Acute visual loss

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Acute Visual LossAcute Visual Lossin General Practicein General Practice

Dr. Riyad BanayotDr. Riyad Banayot

Acute Visual Loss Acute Visual Loss CategoriesCategories

Ocular Media opacities Retinal (most are vascular) Optic nerve (most are vascular)

Non-ocular Stroke Functional Acute discovery of chronic visual loss

Acute Visual Loss Acute Visual Loss OcularOcular

Media Opacities:Media Opacities: Corneal edema - acute angle closure glaucoma,

keratitis (corneal infections) Hyphema Cataract Vitreous hemorrhage

Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma

Characterized by a sudden rise in IOP in a susceptible individual with a dilated pupil, which decompensates the cornea

Aqueous humor (produced behind the iris by the ciliary body) cannot get into anterior chamber to reach trabecular meshwork (drain of the eye)

Symptoms:Symptoms: Severe ocular pain Frontal headache Blurred vision with halos around lights Nausea and vomiting

Signs:Signs: Corneal edema Conjunctival hyperemia Pupil mid-dilated and fixed Iris bowed (bombe’) forward Swollen lids

Acute glaucoma is the “great masquerader” of the red eye syndromes

Recognize it and refer quickly – profound visual loss can result from a delay in treatment

Initial treatment: Pilocarpine q 15 min x 2 Other IOP drops Acetazolamide PO or IV Oral glycerine or isosorbide IV mannitol

Definitive treatment: YAG laser peripheral iridotomy Surgical peripheral iridectomy Cataract extraction

Acute Visual LossAcute Visual LossCorneal UlcerCorneal Ulcer

Acute Visual LossAcute Visual LossHyphemaHyphema

Blood in the anterior chamber Usually caused by trauma Check blacks for sickle cell disease

Acute Visual LossAcute Visual LossHyphemaHyphema

Treatment: Bed rest with head elevated Topical atropine Topical steroids +/- Oral steroids Watch the IOP and cornea - evacuate blood, if

necessary Generally needs urgent referral to

ophthalmology

Acute Visual LossAcute Visual LossCataractCataract

Can develop or worsen quickly Usually in association with trauma or

metabolic imbalances Still, most often this would fall under

category of acute discovery of chronic visual loss

Acute Visual LossAcute Visual LossCataractCataract

Acute Visual LossAcute Visual LossVitreous HemorrhageVitreous Hemorrhage

Usually in association with trauma or neovascularization from diabetes or vascular occlusions

Most often just wait for blood to clear naturally

Use laser, if appropriate, as soon as retina visible

Evacuate blood if not clear by 3-4 months

Acute Visual LossAcute Visual LossVitreous HemorrhageVitreous Hemorrhage

Acute Visual Loss Acute Visual Loss OcularOcular

Retinal causes:Retinal causes: Retinal detachment Macular disease - usually neovascular Retinal vascular occlusions:

Central retinal artery occlusion (CRAO) Branch retinal artery occlusion (BRAO) Central retinal vein occlusion (CRVO) Branch retinal vein occlusion (BRVO)

Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment

Separation of sensory retina from choroid Usually in conjunction with a predisposing

situation Vitreous degeneration and detachment Lattice degeneration (high myopes) Neovascularization of the retina (diabetes) Trauma

Symptoms: Flashing lights Floaters Loss of vision

Examination: Any patient with risk factors should be

dilated and examined A retinal detachment large enough to

cause “window shade” loss of vision is big enough to see with a direct ophthalmoscope

Most often, patients with these symptoms should be referred for examination

Treatment: A number of treatments depending on size

and location: Scleral buckle Laser Cryotherapy Intraocular surgery

Key point is that the sooner the repair, the better the outcome

Acute Visual LossAcute Visual LossMacular diseaseMacular disease

Macula is area of sharp acuity Small anomaly can cause profound visual

loss Most common cause is subretinal

hemorrhage from neovascularization seen in macular degeneration

Acute Visual LossAcute Visual LossSub-Macular neovascularizationSub-Macular neovascularization

Acute Visual LossAcute Visual LossMacular HoleMacular Hole

Acute Visual LossAcute Visual LossMacular DiseaseMacular Disease

Symptoms: Sudden loss of vision Wavy lines (metamorphopsia) Gray areas

Examination: Amsler grid (graph paper) - very sensitive Use direct ophthalmoscope - often see

elevated areas of retina, hemorrhage Fluorescein angiogram

Treatment: Often amenable to laser treatment Occasionally, intraocular surgery to

evacuate the hemorrhage is helpful Again, the sooner treatment is initiated,

the better the outcome - refer quickly

Acute Visual LossRetinal Vascular Occlusions

Central retinal artery occlusion (CRAO) Acute painless loss of vision Usually embolic or thrombotic

Check heart - atrial fibrillation, MI, valvular disease

Check carotids - cholesterol plaques Check ESR for giant cell arteritis in patients

over 60

Acute Visual LossCentral Retinal Artery Occlusion

Profound visual loss will become permanent within hours

Diagnosis made based on appearance: Acute - vascular stasis and very narrow

arterioles Hours later - inner retina becomes opaque

except for macula - “cherry red spot” appearance

Acute Visual LossCentral Retinal Artery Occlusion

Treatment: Little to lose in initiating treatment

Press firmly on eye for 10 seconds Release for 10 seconds Repeat - try to dislodge embolus/thrombus

Ophthalmologist may tap anterior chamber to lower IOP to zero - trying to dislodge embolus

