Transcript Vision Loss
Vision Loss KHADER M.FARWAN Objectives • Review of eye anatomy • Refine history and examination of the eye • Work through emergent causes of sudden monocular vision loss in a case-based format Spelling Review Ophthalmology Anatomy Review Function & transperancy Anatomy Review Anatomy Review • • • • • • Eyelids Tears Cornea Aqueous Lens Vitreous Anatomy Review • Retina – Fovea / “Macula” – Central retinal artery supplied by branch of ophthalmic artery (1st major branch of internal carotid) Anatomy Review • Optic nerve or retinal lesions do not respect vertical meridian • Defects that clear or start at vertical midline signify lesion at chiasm or beyond http://eyesite.ucsd.edu/viewpoint/images/glaucoma.jpg Vision Loss • Categorization – – – – Total or Partial One or Both eyes Sudden or Gradual Painful or Painless History • Question – How long ago? – How sudden? – Course? Danger Signs Recent Sudden: ischemia or bleed Worsening History • What do they see? – Flashes or floaters – “Curtain” rising or falling – Central patch or distortion • Key symptoms – Pain or headache – Nausea / Vomiting History • In addition to general Hx/Px: – Usual corrective glasses / contacts? Still in? – Previous transient episodes? – Trauma? Examination • • • • • • Visual acuity Visual field testing Swinging light test Direct ophthalmoscopy Dilating the eye Tonometry Examination • Visual acuity – Snellen chart • 20 feet distance • Credit for a line if most letters correctly identified • If acuity poorer than largest letter (eg 20/200), measure distance pt can read it (eg 5/200 at 5 feet) Examination • Visual acuity – Practically, if that poor, acuity described by • Finger-counting • Hand-motion • Light perception Examination • Visual acuity To correct refractive error: 1) Use pin hole 2) Use ophthalmoscope Examination • Visual field testing – Confrontation – With the patient looking at your nose, ask if your nose and other facial features are seen clearly • Inability to clearly see your: Nose => central scotoma Eyes or lips => paracentral scotoma Ears => peripheral visual field defect Examination • Swinging light test – Relative Afferent Pupillary Defect (RAPD) – See http://www.richmondeye.com/apd.htm – “Marcus-Gunn Pupil” – Significant retinal or optic nerve disease, in one eye more than the other – Very helpful for Ophtho to know in consult Examination • Direct ophthalmoscopy – Close as possible • Remove your glasses • Switch viewing eye – Start at zero correction • Or to correct observer refraction (eg – 4 diopters) • Rotate counter-clockwise for near-sighted pt Better use of the ophthalmoscope. Luff A, Elkington A. Practitioner. 236(1511): 161-5 Examination • Direct ophthalmoscopy – Red Reflex • • • • Compare brightness and color at 1-2 feet Indicates media free of opacity Not always easy to do, helpful if (N) “Eight-ball” Vitreous hemorrhage – Move in along line of red reflex • Aim for opposite mastoid process • Often brings optic disc straight into view Examination • Direct ophthalmoscopy – Place free hand on forehead • Prevents facial contact • Resting own forehead on thumb stabilises image • Able to lift upper lid if necessary – Comfort • Encourage subject to keep breathing during examination • Sit patient up, avoid hunching Examination • Direct ophthalmoscopy – Use anti-glare filter – Try red-free filter for better vessel visualization Examination • Direct ophthalmoscopy – PanOptic Ophthalmoscope • Greater field of view • “5x larger view of fundus” • USD $400 range Anatomy Review Optic disc • Color: Yellow-orange, central cup whiter • Size: Cup less than half diameter of disc • Margin: Sharp (may be less sharp nasally) imc.gsm.com/integrated/ bcs/heent/page14.html Anatomy Review Fovea / “Macula” • Color: Slightly darker, devoid of retinal vessels • Size: Same as disc • Location: Temporal and slightly inferior to disc imc.gsm.com/integrated/ bcs/heent/page14.html Anatomy Review Vessels Cilioretinal artery • Size: 3:2 Vein:Artery • Caliber: look for abnormal tortuosity • 4 main vascular arcades – Superior- & Inferior– Nasal & Temporal imc.gsm.com/integrated/ bcs/heent/page14.html Examination • Direct ophthalmoscopy – Four quadrant scan – Follow vessels to periphery (may need to re-focus) – Get pt to look at the light to see macula Examination • Dilating the eye – Especially important for suspected • Intraocular FB • Central retinal artery occlusion • Retinal detachment – Hesitancy amongst non-ophthalmologists Examination • Dilating the eye Tropicamide 1% Mydriasis and glaucoma: exploding the myth. A systematic review. Pandit RJ, Taylor