Acute Visual Loss Dr Shueh Wen Lim
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Acute Visual Loss Dr Shueh Wen Lim
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Acute Visual Loss Dr Shueh Wen Lim. Case 1 – Mrs Smith. 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are your DDx?. DDx. - PowerPoint PPT Presentation
Transcript of Acute Visual Loss Dr Shueh Wen Lim
Acute Visual Loss
Dr Shueh Wen Lim
Case 1 – Mrs Smith
70yo woman presents with sudden onset loss of vision in her right eye half hour ago
No improvement sinceNo previous ophthalmic historyWhat are your DDx?
DDx Retinal vessels
Central/ branch retinal artery occlusion Central/ branch retinal vein occlusion
Vitreous Vitreous haemorrhage (diabetic complications) Retinal detachment
Macula ARMD – ‘wet’ ARMD
Optic nerve Anterior ischemic optic neuropathy: arteritic, non-artertic Optic neuritis
Cerebral cortex Stroke: homonymous hemianopia
Transient vision loss – amaurosis fugax
What else would you like to know about the patient?
Case 1 – Mrs Smith
Hx Sudden onset while she was gardening Painless, no associated redness Hx of transient blurring of vision 2 weeks ago
but recovered Medhx – IHD, diabetes (on meds)
Ex Visual acuity <6/60 right eye, 6/9 left eye RAPD Fundus exam
RAPD
What is the most likely dx?
CRAO
Pale oedematous retinaThin attenuated vesselsCherry red spotEmbolus may be seenOptic disc not pale or swollenAfter 6 weeks: Cherry red spot recedesOptic disc pallor becomes evident
CRAO Ix
CDV RFs – lipids, fasting BSL ESR, CRP (r/o GCA) Carotid US Echocardiogram ± Thrombophilia screen
Mx Urgent referral to ophthal Ocular massage Lower IOP (diamox 500mg stat ± ant chamber
paracentesis) Long term aspirin?
Case 2 – Mr Lee
Similar hx 65 yo p/w sudden and painless loss of
vision in left eye Hx of DM and HTN
Similar ex 6/60 left eye, 6/9 right eye RAPD Fundus exam
What is the most likely dx?
CRVO
Intraretinal flame-shaped haemorrhages (visible in all four quadrants)
Optic disc swellingDilated, tortuous veinsCotton wool spots
CRVO
Mx Check BP Screen for diabetes, hyperlipidemia Thrombophilic screen in younger pts
2 major complications Macular edema Neovascularisation of iris and retina
Case 3 – Mrs Abdullah Hx
70yo lady p/w sudden onset loss of vision in her right eye Generalised muscle pain and weakness (but untreated for
past 8 months) Been feeling poor for the past 4 weeks with a flu and fever
that she hasn’t been able to shake Moderate severe headaches during the time Unable to chew food properly because ‘it hurts’, lost 5kgs Pmedhx: T2DM, smoker
Visual acuity Hand movements in right eye, 6/6 left eye RAPD in right eye
What is the most likely dx?
Anterior Ischemic Optic NeuropathyFundoscopy
Pale, swollen optic disc Some haemorrhages, cotton wool spots
Mx ESR (urgent!), CRP, plt count Temporal artery biopsy High dose systemic steroids (but always
check for RFs that may C/I or complicate Rx with steroids)
Case 4 – Mr Holmes
Hx 69yo man who p/w painless loss of vision Recent hx of increased number of visual
floaters and flashes “Dark shadow” in the visual field of left
eye High myopia since 15yo, T2DM
Ex Loss of red reflex RAPD
What is the most likely dx?
Retinal detachment Separation of sensory retina from the retinal pigment
epithelium Risk factors
High myopes Ocular trauma DM Previous eye surgery eg cataract removal
Visual acuity will be affected only if central macula is affected
Examination Abnormal red reflex RAPD ‘Tobacco dust’ Detached retina (grey area)
Urgent opinion from ophthalmologist- surgery?
Wet (neovascular) AMD
Vitreous haemorrhage
Questions?
