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Sudden Loss of Vision

Opthalmology notes - made by Larry Nyanti
by

Larry Ellee

on 30 September 2013

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Transcript of Sudden Loss of Vision

Sudden Loss of Vision
Painful Sudden Loss of Vision
Acute angle-closure glaucoma
Optic neuritis
Endophthalmitis
Orbital cellulitis
Painless sudden loss of vision

-Vitreous haemorrhage
-Retinal detachment
-Retinal artery occlusion

-Arteritic ischemic optic neuropathy
-Non-arteritic ischemic optic neuropathy
=AION
=PION
-Functional LOV
-Macular hemorrhage in AMD
-Ocular migraine (young)
-TIA
Acute Loss of Vision
Definition: Inability to see or the loss or absence of perception of visual stimuli for a few minutes to couple of days.

Begin with THINKING ANATOMICALLY:

Transient painless
TIA
vasospasm
early retinal detachment
Intracranial hypertension
Persistent painless
Retinal detachment
Vitreous hemorrhage
Ischemic Optic Neuropathies
CRAO
CRVO
Stroke
monocular vision loss
binocular vision loss
Vascular I

1. CRA - br. of opthalmic artery, which is a br. of ICA. (supplies retina)
2. CRVO
3. Stroke - bilateral field loss w no visual acuity loss
Hx: Amaurosis fugax
(<5 min "curtain" of blindness)
Ddx: TIA

bilateral vision loss+diplopia+vertigo = vertebrobasilar insufficiency
Hx: autoimmune, infection, emotional stress, cold (a long list!)
Ddx: Vasospastic syndrome (may also have cold hands, hypotensive, migraine, silent MI)
Ischemic Optic Neuropathies
Vascular II
Central retinal artery occlusion
Etiology:
1. Emboli (AF, IE, Coagulopathies, valve disease, IVDA)
-heart emboli - commonest cause <40 yo
-coagulopathies - common in <30 yo
2. very high IOP - acute angle closure glaucoma
3. GCA
4. DM, HTN

Hx: preceding amaurosis fugax may indicate branch occlusion


Ix: Doppler ultrasound on carotids, ECG
ESR, CBC, Glucose, Lipids, blood cultures, coag profile



1. intact retinal pigment epithelium
2. fovea supplied by choriocapillaris
Central retinal artery occlusion
Treatment can be medical or procedural.
Medical:
1. Reduce IOP
-Acetozolamide - reduces rate of aq humour formation by inhibiting carbonic anhydrase (500mg IV)
-Timolol - a beta blocker
-Mannitol - short term, emergency use

2. Increase retinal perfusion
-Vasodilatory drugs
-Increase arterior PCO2 (carbogen therapy)
-Peripheral thrombolytics

3. Increasing O2 delivery
-breathing hyperbaric O2

Procedural
1. Ocular massage - dislodge embolus
2. Anterior chamber Paracentesis - withdraws fluid, lower IOP
cherry red spot in CRAO
Central retinal vein occlusion
Examination: Decreased visual acuity

Fundus findings:
retinal hemorrhages, dilated tortuous retinal veins, cotton-wool spots, macular edema, and optic disc edema.

Later findings: Neovascularisation and subsequently vitreous haemorrhage - in ischemic RVO
Iris neovascularisation - rubeotic glaucoma

Ix is similar to CRAO
Classified as ischemic and non-ischemic (more common). Ischemic is more severe.

