Visual Loss

Santy Kusumawaty
Anatomy Review
 santy.plw@gmail.com
085298270343
Anatomy Review
 Vision Loss

Categorization
Total or Partial
One or Both eyes
Sudden or Gradual
Painful or Painless
 Globe Rupture
Corneal Edema
Hyphema
Iridodialysis
Lens dislocation
Vitreus haemorrhage
Posterior vitreous detachment
Choroidal detachment
Retinal detachment
Traumatic optic neuropathy
Cavernosus sinus thrombosis
 History

Question Danger Signs

How long ago? Recent
How sudden? Sudden: ischemia or bleed
Course? Worsening
 History
What do they see?
Flashes or floaters
Curtain rising or falling
Central patch or distortion

Key symptoms
Pain or headache
Nausea / Vomiting
 Examination
Visual acuity
Visual field testing
Swinging light test
Direct ophthalmoscopy
Dilating the eye
Tonometry
 Examination
Visual acuity
Snellen chart
20 feet distance
Credit for a line if most letters
correctly identified
If acuity poorer than largest letter
(eg 20/200), measure distance
pt can read it (eg 5/200 at 5 feet)
 Examination
Visual acuity
Practically, if that poor, acuity described by
Finger-counting
Hand-motion
Light perception
 Examination
Visual acuity
To correct refractive error:

1) Use pin hole

2) Use ophthalmoscope
 Examination
Visual field testing
Confrontation
With the patient looking at your nose, ask if
your nose and other facial features are seen
clearly
Inability to clearly see your:
Nose => central scotoma
Eyes or lips => paracentral scotoma
Ears => peripheral visual field defect
 Examination
Swinging light test
Relative Afferent Pupillary Defect (RAPD)

Significant retinal or optic nerve disease,

in one eye more than the other
 Examination
Direct ophthalmoscopy
Red Reflex
Compare brightness and color at 1-2 feet
Indicates media free of opacity
 Anatomy Review
Optic disc
Color: Yellow-orange,
central cup whiter
Size: Cup less than half
diameter of disc
Margin: Sharp (may be
less sharp nasally)

imc.gsm.com/integrated/ bcs/heent/page14.html
 Anatomy Review
Fovea / Macula
Color: Slightly darker,
devoid of retinal vessels
Size: Same as disc
Location: Temporal and
slightly inferior to disc

imc.gsm.com/integrated/ bcs/heent/page14.html
 Anatomy Review
Vessels
Size: 3:2 Vein:Artery
Caliber: look for abnormal
Cilioretinal artery tortuosity
4 main vascular arcades
Superior- & Inferior-
Nasal & Temporal

imc.gsm.com/integrated/ bcs/heent/page14.html
 Examination
Direct ophthalmoscopy
Four quadrant scan
Follow vessels to periphery
(may need to re-focus)
Get pt to look at the light
to see macula
 Examination
Dilating the eye
Especially important for suspected
Intraocular FB
Central retinal artery occlusion
Retinal detachment
Hesitancy amongst non-ophthalmologists
 Examination
Dilating the eye
Tropicamide 1%
Mydriasis and glaucoma: exploding the myth. A systematic review.
Pandit RJ, Taylor R. Diabet Med. 2000 Oct;17(10):693-9
Risk of inducing acute glaucoma following tropicamide alone
close is to zero, no case being identified

Near fatal anticholinergic intoxication after routine fundoscopy.

