pupil (very common)

Optic Neuritis (pappiledema)

Optic Neuritis: Mgmt


Ophtho referral
eval for other ocular dz
formal visual field testing

MR of brain & orbits confirmatory


and to look for early M.S.

Optic Neuritis
MR: look for white matter plaques
IV steroids if +
Decreases further MS-related events
Hastens visual recovery
No change in final Va outcome
If neg, IV steroids of no proven benefit
Consider in single-eye patients
Never use PO steroids
Increased recurrence of O.N.

Exudative Macular Degeneration


#1 Cause of blindness >65 y/o
Worsen gradually or suddenly
Metamorphopsia common
Photopsia +/ Central scotoma +/ More commonly: subacute-

chronically progressive vision loss

Exudative Macular Degeneration:


Central Scotoma

Exudative Macular Degeneration


Signs
Decreased Va
Drusen: yellowish deposits deep to
retina
Limit nutritional/metabolic support to outer
retina

Exudative Macular Degeneration:


Drusen

Exudative Macular Degeneration


Management
Optho referral
Amsler grid
Fluoresscein angiography
Tx: laser photocoagulation (selected cases)

Miscellaneous
CVA
Functional