R. Diabet Med. 2000 Oct;17(10):693-9 “Risk of inducing acute glaucoma following … tropicamide alone close is to zero, no case being identified” Near fatal anticholinergic intoxication after routine fundoscopy. Brunner GA, et al. Intensive Care Med. 1998 Jul;24(7):730-1. Examination • Dilating the eye Tropicamide 1% Contraindications: • Acute head injury/coma • Acute or intermittent angle-closure glaucoma (but NOT chronic open-angle glaucoma) • Probably anyone at high risk for above (eg. Older asian lady, severely far-sighted person) Examination • Dilating the eye Tropicamide 1% – Onset 10-15 mins, duration 4-6 h – Side effects: blurred vision, light sensitvity – Safety: must not drive for 6 h The effect of pupil dilation with tropicamide on vision and driving simulator performance. Potamitis, T., et al. Eye. 2000 Jun;14 (3A):302-6 Examination • Tonometry Tonopen – Contraindicated if suspected ruptured globe – Ttono = 10 – 21 mm Hg (N) – False elevation IOP • Blepharospasm (“squeezers”) • Avoid pressure on the eye by holding eyelids only against bony orbital rim Case 1 SUDDEN, TOTAL LOSS, ONE EYE • 70 yo F with HTN, DM lost vision in one eye over a few minutes earlier this morning. • No trauma. No eye pain, or N/V • Findings: – (N) External eye and EOM, red reflex – (N) Acuity on left, only hand motion right – RAPD+ – (N) Fundoscopy unaffected eye Case 1 • Retina pale • “Cherry Red Spot” fovea • Splinter hemorrhage Clinical Eye Atlas Case 1 • Diagnosis? • Treatment? a) Massage eyeball b) Timoptic drops c) Sticking a needle in the eye Clinical Eye Atlas Central Retinal Artery Occlusion • Sudden painless monocular loss of vision • May have history of previous transient episodes. “Amaurosis fugax” http://meded.ucsd.edu/isp/1994/im-quiz/images/crao.jpg Central Retinal Artery Occlusion • Retina infarction => pallor, edema, less transparency • Irreversible damage begins at 90 mins http://meded.ucsd.edu/isp/1994/im-quiz/images/crao.jpg Central Retinal Artery Occlusion • Macula, thinnest portion, remains visible • Cherry red spot may take 24 h to develop • Visual acuity may be normal if cilioretinal vessel patent http://www.umanitoba.ca/faculties/medicine/units/ophthalmology/tutorial_folders.html/images/Cra.jpg Central Retinal Artery Occlusion • Causes – – – – – – Embolic (carotid, cardiac) Thrombosis Temporal arteritis Vasculitis (eg. lupus) Sickle cell disease Trauma www.emedicine.com/emerg/ images/521crao1.JPG Central Retinal Artery Occlusion • Treatment Attempt moving embolus distally: – Digital massage • Firm steady pressure x 15 seconds, release, repeat – IOP lowering drugs • Beta-blockers/CAI/alpha-agonists… – +/- Vasodilation techniques • Rebreathing to increase PaCO2 Central Retinal Artery Occlusion • Treatment – Consult ophthalmology immediately • Paracentesis anterior chamber • ?? HBO, thrombolytics – Locate source • ESR for temporal arteritis • ECG for A. fib • Medicine consult (Carotid doppler, ECHO?…) How to Tap an Eye Anterior chamber paracentesis 1. 2. 3. 4. Administer local anesthesia Use a 30-gauge needle on a tuberculin syringe Enter the eye at the limbus with bevel up Ensure that the needle does not damage the lens 5. Withdraw fluid until the anterior chamber shallows slightly (0.1-0.2 cc) 6. Administer a topical antibiotic post-procedure http://www.emedicine.com/oph/topic387.htm Central Retinal Artery Occlusion • Complications – Vision loss • Prognosis poor in most • But up to 10% retain central vision (acuity improves to 20/50 or better in 80% of those) – Recurrent thromboemboli • CVA • Further visual loss to same or contralateral eye – Progression of temporal arteritis Case 2 PARTIAL LOSS, ONE EYE • A 60 yo M with HTN and DM complains of progressive loss of vision in one eye over the last 2 days. • No other symptoms • Painless uniform dulling of vision. • Findings: – – – – (N) External eye and EOM Acuity 20/25 OD, 20/200 OS RAPD+ (N) Fundoscopy unaffected eye Case 2 How would you manage this at 2 AM? a) b) c) d) e) Immediate ophtho consult Thrombolytic therapy Decrease the intraocular pressure Globe massage to dissolve clot None of the above Clinical Eye Atlas Case 2 Unmistakable fundoscopy: • “Blood and Thunder” or “Ketchup fundus” • Dilated tortuous veins • Flame hemorrhages • Disc edema Clinical Eye Atlas Central Retinal Vein Occlusion • Key facts – 10 times more common than CRAO – Painless monocular loss of vision over hours to days – Vision may improve through the day – ? CRV impingement by lamina or atherosclerosis of CRA • Ischemic vs. non-ischemic types Central Retinal Vein Occlusion • Risk Factors – – – – – – Age > 50 