Sudden Painless Loss of Vision

MajAhsan Mukhtar

FCPS, FRCS (Ophth)Classified Eye Specialist

Registrar VR SurgeryAFIO

Objectives

• Know Imp points in History and Exam

• Enumerate common Causes

• Know the clinical appearance of various diseases

History

• True sudden vision loss OR sudden realisation of visual loss?

• One eye or both eyes? • Onset and progression • Associated visual symptoms – flashes suggest retinal traction (but can be cortical

e.g. CVA, migraine) – floaters suggest vitreous debris

History

• Past ocular history – trauma and myopia are risk factors for retinal

detachment

• Systems review – in elderly patients, ask about headache and

polmyalgia (temporal arteritis) – history of diabetes– cardiovascular disease, TIA symptoms suggest

emboli

Examination

• External ocular appearance• Visual acuity• Colour vision assessment• Pupil Examination• Visual field assessment• Fundoscopy• Palpation of temporal arteries• Cardiovascular examination• Neurological examination

RAPD

• Darken the room• Have the patient fix on

a distant target (e.g. the top letter on a Snellen chart)

• Alternate a bright light rapidly (<1 second) between the two eyes, spending 2 seconds on each eye

CAUSES

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Methyl alcohol metabolized very slowly, stay longer period

Oxidised in to formic acid & formaldehyde

oedema

Degenaration of ganglion cell of retina

Complete blindness

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THANK YOU

Sudden Painless Visual Loss

• Alarming to both the patient and clinician alike

• Requires careful history and examination to determine underlying cause

• Visual Obscuration may range from – a symptom of dry eye– or it may herald the onset of irreversible visual

loss or stroke

Aims

• Focused history to identify the anatomic site of the pathology

• Focused examination• Know the causes• Understand the importance of Simple

examination techniques such as – visual acuity measurement– confrontational visual field testing– pupil assessment– fundoscopy

Retinal Detachment

• Patients may notice an enlarging shadow in peripheral vision(not just a floater)

• Sudden loss of central vision occurs when the macula detaches

• Flashes and floaters are common associated symptoms

• Ocular history of trauma, surgery and myopia.

Retinal Detachment

• Acuity normal = macula "on" • Acuity poor = macula "off' • RAPD • Visual field defect corresponding to area of

detached retina • Fundus examination is diagnostic (but may be

difficult to pick with direct ophthalmoscope)

Vitreous Haemorrhage

• Causes– Proliferative diabetic retinopathy (new vessels

present) – BRVO with new vessels – Retinal tears (tear through a retinal vessel)

Vitreous Haemorrhage

• History– Blurred vision with floaters – Diabetes(may be undiagnosed)

• Vision: varies with severity of haemorrhage (6/6 to PL)

• Pupils: NO RAPD (unless retina detached as well)

• Fundus: reduced red reflex and difficult to see retinal detail

Central Retinal Artery Occlusion

• Sudden total loss of vision • Previous episodes of amaurosis fugax • Cardiovascular disease • Vision may be NPL • Afferent pupil defect • Total field loss

Central Retinal Artery Occlusion

• Cloudy swelling of infarcted posterior retina • Cherry red spot at fovea (where retina

thinnest) • Segmentation of blood columm in retinal

veins (slow flow) • Look for emboli in the retinal arteries

Central retinal vein occlusion (CRVO)

• Patients usually>50 yrs • Strong association with hypertension and

cardiovascular disease • Sudden painless bIur of vision • Vision varies with severity (from 6/6 to hand

movements) • Afferent pupil defect if severe CRVO (HM

vision)

Central retinal vein occlusion (CRVO)

• extensive retinal haemorrhages in all quadrants

• retinal venous distension • optic disc swelling

AION

• Elderly patients (age >65) • Sudden and severe loss of vision in one eye

initially • Systemic symptoms are headaches, scalp

tendemess,malaise, jaw claudication • Vision 6/60 or worse RAPD • Extensive visual field loss • Pale swollen optic disc (anterior ischaemic optic

neuropathy), rarely CRAO.

AION

• Aim to prevent loss of the other eye! • Urgent ESR (expect >60) • Prednisolone l00mg stat • Urgent referral• Temporal artery biopsy will confirm the

diagnosis

Optic Neuritis

• Typically affects one eye of young women • Vision progressively dims over 48 hours (not

truly "sudden") • Ache around eye at onset (worse with eye

movement) • Reduced acuity and colour vision • A relative afferent pupil defect (RAPD) is

present

Optic Neuritis

• Fundus may be normal (retrobulbar neuritis) • Recovery over 6 weeks, more rapid if IV

methylprednisolone. • Strong association with MS (MRI Brain will

help predict risk)

Alcohol Amblyopia

Acute onsetResulting in optic atrophy & permanent blindnessEtiology-• Intake of wood alcohol spirit in cheap adulterated

beverages• Inhalation of fumes in industries

Methyl alcohol metabolized very slowly, stay longer period

Oxidised in to formic acid & formaldehyde

oedema

Degenaration of ganglion cell of retina

Complete blindness

Methyl alcohol amblyopia

• Mild disc oedema

• Markedly narrowed blood vessels

• Bilateral optic atrophy

Eye Pain

RAPD Key findings

CRAO No Yes Pale retina, cherry-red spot

CRVO No +/- Blood and thunder / “Ketchup” fundus

RD No +/- May have localized field defect, cloudy veil. But suspect on history

AION No Yes Swollen pale disc, signs of temporal arteritis

Optic Neuritis Yes Yes Painful EOM, young female pt

Urgency Can wait till AM? ED Treatment

CRAO CALLIMMEDIATELY

Only if subacute (Many days old)

Orbital massage Lower the IOP

CRVO CALL when convenient

Yes, wait ASA

RD CALLIMMEDIATELY

At their discretion

Bed rest supineEye shield

AION CALL if TA, severe sx, uncertain dx, can wait if not TA

Yes, wait Steroids if TA

Optic Neuritis

CALL Yes, for ophth AVOID oral steroids