Date post: | 05-Aug-2015 |
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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)
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Symptoms:Symptoms: Severe ocular pain Frontal headache Blurred vision with halos around lights Nausea and vomiting
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Signs:Signs: Corneal edema Conjunctival hyperemia Pupil mid-dilated and fixed Iris bowed (bombe’) forward Swollen lids
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
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
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Initial treatment: Pilocarpine q 15 min x 2 Other IOP drops Acetazolamide PO or IV Oral glycerine or isosorbide IV mannitol
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Definitive treatment: YAG laser peripheral iridotomy Surgical peripheral iridectomy Cataract extraction
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
Acute Visual LossAcute Visual LossAcute Angle Closure GlaucomaAcute Angle Closure Glaucoma
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
Acute Visual LossAcute Visual LossHyphemaHyphema
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
Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment
Symptoms: Flashing lights Floaters Loss of vision
Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment
Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment
Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment
Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment
Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment
Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment
Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment
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
Acute Visual LossAcute Visual LossRetinal DetachmentRetinal Detachment
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 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
Acute Visual LossAcute Visual LossMacular DiseaseMacular Disease
Examination: Amsler grid (graph paper) - very sensitive Use direct ophthalmoscope - often see
elevated areas of retina, hemorrhage Fluorescein angiogram
Acute Visual LossAcute Visual LossMacular DiseaseMacular Disease
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
Acute Visual LossCentral Retinal Artery Occlusion
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
Acute Visual LossBranch Retinal Artery Occlusion
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%)
Acute Visual LossCentral Retinal Vein Occlusion
Associations: Hypertension Atherosclerotic vascular disease Glaucoma Hyperviscosity syndromes
Acute Visual LossCentral Retinal Vein Occlusion
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
Acute Visual LossCentral Retinal Vein Occlusion
Acute Visual LossCentral Retinal Vein Occlusion
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)
Acute Visual LossOptic Neuritis
Examination - optic nerve usually normal; sometimes hyperemic and edematous
Usually resolves with time Treatment controversial Prognosis of a single attack is usually
good
Acute Visual LossOptic Neuritis
Acute Visual LossOptic Neuritis
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 LossOptic Nerve edema
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
Acute Visual LossIschemic Optic Neuropathy
Signs: Acutely - hyperemic, swollen nerve -
sometimes sectoral Later - pallid nerve
Important: Check ESR for giant cell arteritis in patients
over 60
Acute Visual LossIschemic Optic Neuropathy
Acute Visual LossIschemic Optic Neuropathy
Acute Visual LossIschemic Optic Neuropathy
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
Acute Visual LossGiant Cell Arteritis
Symptoms: Jaw claudication Headache Scalp tenderness Myalgias Fever Acute visual loss
Acute Visual LossGiant Cell Arteritis
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
Acute Visual LossGiant Cell Arteritis
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