Brunner GA, et al. Intensive Care Med. 1998 Jul;24(7):730-1.
 Examination
Dilating the eye
Tropicamide 1%
Contraindications:
Acute head injury/coma
Acute or intermittent angle-closure glaucoma
(but NOT chronic open-angle glaucoma)
Probably anyone at high risk for above
(eg. Older asian lady, severely far-sighted person)
 Examination
Dilating the eye
Tropicamide 1%
Onset 10-15 mins, duration 4-6 h
Side effects: blurred vision, light sensitvity
Safety: must not drive for 6 h

The effect of pupil dilation with tropicamide on vision and driving

simulator performance. Potamitis, T., et al. Eye. 2000 Jun;14 (3A):302-6
 Examination
Tonometry
Contraindicated if suspected ruptured globe
Ttono = 10 20 mm Hg (N)
False elevation IOP
Blepharospasm (squeezers)
Avoid pressure on the eye by holding eyelids only
against bony orbital rim
 Case 1
SUDDEN, TOTAL LOSS, ONE EYE
70 yo F with HTN, DM lost vision in one eye over
a few minutes earlier this morning.
No trauma. No eye pain, or N/V
Findings:
(N) External eye and EOM, red reflex
(N) Acuity on left, only hand motion right
RAPD+
(N) Fundoscopy unaffected eye
 Case 1

Retina pale
Cherry Red Spot
fovea
Splinter
hemorrhage

Clinical Eye Atlas

 Case 1

Diagnosis?

Treatment?
a) Massage eyeball
b) Timoptic drops
c) Sticking a needle
in the eye

Clinical Eye Atlas

Central Retinal Artery Occlusion
Sudden painless
monocular loss of
vision
May have history of
previous transient
episodes.
Amaurosis fugax

http://meded.ucsd.edu/isp/1994/im-quiz/images/crao.jpg
Central Retinal Artery Occlusion
Retina infarction =>
pallor, edema, less
transparency
Irreversible damage
begins at 90 mins

http://meded.ucsd.edu/isp/1994/im-quiz/images/crao.jpg
Central Retinal Artery Occlusion
Macula, thinnest
portion, remains
visible
Cherry red spot may
take 24 h to develop
Visual acuity may be
normal if cilioretinal
vessel patent

http://www.umanitoba.ca/faculties/medicine/units/ophthalmology/tutorial_folders.html/images/Cra.jpg
Central Retinal Artery Occlusion
Causes
Embolic (carotid, cardiac)
Thrombosis
Temporal arteritis
Vasculitis (eg. lupus)
Sickle cell disease
Trauma

www.emedicine.com/emerg/ images/521crao1.JPG
Central Retinal Artery Occlusion
Treatment
Attempt moving embolus distally:
Digital massage
Firm steady pressure x 15 seconds, release, repeat
IOP lowering drugs
Beta-blockers/CAI/alpha-agonists
+/- Vasodilation techniques
Rebreathing to increase PaCO2
Central Retinal Artery Occlusion
Treatment
Consult ophthalmology immediately
Paracentesis anterior chamber
?? HBO, thrombolytics
Locate source
ESR for temporal arteritis
ECG for A. fib
Medicine consult (Carotid doppler, ECHO?)
Central Retinal Artery Occlusion
Complications
Vision loss
Prognosis poor in most
But up to 10% retain central vision
(acuity improves to 20/50 or better in 80% of those)
Recurrent thromboemboli
CVA
Further visual loss to same or contralateral eye
Progression of temporal arteritis
 Case 2
PARTIAL LOSS, ONE EYE
A 60 yo M with HTN and DM complains of progressive
loss of vision in one eye over the last 2 days.
No other symptoms
Painless uniform dulling of vision.
Findings:
(N) External eye and EOM
Acuity 20/25 OD, 20/200 OS
RAPD+
(N) Fundoscopy unaffected eye
 Case 2
How would you manage
this at 2 AM?

a) Immediate ophtho consult

b) Thrombolytic therapy
c) Decrease the intraocular pressure
d) Globe massage to dissolve clot
e) None of the above
Clinical Eye Atlas
 Case 2
Unmistakable fundoscopy:
Blood and Thunder or
Ketchup fundus
Dilated tortuous veins
Flame hemorrhages
Disc edema

