Visual lossDr Amani Badawi

ASSISTANT PROFESSOR

OPHTHALMOLOGY

04/21/23Amani Badawi

Acute Visual Loss

Acute visual loss

History

• Age

• POH & PMH

• Onset

• Duration

• Severity of visual loss compared to baseline

• Monocular vs. binocular ?

• Any associated symptoms

• Visual acuity assessment

• Visual fields

• Pupillary reactions

• Penlight or slit lamp examination

• Intraocular pressure

• Ophthalomoscopy

- red reflex

- assessment of clarity of media

- direct inspection of the fundus

Examination

1-Central Retinal Artery Occlusion (CRAO)

• True ophthalmic emergency!

• Sudden painless and often severe visual loss

• Permanent damage to the ganglion cells caused by prolonged interruption of retinal arterial blood flow

• Characteristic “ cherry-red spot ”

• Months later, pale disc (optic atrophy) due to death of ganglion cells and their axons

1-Central Retinal Artery Occlusion (CRAO) treatment

• As before +

• Ocular massage:

-To dislodge a small embolus in CRA and restore circulation

-Pressing firmly for 10 seconds and then releasing for 10 seconds over a period of ~ 5 minutes

• Ocular hypotensives, vasodilators, paracentesis of anterior chamber

•

2-Branch Retinal Artery Occlusion (BRAO)

• Sector of the retina is opacified and vision is partially lost

• Most often due to

embolus

• Treat as CRAO

3-Central Retinal Vein Occlusion (CRVO)

• Acute loss of vision

• Disc swelling, venous engorgement, cotton-wool spots and diffuse retinal hemorrhage.

• Needs medical evaluation

• Long term complication: neovascular glaucoma, and macular edema so periodic ophthalmic follow up

4-Optic Nerve Disease

• Non-Arteritic Ischemic Optic Neuropathy (NAION)

- vascular disorder

pale, swollen disc +/- splinter hemorrhage

loss of VA , VF ( often altitudinal )

- Treatment : systemic steroids

4-Optic Nerve Disease

• Optic neuritis - idiopathic or associated with multiple

sclerosis - young adults - Unilateral decreased visual acuity and colour

vision -RAPD -pain with ocular movement -bulbar (disc swelling) or retrobulbar (normal

disc)

5-Retinal Detachment• Retinal detachment

- flashes, floaters, shade over vision

- elevated retina +/- folds

• Macular disease

- decrease central vision

- metamorphopsia

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Separation of sensory retina from RPE by subretinal fluid (SRF)

Rhegmatogenous - caused by a retinal break

Non-rhegmatogenous - tractional or exudative

Trauma6-Trauma

Hyphema

Ruptured globe

• Open globe should be suspected in any patient who has a history of trauma to the eye, especially with a laceration or puncture wound that extends through the eyelid, followed by pain and decreased visual acuity &hyptony.

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Anterior segment complications of blunt trauma

Sphincter tear

Cataract Angle recession

Hyphaema

Lens subluxation

Iridodialysis Vossius ring

Rupture of globe

Macular hole Optic neuropathy RD

Posterior segment complications of blunt trauma

Choroidal rupture and haemorrhageCommotio retinae Avulsion of vitreous base

and retinal dialysis

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Complications of penetrating trauma

Flat anterior chamber

Vitreous haemorrhage

Damage to lens and iris

EndophthalmitisTractional retinal detachment

Uveal prolapse

7-Media Opacities• Corneal edema: - ground glass appearance - as in acute congestive

glaucoma

• Corneal abrasion &ulcer• Vitreous hemorrhage - traumatic - retinal neovascularization

8-Endophthalmitis

Background: Bacterial endophthalmitis is an inflammatory reaction of the intraocular fluids or tissues caused by microbial organisms.

History

Classification is based on routes of entry.

•Exogenous

•Endogenous

Physical General findings

•Visual acuity decreased below the level expected

•Lid edema

•Conjunctival hyperemia

•Corneal edema

•Anterior chamber cells and flare &Hypopyon

•Vitritis

•Loss of red reflex

•Retinal periphlebitis if view of fundus possible

9-Visual Pathway Disorders

Hemianopia

- Causes: vascular or tumors

-Types

Cortical Blindness

- Extensive bilateral damage to cerebral pathways

- Normal pupillary reactions and fundi

Chronic Visual Loss

Case 1

• A 75 year old woman is seen for an annual physical examination and complains of mild difficulty in reading and seeing street signs

• Vision is especially worse at night

• PHx: HTN, T2DM diet controlled

• O/E: VA R 6/18 and L 6/12

Case 1• What is the likely diagnosis?