Etiology:
-HTN, DM, CVS disorder, coag, vasculitis, AI disease, OCP use,
alcohol, POAG, PACG

Hx: LOV may not be as acute as CRAO


Central retinal vein occlusion
Treatment:
*no known effective medical tx. Identify systemic/co-morbidities

Surgical:
1. Retinal Laser Treatment
-PRP pan retinal photocoagulation

2. Chorioretinal venous anastamosis
-to bypass occlusion site
-low success rate
-complications - vitreous haemorrhage, choroidal neovascularisation

3. Radial optic neurotomy
-for non-ischemic CRVO
-based on idea that vein is compressed at narrow opening of cribiform plate

4. Vitrectomy
-reduces traction on macula, less edema
a) Anterior ION (1mm of optic nerve head)
Ischemic Optic Neuropathies
so many associations!
Early AAION
Late AAION
Classic sectoral/segmental disc
edema in NAION
b) Posterior ION
Anatomy: The posterior or retrobulbar optic nerve is the long segment (23 to 30 mm) of nerve lying within the orbit.
Hx: acute vision loss + RAPD. similar risk factors
Finding:
VF: altitudinal field defect
Normal optic disc initially.
How do you treat IONs?
-control risk factors
-steroids in AI disease
-no surgically proven therapy
Investigations:
-ESR (esp in AION), Cerebral circulation angiography --> GCA
-Fluorescein angiography in differentiating AAION and NAION (longer filling time in AAION)
Vitreous Haemorrhage
Anatomical attachments:
-ora serrata (anterior retina)
-optic head

Hx: Floaters, haze (small haemorrhage) or total visual loss (big haemorrhage)

Pathophysiology:
1. Ischemia
2. Breathrough bleeding (AMD, choroidal melanoma)

Etiology:
-Proliferative retinopathy
-Retinopathy of prematurity
-Ischemic retinopathy due to Retinal vein occlusion
-Retinal detachment
-Trauma
-Posterior vitreous detachment
-AMD

Complicates to: Glaucoma
Retinal detachment
Rhegmatogenous
-tear in retina
Exudative
-toxemia of
pregnancy
Tractional
-DM
Risk: high myopes, cataract surgery
trauma, previous detachment

Hx: Floater, flashing lights before a curtain-like field defect, fall in acuity if macula involved

Signs: Visible tear, pinkish grey membrane obscuring choroidal vascular detail
Surgical management!
Procedure:
a) subretinal fluid is drained
b) cryotherapy/laser
c) a silicone sponge is sutured to the globe to indent the sclera over the retinal break
Procedure:
Inject an inert fluorocarbon gas
which keeps the defect closed
To remove vitreous gel /
blood that obscures vision

-laser to coagulate
-cryotherapy to induce
adhesion

-finally, silicone gas or
oil is injected to replace
vitreous
Acute angle closure glaucoma
Keyword: RED EYE!
OPTIC NEURITIS
Hx: headache + movement
aggravated
DDx: Intracranial HTN

Findings: Optic disc swollen
+ field loss

Ix: MRI, MRA
-Young & Female (20-45 y.o. F:M 3:1)
-"MOVING EYE HURTS"
-Visual loss over hours or days
-May be the 1st demyelinating event in MS!
Reduced acuity, colour vision (Red), decreased contrast sensitivity
VF: Central scotoma, arcuate defect, or total loss





Normal disc = retrobulbar neuritis
Swollen disc = papillitis
Do an MRI (gadolinium enhanced)
-shows enlarged, enhancing optic nerve
-show MS plaques
-given with oral steroids
-speed rate of recovery
-no effect on ultimate visual acuity
-doesn't prevent MS onset
Neuroretinitis: Bartonella henselae infection in a 14 year old girl.
"cat scratch
disease"
Endophthalmitis
inflammatory condition of the intraocular cavities (ie, the aqueous and/or vitreous humor) usually caused by infection.

ETIOLOGY:
-Endogenous - bacterial / fungal (hematogenous spread)
-Postoperative - acute / delayed onset / bleb associated

COMPLICATIONS:
panuveitis, orbital cellulitis
History
-pain and blur vision
-floaters
-photophobia
-headache
-SYSTEMIC: fever rigor
Post-op Symptoms:
Visual symptoms in any hospitalized patient or patient taking immunosuppressive therapy
Visual loss
Eye pain and irritation
Headache
Photophobia
Ocular discharge
Intense ocular and periocular inflammation
Injected eye
Complication
Impaired loss of vision
Complete loss of vision
Loss of eye architecture
Eunucleation
Postoperative endophthalmitis
1. Pars plana vitrectomy or vitreous aspiration may be performed by an ophthalmologist with administration of intravitreal antibiotics (ie, vancomycin, amikacin, ceftazidime).
2. Consider systemic antibiotic administration as well as intravitreal steroids.