Clinical Eye Atlas

 Central Retinal Vein Occlusion
Key facts
10 times more common than CRAO
Painless monocular loss of vision over hours
to days
Vision may improve through the day
? CRV impingement by lamina or
atherosclerosis of CRA
Ischemic vs. non-ischemic types
 Central Retinal Vein Occlusion
Risk Factors
Age > 50
Diabetes
HTN
Hyperviscosity syndromes
Glaucoma
Recurrent amaurosis
fugax

http://www.umanitoba.ca/faculties/medicine/units/ophthalmology/tutorial_folders.html/images/CRV_occlusion
 Central Retinal Vein Occlusion
Non-ischemic
Good vision
RAPD absent
Fewer retinal
hemorrhages
Cotton-wool spots
May resolve fully or
progress to ischemic type
 Central Retinal Vein Occlusion
Ischemic
Severe visual loss
RAPD+
Extensive retinal
hemorrhage and cotton-
wool spots
 Central Retinal Vein Occlusion
Treatment
No known effective treatment or prevention
Ophthalmology may consider:
ASA
Anti-coagulation
Fibrinolytics
Corticosteroids
Anti-inflammatories
 Central Retinal Vein Occlusion
Treatment
Medical follow-up to screen for atherosclerosis
and other risk factors
Ophthalmology assessment to follow for late
complications (~ 3 mos)
 Central Retinal Vein Occlusion
Complications
Ocular neovascularization
Anterior => neovascular glaucoma
Posterior => vitreous hemorrhage
Poor vision (20/200 or worse in 90%)
 Case 3
A 50 yo M presents with a 2 day history of
persistent flashing lights and floaters in one eye,
as well as a tiny shadow in one corner
Findings:
(N) External eye and EOM
(N) Acuity 20/20 bilaterally
(N) Visual field testing
RAPD absent
(N) Fundoscopy unaffected eye
 Case 3
At 2 AM would you:
a) Send home with GP follow-up
b) Instill tropicamide and repeat exam
c) Call ophthalmology immediately
d) Keep the patient overnight for ocular U/S
Retinal Detachment
Separation of inner
sensory layers from
underlying RPE
Tear in retina
Traction
Subretinal fluid
Mechanical stimulation
of retinal tissue.
 Retinal Detachment
Risk Factors
Severe myopia (eg. 12 to 15)
Advanced age
Previous cataract surgery
Blunt trauma
Family history
 Retinal Detachment
History
Shower of black spots or floaters
Flashing lights (photopsia)
From a shadow in periphery to dark curtain
Wavy distortion of objects (metamorphopsia)
 Retinal Detachment
Beware!
Visual field defects
Late sign
Patients less aware of superior field defects
Most common defect is inferiorly
(hard to detect because of nose)
Fundoscopy
Dilated eye exam a MUST (maybe not by us)
Detachments start in periphery, difficult to visualize
 Retinal Detachment
Beware!
Location
Superior field defect indicates an inferior retinal
detachment
Detachments of the superior retina are far more
serious
May rapidly extend inferiorly to involve the macula and
thereby cause the loss of central vision.
Retinal Detachment
 Retinal Detachment
Treatment
Consult ophthalmology
immediately any time of
night esp. if mac on
Prevent worsening RD
Bed rest, supine if
superior RD
Protect eye from trauma
(eg. metal eye shield)
 Retinal Detachment
Treatment
Transient floaters not as urgent
Full exam in clinic likely needed
Home with ophtho call and follow-up
WARNING: RT ED if FURTHER flashing lights or
floaters, LASTING more than seconds
 Case 4
SUDDEN, TOTAL LOSS, ONE EYE
60 yo F with a unilateral headache for one week
lost all vision in her right eye over a few minutes.
No trauma, eye pain, or N/V
Findings:
(N) External eye and EOM
(N) Acuity on left, only hand motion right
RAPD+
Visual field testing normal
(N) Fundoscopy unaffected eye
 Case 4
The patient most likely has
a) Papilledema
b) CRAO
c) CRVO
d) Ischemic Optic
Neuropathy (ION)
e) Temporal arteritis
Clinical Eye Atlas
Case 4 vs Case 1

