Acute Vision Loss

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Acute Vision Loss

• Dr. Anisman
• 17 March 2008

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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

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Retinal Artery Occlusion Hx

• Central (CRAO) or branched (BRAO)
• May have macular sparing (cilioretinal artery)
• Sudden, painless, unilateral
• Loss central vision one/more fields ? CRAO
• Loss one (horiz) field loss ? BRAO
• Transient loss, esp curtain descending ?
  amaurosis fugax impending RAO

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Retinal Artery Occlusion Signs

• Marcus-Gunn pupil (relative afferent pupillary
  defect)
• Retinal edema (after 1st few hrs)
• 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

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CRAO
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BRAO
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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

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Retinal Artery Occlusion Etiology

• IV drug use (talc retinopathy)
• Lipid emboli from trauma
• DIC
• Sickle cell
• Polyarteritis nodosa
• Retinal migraine

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Retinal Artery Occlusion W/U

• Heart, Carotid exam
• TA tenderness
• Neuro exam
• Va, visual fields, pupil and retinal exam
• Carotid u/s
• ECHO

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Retinal Artery Occlusion W/U

• Labs
• ESR/CRP
• CBC w/ diff
• Coags
• Consider hypercoag w/u

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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

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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

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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)

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Retinal Vein Occlusion Signs

• Marcus-Gunn pupil
• blood and thunder fundus
• Dilated tortuous veins
• Flame-shaped hemorrhage
• Cotton-wool spots
• Macular edema
• Exudates

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CRVO blood thunder
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CRVO cotton wool spots
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BRVO
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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

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Retinal Vein Occlusion Mgmt

• Optho eval w/in 48-72 hrs
• Laser photocoagulation to reduce macular edema
  and neovascular complications

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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)

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Retinal Detachment Sx

• Flashing lights
• Floaters
• Visual field loss curtain, shadow or bubble
• Metamorphopsia
• Decreased Va
• Painless

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Metamorphopsia
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Retinal Detachment Signs

• Marcus-Gunn
• Unilateral visual field loss
• Sectoral, quadrant, hemifield, total
• Retinal exam w/ direct ophthalmoscope may be
  unrevealing

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Retinal Detachment
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Retinal Detachment
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Retinal Detachment W/U Mgmt

• Immediate Ophtho referral!!
• Surgical intervention
• If acute or progressive should be referred to
  Ophthalmology lt24h, if chronic may be seen with
  2-4 weeks

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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

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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

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Vitreous Hemorrhage
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Angle Closure Glaucoma

• Outflow of aqueous humor from shallow anterior
  chamber is occluded when pupil dilates
• FM 3-41, high incidence in asians
• Peak age 55-70
• Shorter, smaller far-sighted eyes

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Normal Angle
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Narrow or Closed Angle
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Angle Closure Glaucoma

• Precipitating factors
• Enter darkened room
• Stress
• Dilating drugs
• Systemic rx
• Anticholinergics
• sympathomimetics

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Angle Closure Glaucoma Sx

• Intense pain photophobia
• Blurred vision, usually unilateral
• Halos around lights
• Vasovagal sx (diaphoresis, n/v)

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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)

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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

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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

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Corneal Ulcer Sx

• Pain
• Redness
• Decreased Va
• photophobia

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Corneal Ulcer Signs

• Dense corneal infiltrate w/ overlying epithelial
  defect
• Hypopyon
• Corneal destruction and ocular perforation
• Ulcer w/ feathery border fungal

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Corneal ulcer w/ hypopion
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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

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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

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Uveitis
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Uveitis
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Uveitis
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Uveitis
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Uveitis

• Etiol most idiopathic many systemic causes
• W/U careful HP, 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

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Uveitis

• Tx
• ophtho referral w/in 24h
• cycloplegia (topical homatropine 5 bid)
• topical steroid (Pred-Forte 1) initiated by an
  ophthalmologist

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Optic Neuritis

• 15-45 y.o.
• Usually subacute (several days)
• Pain w/ eye movement (/-)
• May have h/o transient neurological disturbances
• Assoc w/ MS

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Optic Neuritis

• Signs
• Optic Disc edema (unusual)
• Visual field cuts, esp. central
• Maracus-Gunn pupil (very common)

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Optic Neuritis (pappiledema)
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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.

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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.

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Exudative Macular Degeneration

• 1 Cause of blindness gt65 y/o
• Worsen gradually or suddenly
• Metamorphopsia common
• Photopsia /-
• Central scotoma /-
• More commonly subacute-chronically progressive
  vision loss

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Exudative Macular Degeneration Central Scotoma
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Exudative Macular Degeneration

• Signs
• Decreased Va
• Drusen yellowish deposits deep to retina
• Limit nutritional/metabolic support to outer
  retina

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Exudative Macular Degeneration Drusen
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Exudative Macular Degeneration

• Management
• Optho referral
• Amsler grid
• Fluoresscein angiography
• Tx laser photocoagulation (selected cases)

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Miscellaneous

• CVA
• Functional