Back to Basics Ophthalmology:

Acute visual disturbance/loss

Sylvia ChenPGY-3 Ophthalmology

Outline

• History• Exam• Acute visual loss

– Trauma– Acute angle closure glaucoma– Retinal detachment– Retinal vascular occlusion– Diabetic retinopathy– Wet macular degeneration– Optic nerve disease

Ophthalmology Consult Pet-Peeves

• Examples

– “floaters”• Vision? Which eye? How long? Flashes of light? Curtain over vision?

– “decreased vision”• Vision - 20/30 vs 20/200? Sudden onset vs. gradual? RAPD?

DM/HTN/Cholesterolemia/CAD/headache

– “red eye”• Vision? Recent viral illness? Discharge? Photophobia?

– “swollen eye – can’t see eye”• Vision?• Trauma? Mechanism? Allergy? Recent illness/Infection?• Blood? From where? – lid/conjunctiva/inside eye (hyphema)

History

• Onset– Acute vs. chronic

• Acute onset vs acute perception of visual loss– One eye or both eyes– Trauma?

• Mechanism

• Character– Sudden vs. gradual– Permanent vs. transient– Flashes– Floaters “flies, cobwebs”– Veil covering vision– “Curtain coming down”

• Associated symptoms– Headache– Pain on eye movement– Photophobia– Temporal headache, jaw claudication, weakness, fever, wt loss,

loss of appetite

• Past Medical History– DM– HTN– Dyslipidemia– Afib– CAD– PMR– Arthritis

• FamHx– Any ocular probs

• RD, macular degeneration, glaucoma, blindness

• Meds– Plaquenil/chloroquine for RA– Diamox for glaucoma– Anticholinergics – allergy meds, antidepressants– Eye drops

• Social– Tobacco– EtOH abuse

• Trauma– Tetanus, last meal, allergies

Past Ocular History

• Visual history– Lazy eye, crossed eyes, asymmetric vision as child– Glasses (hyperope/myope), CL use

• Eye Injury– Treatment required? Visual outcome?

• Eye Surgery– Cataract, glaucoma, retinal detachment (buckle, gas bubble), crossed

eyes

• Laser Treatment– DM, Glaucoma, after cataract surgery, retinal hole or detachment

• Drops– Prescription or not? For glaucoma (eye pressure)? Post-op? Steroid?

Antibiotics?

Examination

• Visual acuity– 20/30 vs. 20/200

• Pupils/Iris– RAPD– peaked pupil

• Muscles– Movements

External Exam

• Lids• Conjunctiva

– injection– chemosis

• Corneal– abrasion– haze

• Anterior chamber– Blood?

• IOP• Visual field

Fundus – a bonus if you can see it!

• Optic nerve swelling• Macula

– Drusen– Exudates– Blood

• Vessels– Dilated– Tortuous– Retinal blood

• Vitreous haze/hemorrhage

Acute vision loss: TRAUMA

• Mechanism of injury

• Globe Rupture

• Ophthalmic Emergency!– Vision– Tetanus– Ancef– NPO– CT orbits– OR tonite!

Hyphema

• Blunt trauma– Soccer ball / baseball– Bungee cord– Punch

• Associated corneal abrasion• Occult globe rupture? – check IOP

Angle Closure Glaucoma

• Symptoms– Pain– Nausea & vomiting– Decreased vision

• History– Hyperope (short eye)– F>M– Increasing age – Meds: anticholinergics, antidepressants

• Signs– Cloudy cornea– Red eyes– Mid-dilation of the pupil– Forward bowing iris

(narrow drainage angle) – High intraocular

pressure (as high as 4X normal pressure)

• Ophtho today

Retinal Detachment

• Risk factors– Myopia– Personal history of tear/detachment– Family history of tear/detachment– Intraocular surgery– Pseudophakia

• Signs– Floaters

• 50-100 new “flies”– Flashes

• Lightning flashes– Veil covering vision– Painless

• Macula on– Ophtho today

• Macula-off– can wait till

tomorrow

Branch retinal vein occlusion (BRVO)

• Painless loss in vision

• Visual field defect

• Not an emergency

Central retinal vein occlusion (CRVO)

• Painless vision loss

• May have an RAPD

• If young– hypercoagulation workup

• Not an emergency

Branch retinal artery occlusion (BRAO)

• Painless vision loss

• Embolic work-up– ECG, Echo, Carotid

dopplers

• RF management– Chol, BP, DM

• Not an emergency

Central retinal artery occlusion (CRAO)

• Painless vision loss

• May have an RAPD

• If within first 90 minutes– Ocular massage

• Embolic work-up– ECG, Echo, Carotid dopplers

• RF management – Chol, BP, DM

• Not an emergency

Stroke

• Both eyes affected• Homonymous visual defect

Diabetic Retinopathy

• Glucose control?– HgA1c

• BP control?• Nephropathy/neuropathy?

• Proliferative disease– Look at fellow eye– Prior laser treatment?

Vitreous hemorrhage

• Most commonly from proliferative diabetic retinopathy

• Also retinal tear, trauma, tumour…

• Refer to Ophthalmology

Neovascular glaucoma

• Neovascularization of the iris• Diabetes• Ocular ischemia

– CRVO• 90-day glaucoma

Wet AMD

• Risk factors– White– Female– >65 y.o.– Smoker– History of dry AMD

• 10% year convert to wet– Family history

• Amsler grid– Scotoma– Distortion

Optic nerve disease: Optic neuritis

• Young• Female• Progressive vision loss over

few days• Decreased colour vision• RAPD• Pain with eye movement (90%)• Optic nerve swelling (2/3)

Optic nerve disease: Giant Cell Arteritis

• History– Age > 60 y.o.– Vision loss (curtain coming down), temporal headache, jaw

claudication, fever, wt loss, anemia, proximal muscle weakness (associated with PMR)

• Decreased vision +/- RAPD, +/- disc swelling or heme• Rest of exam normal

• Labs: CBC, ESR, CRP• Oral prednisone: 1mg/kg/day

– 80% risk of vision loss in other eye!

• Then refer to Ophtho

Referral to Ophtho

• Emergency– Globe rupture

• Same day– Acute angle closure

glaucoma– Mac-on RD– Hyphema

• Next day– GCA

• Do CBC, ESR, CRP, start steroids

– Mac-off RD– Hyphema

• Head elevated, limit activity

– VH in non-DM

• Same week– Vitreous hemorrhage in

DM– New wet AMD– Optic neuritis

• Non-urgent– Retinal vascular occlusion

(BRVO/CRVO, BRAO/CRAO)– Stroke

Summary

• Take a good history – You can determine the diagnosis with history in

90% of patients!

• Take a vision!

• Don’t miss a globe rupture

• Do you best on the rest of the exam