Pale,
swollen
optic disc
Clinical Eye Atlas
 Anterior Ischemic Optic
Neuropathy (AION)
Acute ischemia or
infarction optic nerve
head
Arteritic
Non-arteritic

http://webeye.ophth.uiowa.edu/dept/AION/fig4.htm
 Anterior Ischemic Optic
Neuropathy (AION)
Sudden unilateral loss of
vision
May be altitudinal

Pallid optic disc swelling

Chalky white

http://webeye.ophth.uiowa.edu/dept/AION/fig4.htm

http://webeye.ophth.uiowa.edu/dept/AION/7-AION-features.htm
 Arteritic (AAION)
Association with Temporal Arteritis
Suspect if
Age >50
Headache
Jaw pain or fatigue on chewing (claudication)
Scalp tenderness
Puts other eye at up to 50% risk of same
 Arteritic (AAION)
Treatment
Send ESR and start steroids if elevated
Prednisone 60-100 mg PO OD
Temporal artery biopsy within 1 week
 Non-Arteritic (NAAION)
Presumably atherosclerotic
Treatment
Follow-up for atherosclerotic risk factors
ASA
 Case 5
SUDDEN, PARTIAL LOSS, ONE EYE
60 yo M with migraine history complains of painful
blurry vision in one eye over a few minutes.
No trauma. Unlike past migraines
Significant nausea, vomiting, diaphoresis
Findings
Red eye
Only hand motion visual acuity one eye
Unable to examine further because of photophobia
 Case 5
SUDDEN, PARTIAL LOSS, ONE EYE
60 yo M with migraine history complains of
painful blurry vision in one eye over a few
minutes.
 Acute Angle Closure Glaucoma
Aqueous humor produced in
posterior chamber
Blockage of normal drainage
and circulation to anterior
chamber
Increasing IOP worsens outflow
as iris pushed forward
Often 40-80 mm Hg
 Acute Angle Closure Glaucoma
History
Sudden onset
Precipitant
Bending forward
Dark environment
Illness or sympathetic overdrive
Dilating drops
Anticholinergic med (even benadryl!)
 Acute Angle Closure Glaucoma
History
Pain (eye, head, ear, sinuses, or teeth)
Photophobia
Vision: blurry, halos or starbursts around lights
Nausea / Vomiting
Diaphoresis

** May mimic migraine, heart, or GI

disease because of systemic complaints
 Exam
Decreased visual acuity
Red eye
Pupil
Sluggish mid-dilated
Can be irregular
(eg. slightly oval)
Corneal haziness
Eyeball firm to palpation

http://www.emguidemaps.homestead.com/files/redeye.html www.kocmut.com/assets/ images/glaucoma.JPG

 Acute Angle Closure Glaucoma
Exam
Anterior chamber
Shallow
Shadow sign
Cells and flare

www.opt.indiana.edu/riley/HomePage/Direct_Oscope/Text_Direct_Oscopt.html www.hypertension-consult.com/Secure/textbookarticles/Primary_Care_Book/126.htm
 Acute Angle Closure Glaucoma
Treatment
Immediate ophtho consult
Treat pain and nausea
Avoid dilating drops!
Lower IOP
 Acute Angle Closure Glaucoma
Treatment
Block aqueous production
Beta blocker (eg. Timolol 0.5% 1 drop)
Onset 30 mins, peak 1-2 h
Caution if asthma, heart failure, heart block
CAI (eg. Acetazolamide 500 mg IV/PO/IM)
Avoid in sulfa allergy, renal insufficiency
Alpha-2 agonist (eg. Apraclonidine 1 drop)
Additive effect
 Topical Eye Drops
1. Nasolacrimal occlusion
2. Eyelid closure

Simple techniques
Decrease systemic absorption (by 60%)
Increases bioavailability

