SUDDEN VISUAL LOSS

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 Prolonged ACG Optic Neuritis Fleeting embolic migrain Raised ICP Painless Prolonged ION
CRAO

GCA
Orbital cellulitis
Endopthal

CRVO VIT.HGE

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) Sudden, painless, unilateral
May have macular sparing (cilioretinal artery) 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