Transcript Acute Visual Loss

UBC Ophthalmology Interest Group Seminar Series
1.18.2012
ACUTE VISUAL LOSS
ANATOMY REVIEW
24 mm
Photo courtesy: Heather O’Donnell, PGY2, UBC
PRIMARY CARE APPROACH

History
 Onset
ie. minutes vs days, following trauma?
 Transient vs permanent
 Mono vs binocular
 Associated symptoms eg. pain, swelling, floaters
 Other medical conditions and eye history
 Medications

Eye Exam
 Visual
acuity
 Equivalent
to vitals for the eye
VISUAL ACUITY TESTING

Eye Exam

Visual acuity
 Equivalent

to vitals for the eye
Pupils, RAPD
 Another
‘vitals’, from eye/neuro/trauma point of view
Confrontational visual field
 Extraocular movement
 Tonometry
 External examination
 Slit lamp: lids, conjunctiva, AC
 Dilated examination, fundoscopy

CASE 1
Previously well 75F presents to ED for sudden
R eye pain and blurry vision while watching TV
at night
 c/o “halo” around lights
 Symptoms not resolved
 Hx: cataract in both eye, mild HTN
 No medications

CASE 1
OD CF, OS 20/25
 R pupil fixed 4mm
 Rock hard globe
 Corneal edema
 Conj injections
 Opposite eye looks
normal
 Nausea, vomit x 1

Photo courtesy: A. Doan, MD,
University of Iowa
IMPRESSION AND PLAN?
A. Urgent head CT r/o mass lesion in brain
causing high ICP
 B. Acute bacterial conjunctivitis, pt needs abx
eye drops
 C. Chemical keratitis, rinse eye in sterile water
for 10 min immediately
 D. Acute angle closure glaucoma, consult
ophthalmology STAT

ACUTE ANGLE CLOSURE GLAUCOMA
Results from aqueous outflow obstruction by
iris, rise in IOP, ischemia and permanent
glaucomatous damage: emergency!
 IOP = 42 mmHg (normal 12-20mmHg)
 Acetazolamide and timolol were given initially,
followed by pilocarpine 1 hour later.
 IOP decreased to 19 mmHg
 Laser peripheral iridotomy arranged the next
day is the definitive treatment

LASER PERIPHERAL IRIDOTOMY

Photo courtesy: A. Doan, MD, University of Iowa
CASE 2
50M highly myopic pt
sees GP for c/o new
onset of “flashing
lights and floaters”
 Blurry vision but no
pain
 Otherwise healthy

Rev Ophthalmol, 2006, 6:15
CASE 2
OD 20/80, OS 20/20
 Pupils, anterior
segment normal
 Vitreous: tobacco dust
 IOP: OD 10 mmHg, OS
13 mmHg

Rev Ophthalmol, 2006, 6:15
RETINAL DETACHMENT
Rhegmatogenous most common, start as a
tear, fluid build up beneath neuroretina
separates it from retinal pigment epithelium
 High myopia is a risk factor
 In office: avoid pressure on globe, protect the
eye
 Immediate ophthalmological consult required
 Surgery is definitive treatment, often urgent

CASE 3
75F with sudden
painless loss of vision
OD yesterday comes
to GP office
 A “grey spot” in her
vision, grown over 10
min
 Hx incl. CAD, HTN, TIA
 Denies eye problems

Photo courtesy: AAO 2011
CASE 3
OD CF, OS 20/30
 R pupil sluggish 3mm
RAPD
 EOM full
 Cornea, AC grossly
normal
 IOP 10mmHg B/L
 Cranial nerves intact

Photo courtesy: AAO 2011
MANAGEMENT
A. Assure pt that her vision is unsalvageable,
she needs to start Plavix to prevent a stroke
 B. Send pt to emergency department STAT
 C. Compress and release the eye right now
 D. You don’t know what this is, so you make a
regular referral to ophthalmologist in 2-3 weeks

CRAO
Central retinal artery occlusion often secondary
to embolus in a vasculopathic patient
 Ophthalmological emergency
 Immediate restoration of retinal blood flow is
necessary to save sight
 Even with compress, sight is often not
salvageable.
 Need to evaluate etiology

CASE 4
85F comes to GP for sudden vision loss today
 2 months of transient double vision
 She has been feeling fatigued with muscle and
joint aches for the last 6 months
 New headache in her R temple particularly
when she combs her hair
 Her jaw is painful when she’s eating

BMJ 2011, 343d4783
CASE 4
OD LP, OS 20/40
 R pupil 3mm RAPD
 EOM full
 VF: wide spread loss
 Anterior segment
normal
 ESR from last week:
80 mm/h

Dx:
A. Temporal arteritis
B. Amaurosis fugax
C. Multiple sclerosis
D. Compressive optic
neuropathy
NEXT STEP?
A. Urgent neurology referral as stroke is
imminent
 B. Start patient on high dose steroids
empirically because benefits outweigh risks
 C. Ophthalmology referral for a temporal artery
biopsy to confirm diagnosis
 D. Urgent MRI of brain as it’s most sensitive
and specific for confirming a central lesion

TEMPORAL ARTERITIS
Aka giant cell arteritis. Another classic
ophthalmological emergency
 Suspect in older women with new headache,
vision loss, and systemic sx
 Elevated ESR/CRP helps to rule in dx
 Must initiate high dose steroids immediately
followed by temporal artery biopsy

SUMMARY
Approach: Hx, Va, Pupils, out to in, front to back
 Acute vision loss is often a sign of serious
ocular disease process:

 Acute
angle closure glaucoma
 Retinal detachment
 Central retinal artery occlusion
 Temporal arteritis
Urgent ophthalmological referral is needed
(timeframe usually minutes to hours)
 Immediate action is also required; time is sight

QUESTIONS ?

Acknowledgement
 Case

editor: Steven Schendel, PGY-4 UBC
Contact
R
Tom Liu, UBC Med 2013
 [email protected]