Improving the therapeutic index of topically applied ocular drugs. Zimmerman

TJ, et al. Archives of Ophthalmology. 102(4):551-553, 1984.
 Acute Angle Closure Glaucoma
Treatment
Reduce vitreous volume
Hyperosmotic agents (eg. Mannitol 1-2 g/kg IV)
 Acute Angle Closure Glaucoma
Treatment
Improve aqueous outflow
Supine position
May help iris fall back posteriorly

+/- Miotic agent (eg. Pilocarpine 1 drop q15 mins)

Often requires IOP < 40 mm Hg before effective
Beware WORSENS certain AACG types
 Case 6
ACUTE, PARTIAL LOSS, ONE EYE
30 yo F with recent URI noticed pain and
decreased vision in one eye over a few days.
No trauma, or N/V
Findings:
Red eye and painful EOM
RAPD+
(N) Acuity
(N) Fundoscopy
 Optic Neuritis
Key Points
Relatively common and important cause of
visual loss
Usually in young adults, esp. caucasian women
Commonly first manifestation of MS
Presumably autoimmune reaction with
demyelinating inflammation of optic nerve
 Optic Neuritis
History
May have preceding viral illness, or previous episodes
Usually monocular
Pain
Variable degree
Worse on eye movement
Vision loss
Exacerbated by heat or exercise (Uhthoff phenomenon)
Central scotoma or altered color/brightness/depth perception
 Optic Neuritis
Exam
Visual acuity variable
RAPD +
Field defects (central scotoma, altitudinal, arcs)
Fundoscopy
Often normal (retrobulbar in 2/3)
+/- Pale or swollen disc
 Optic Neuritis
Management
Consult ophtho and neurology
Steroids?

Beck RW, Cleary PA, Anderson MM, et al: A randomized, controlled trial
of corticosteroids in the treatment of acute optic neuritis.
N Engl J Med 1992;326:581-588.

Optic Neuritis Study Group: The 5-year risk of multiple sclerosis after
optic neuritis: experience of the Optic Neuritis Treatment Trial.
Neurology 1997;49:1403-1413.
 Optic Neuritis
Optic Neuritis Treatment Trial (ONTT)
Vision
Speeds recovery
No effect on visual outcome at 5 yrs
AVOID oral steroids due to increased
recurrence
Multiple Sclerosis
IV steroids may help decrease short-term risk of MS
No long term protection
 Summary
Eye RAPD Key findings
Pain
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
Acute Angle Yes +/- Painful red eye, hazy cornea,
Closure irregular pupil, shadow sign,
Glaucoma firm globe
Optic Neuritis Yes Yes Painful EOM, young female pt
 Summary
Urgency Can wait till AM? ED Treatment
CRAO CALL Only if subacute Orbital massage
IMMEDIATELY (Many days old) Lower the IOP
CRVO CALL when Yes, wait ASA
convenient
RD CALL At their discretion Bed rest supine
IMMEDIATELY Eye shield
AION CALL if TA, severe Yes, wait Steroids if TA
sx, uncertain dx,
can wait if not TA
Acute Angle CALL No Lower the IOP
Closure IMMEDIATELY Treat N/V
Glaucoma
Optic CALL Yes, for ophtho AVOID oral
Neuritis steroids
THANK YOU
 Traumatic Optic Neuropathy
Mechanism:
Hemorrhage of optic nerve sheath
Avulsion optic nerve
Most cases retrobulbar (no external or ophthalmoscopic
evidence of injury)
Difficulties:
Poor correlation between severity of impact and degree
of visual loss.
Visual deterioration immediately or after several hours
 Traumatic Optic Neuropathy
Management:
Controversial
Anecdotal evidence for steroids
Role and timing of surgical tx unclear
(reserved for those who fail to improve, or deteriorate despite steroids?)

Acute visual loss and other disorders of the eyes. Laskowits et al.
Neurology Clinics of North America. 16 (2) p. 323-49. May 1998.
 History
In addition to general Hx/Px:
Usual corrective glasses / contacts? Still in?
Previous transient episodes?
Trauma?