1-Cataract

• Symptoms gradual over years

• 1. Reduction in visual acuity

• Worsening of existing myopia

• Correction of hyperopia “second sight of the aged”

• 2. Loss of contrast sensitivity in low light

• 3. Glare in bright light :Forward scatter of light

Case 2

• A 76 year old man has noted visual distortion over the past week

• Straight lines viewed through his right eye dipped down in the centre

• Round plates seem to have “edges”

• O/E: VA R 6/18 and L 6/6

• What is the likely diagnosis?

• What test are you going to do?

Case 2

Case 2

Case 2

2-Macular degeneration• Loss of central vision

• Reading, recognizing faces impaired

• Leading cause of legal blindness in developed world

• Multifactorial• Age

• Smoking, vascular disease, UV light, diet, FHx, …

• Atrophic (dry) or exudative (wet)

Geographic atrophy – dry AMD

Choroidal neovascularisation – wet AMD

Macular scarring – wet AMD

Management – dry AMD

• Lifestyle

• Stop smoking, reduce UV exposure, Zinc & antioxidants

• Low vision aids

• Legal blindness and driving

• Monitoring with Amsler chart

Management – wet AMD =CNV

• Observation• Laser photocoagulation

• Photodynamic therapy (PDT)

• Intra-vitreal injection of Anti-VEGF

Anti-VEGF therapies

• VEGF-A stimulates angiogenesis and vascular permeability

• Intravitreal injection of monoclonal antibodies

• Ranibizumab (Lucentis) • Off-label Bevacizumab (Avastin)

Case 3

• A 68 year old man was referred from his optometrist for visual field testing

• He has not reported any problems with vision, but the test report shows a reduction in peripheral vision in the Right eye

Case 3

• What is your likely diagnosis?

• What further examination are you going to do?

Case 3LE RE

3-Glaucoma

• 1. Optic nerve damage (optic disc cupping)

• Increased Cup:disc ratio

• Loss of neuroretinal rim

• 2. Increased IOP

• 3. Peripheral visual defects

The trick of IOP

• Only 10% with IOP>21 have glaucoma

• The rest have ocular hypertension

• Only 50% of glaucoma patients have IOP>21

• The rest have normal tension glaucoma

Glaucoma

• Types

• Primary

• Open angle (90%)

• Closed angle

• Secondary

• Congenital

Primary open angle glaucoma

• “The silent thief of sight”

• Asymptomatic

• Usually detected on routine examination

• Risk factors: IOP, age, FHx, DM, myopia

• Impaired drainage of aqueous humor through trabecular meshwork

• Due to age-related morphological changes

Primary open angle glaucoma

Management

• Aim to stop progress

• Medical – reduction of aqueous secretion

• Beta-blockers (Timolol)

• Alpha-agonists (Brimonidine)

• Prostaglandin analogues (Latanoprost)

• Parasympathomimetics (Pilocarpine)

• Carbonic anhydrase inhibitors (Brinzolamide)

Management

• Surgical

• Argon and selective laser trabeculoplasty

• Filtering surgery

• Trabeculectomy

• Laser peripheral iridotomy : Yag laser

Case 4

• A 13 year old girl is seen for physical examination at school. She admits to difficulty in reading the blackboard, but not in reading textbooks. She does not wear glasses.

• O/E: VA R 6/36 ph 6/6 and L 6/36 ph 6/6

• What is your diagnosis?

4-Refractive error

• Corrects with pinhole

• Management: glasses, contact lenses, refractive surgery

Case 5 – spot diagnosis

5-Retinitis pigmentosa

• Genetically inherited

• Progressive retinal dystrophy

• Night blindness, tunnel vision, legal blindness

• Bony spicules from mottling of RPE

• Incurable

• Future: gene therapy, bionic eye, …?

6 – diabetic retinopathy

• Microvascular retinal changes

• Blindness is progressive, but preventable

• Annual retinal examination

• Tight T2DM control HbA1c 6-7%

• laser treatment

• Pre-proliferative retinopathy

• Proliferative retinopathy

• Also predisposes to cataract & glaucoma

Diabetic retinopathy

Diabetic retinopathy

Diabetic retinopathy

Diabetic retinopathy

Diabetic retinopathy

Diabetic retinopathy

Diabetic retinopathy

Diabetic retinopathy

Diabetic retinopathy

Summary

Causes of chronic visual loss• Cataract

• Glaucoma

• Age-related macular degeneration

• Refractive error

• Retinitis pigmentosa

• Diabetic retinopathy

Thank you