Also, re-breathing CO2, hyperbaric O2, Ca channel blockers - none work well

Acute Visual LossBranch Retinal Artery Occlusion

Sudden painless loss of vision – severity depends on location of occlusion

Usually embolic Look for cholesterol plaques on exam

Acute Visual LossBranch Retinal Artery Occlusion

Treatment: Little can be done Try to prevent another plaque-related

insult (stroke) Check carotids Lower cholesterol +/- Aspirin

Acute Visual LossCentral Retinal Vein Occlusion

Less sudden painless loss of vision Rarely complete, but often severe

Usually elderly patients Often becomes bilateral (10%)

Associations: Hypertension Atherosclerotic vascular disease Glaucoma Hyperviscosity syndromes

Examination: Use direct ophthalmoscope “Blood and thunder” appearance

Many diffuse flame and blot hemorrhages Cotton wool spots (white patches of retina) Engorged veins

Optic nerve head edema

Treatment Hemorrhages and cotton wool spots

resolve with time Vision may improve a little bit Retina may become ischemic

Watch for neovascularization - 90 day glaucoma

Needs close follow-up - may need laser

Acute Visual LossBranch Retinal Vein Occlusion

Semi-sudden, painless loss of vision - severity depends on location of occlusion

Same associations as CRVO Looks like CRVO except for is sectoral Treat the same way:

Watch for neovascularization Laser for neovascularization or non-resolving

macular edema

Acute Visual LossBranch Retinal Vein Occlusion

Acute Visual LossOcular

Optic nerve disorders: Optic neuritis Optic nerve edema Ischemic optic neuropathy (ION) Giant cell arteritis

Acute Visual LossNormal Nerve

Acute Visual LossOptic Neuritis

Inflammation of the optic nerve Idiopathic - often associated with multiple

sclerosis Signs and symptoms - decreased vision,

decreased color vision, afferent pupillary defect (APD), pain with eye movements, and visual field cuts (central scotomas)

Examination - optic nerve usually normal; sometimes hyperemic and edematous

Usually resolves with time Treatment controversial Prognosis of a single attack is usually

Acute Visual LossOptic Nerve edema

Many possible causes - including: Malignant hypertension Tumors Elevated intracranial pressure Meningitis

Often need CT/MRI and lumbar puncture Possibly an ophthalmologic or life

emergency - react quickly

Acute Visual LossOptic Nerve edema

Acute Visual LossUnilateral Optic Nerve edema

A - AION (acute ischemic optic neuropathy)

T - Tumor O - Optic neuritis, orbital pseudotumor U - Uveitis C - CRVO H - Hypotony

Acute Visual LossBilateral Optic Nerve edema

M - Mass M - Malignant Hypertension M - Meat (pseudotumor cerebri) M - Mucked up drainage (hydrocephalus,

DVO) M - Meningitis M - Medicines (vitamin A, tetracyclines)

Acute Visual LossBilateral Optic Nerve edema

Acute Visual LossOptic Nerve edema - Pailloedema

Pailloedema A term reserved for optic nerve edema,

usually bilateral, caused by elevated intracranial pressure

A definite ophthalmologic or life emergency

Acute Visual LossIschemic Optic Neuropathy

Ischemic optic neuropathy (ION) Usually painless Vascular - embolic or thrombotic Symptoms

Decreased visual acuity Decreased color vision Visual field defect - often altitudinal

Signs: Acutely - hyperemic, swollen nerve -

sometimes sectoral Later - pallid nerve

Important: Check ESR for giant cell arteritis in patients

over 60

Treatment: Little can be done Consider:

Checking carotids Checking heart +/- Aspirin

Acute Visual LossGiant Cell Arteritis

A true ocular and sometimes life threatening emergency

Generalized inflammatory disease of large and medium sized arteries Nearly all patients over 50 years old Most at least 60

Symptoms: Jaw claudication Headache Scalp tenderness Myalgias Fever Acute visual loss

Ischemic optic neuropathy is most common ocular manifestation

Central retinal artery occlusion (CRAO) is also common

Motor nerve palsies can occur Profound visual loss Other eye can become involved within

hours or days

Giant Cell Arteritis:Ischemic Optic Neuropathy

Giant Cell Arteritis:Central Retinal Artery Occlusion

Giant Cell Arteritis:Third Nerve Palsy

Giant Cell ArteritisPathology

Diagnosis - prompt diagnosis and treatment are critical History Stat ESR +/- Fluorescein angiogram Temporal artery biopsy

Acute Visual LossGiant Cell Arteritis (GCA)

If GCA suspected, start steroids immediately

Don’t wait for biopsy Sometimes immunosuppressive therapy is

needed

Acute Visual LossNon-Ocular Causes

Stroke, cerebral mass, or bleeding Usually painless Vision loss is bilateral unless insult is anterior

to chiasm Often, there are associated symptoms

Numbness Weakness Paresthesias Impaired thinking or talking

Acute Visual LossStroke, Mass, or Bleeding

Most common manifestation is a homonymous visual field defect

Workup and treatment are urgent or semi-urgent CT scan Send patient to ER or primary care physician DO NOT send patient to ophthalmology – at

least not at first

Acute Visual LossRight Homonymous Hemianopia

Left Right

Acute Visual LossRight Homonymous Hemianopia

Left Right

Acute Visual LossNon-Ocular

Functional visual loss Hysteria - implies patient truly believes he has

visual loss even though he doesn’t Malingering - implies patient is aware he has

no visual loss, but is faking it for 2ry gain Money Enjoy the sick role

Acute Visual LossNon-Ocular

Acute discovery of chronic visual loss More common than you think Scenarios

One day patient decides to cover one eye and discovers other eye has decreased vision

One day patient decides that lack of new glasses has caused his vision to acutely drop

One day 80 year old patient decides his dense cataracts that have been building up for 20 years are suddenly causing visual loss

Acute visual loss

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