Traumatic endophthalmitis
1. Vancomycin and an aminoglycoside or a third-generation cephalosporin are indicated. Consider clindamycin until Bacillus species can be ruled out if soil contamination is suspected.
Topical fortified antibiotics are used.
Intravitreal antibiotics should be administered.
Consider pars plana vitrectomy.
Tetanus immunization is necessary if immunization record is not current.

Bacterial endophthalmitis
-same as traumatic in terms of antibiotics

Candida endophthalmitis
-oral fluconazole, AmpB
History:
(Infectious hx) Preceding viral illness, URTI
(Dyschromatopsia) Patient may complain that red colour appears less intense.
(Progression) LOV may improve in d/wks
(MS symptom in 40-70%) Any limb weakness?
(Uthoff phenomenon) Pain agg by heat/exercise
(Pulfrich phenomenon) Straight-line moving objects appear curved
Examination: RAPD positive!
demyelinating, infective, or inflammatory process of the optic nerve
Etiology: MS (most common)
Other causes:
1. Infectious diseases (eg, viral encephalitis [particularly in children], sinusitis, meningitis, TB, syphilis, HIV). may also follow an infection
2. Non-infectious AI: sarcoidosis, SLE, PAN
3. Tumor metastasis to the optic nerve
4. Chemicals and drugs (eg, lead, methanol, quinine, arsenic, antibiotics)
Types:
1. Papillitis (optic nerve head, common in children)
2. Retrobulbar neuritis (head not involved, common in MS)

To rule out other possible causes of optic neuropathy:
-ESR, TFT, ANA, ACE, RPR (if there are systemic signs)

-CSF analysis - oligoclonal bands, elevated IgG index (MS)
-Visual evoked potentials (MS)
Prognosis: most episodes resolve in 2-3mth
Management: IV Steroids
3. Neuroretinitis (rare, characteristic macular star)
post-op patient complaining of pain, redness, photophobia
History (Endogenous bacterial)
underlying DM, Cardiac disease, malignancy,
IVDA, catheters, liver abscess, pneumonia,
IE, UTI, meningitis...
History (Fungal)
Immunocompromised
IVDA, Parenteral nutrition
Penetrating plant/soil injury
hypopyon
conjunctival hyperemia
corneal edema
Important complication of cataract surgery
Staph, Strepto
Corneal ulcer
Necrosis of corneal wound
Diagnosis
-mainly clinical
-Can do Vitreous tap to confirm organism
-Gstain, culture, PCR
TREATMENT IS PROCEDURAL AND MEDICAL
Painful Sudden Loss of Vision
Acute angle-closure glaucoma
Optic neuritis
Endophthalmitis
Orbital cellulitis
Painful Sudden Loss of Vision
Acute angle-closure glaucoma
Optic neuritis
Endophthalmitis
Orbital cellulitis
Orbital Cellulitis: infection of the soft tissues of the orbit posterior to the orbital septum
Systemic signs: fever, malaise

Risk:
sinusitis, URTI, trauma, surgery, dental
Hx: Floaters and flashing lights
-followed by-
"curtain" loss of vision (detachment)
Think of: Retinal Detachment
Hx: Floaters and flashing lights
with red blurry vision
Think of: Vitreous Haemorrhage
Signs:
-LOV - counting fingers/light perception
-Visible white/bright yellow emboli - branch point
-Pale disc + retina is swollen and white (edematous)
-Fovea is red ("cherry red spot")
-RAPD positive
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