Diabetes HTN Hyperviscosity syndromes Glaucoma Recurrent amaurosis fugax http://www.umanitoba.ca/faculties/medicine/units/ophthalmology/tutorial_folders.html/images/CRV_occlusion Central Retinal Vein Occlusion Non-ischemic – Good vision – RAPD absent – Fewer retinal hemorrhages – Cotton-wool spots • May resolve fully or progress to ischemic type http://webeye.ophth.uiowa.edu/dept/crvo/fig12.htm Central Retinal Vein Occlusion Ischemic – Severe visual loss – RAPD+ – Extensive retinal hemorrhage and cottonwool spots http://webeye.ophth.uiowa.edu/dept/crvo/fig12.htm Central Retinal Vein Occlusion • Treatment – No known effective treatment or prevention – Ophthalmology may consider: • • • • • ASA Anti-coagulation Fibrinolytics Corticosteroids Anti-inflammatories Central Retinal Vein Occlusion • Treatment – Medical follow-up to screen for atherosclerosis and other risk factors – Ophthalmology assessment to follow for late complications (~ 3 mos) Central Retinal Vein Occlusion • Complications – Ocular neovascularization • Anterior => neovascular glaucoma • Posterior => vitreous hemorrhage – Poor vision (20/200 or worse in 90%) Case 3 • A 50 yo M presents with a 2 day history of persistent flashing lights and floaters in one eye, as well as a tiny shadow in one corner • Findings: – – – – – (N) External eye and EOM (N) Acuity 20/20 bilaterally (N) Visual field testing RAPD absent (N) Fundoscopy unaffected eye Case 3 • At 2 AM would you: a) b) c) d) Send home with GP follow-up Instill tropicamide and repeat exam Call ophthalmology immediately Keep the patient overnight for ocular U/S Retinal Detachment • Separation of inner sensory layers from underlying RPE – Tear in retina – Traction – Subretinal fluid • Mechanical stimulation of retinal tissue. http://www.vilegel.com.au/diseases/retinaltear/rt3.jpg Anatomy Review www.avclinic.com/ photodynamic_therapy.htm Potential space with no adhesions between layers Retinal Detachment • Risk Factors – – – – – Severe myopia (eg. –12 to –15) Advanced age Previous cataract surgery Blunt trauma Family history Retinal Detachment • History – – – – Shower of black spots or floaters Flashing lights (photopsia) From a “shadow” in periphery to “dark curtain” Wavy distortion of objects (metamorphopsia) Retinal Detachment • Beware! – Visual field defects • Late sign • Patients less aware of superior field defects • Most common defect is inferiorly (hard to detect because of nose) – Fundoscopy • Dilated eye exam a MUST (maybe not by us) • Detachments start in periphery, difficult to visualize Retinal Detachment • Beware! – Location • Superior field defect indicates an inferior retinal detachment • Detachments of the superior retina are far more serious – May rapidly extend inferiorly to involve the macula and thereby cause the loss of central vision. Retinal Detachment http://www.vilegel.com.au/diseases/retinaltear/rt3.jpg Retinal Detachment • Treatment – Consult ophthalmology immediately any time of night esp. if “mac on” – Prevent worsening RD • Bed rest, supine if superior RD • Protect eye from trauma (eg. metal eye shield) http://insight.med.utah.edu/opatharch/images/retina/22078.jpg Retinal Detachment • Treatment – Transient floaters not as urgent • Full exam in clinic likely needed • Home with ophtho call and follow-up • WARNING: RT ED if FURTHER flashing lights or floaters, LASTING more than seconds Case 4 SUDDEN, TOTAL LOSS, ONE EYE • 60 yo F with a unilateral headache for one week lost all vision in her right eye over a few minutes. • No trauma, eye pain, or N/V • Findings: – – – – – (N) External eye and EOM (N) Acuity on left, only hand motion right RAPD+ Visual field testing normal (N) Fundoscopy unaffected eye Case 4 The patient most likely has a) Papilledema b) CRAO c) CRVO d) Ischemic Optic Neuropathy (ION) e) Temporal arteritis Clinical Eye Atlas Case 4 vs Case 1 Pale, swollen optic disc Clinical Eye Atlas Anterior Ischemic Optic Neuropathy (AION) • Acute ischemia or infarction optic nerve head – Arteritic – Non-arteritic http://webeye.ophth.uiowa.edu/dept/AION/fig4.htm Anterior Ischemic Optic Neuropathy (AION) • Sudden unilateral loss of vision – May be altitudinal • Pallid optic disc swelling – “Chalky white” http://webeye.ophth.uiowa.edu/dept/AION/fig4.htm http://webeye.ophth.uiowa.edu/dept/AION/7-AION-features.htm Arteritic (AAION) • Association with Temporal Arteritis • Suspect if – – – – Age >50 Headache Jaw pain or fatigue on chewing (claudication) Scalp tenderness • Puts other eye at up to 50% risk of same Arteritic (AAION) • Treatment – Send ESR and start steroids if elevated Prednisone 60-100 mg PO OD – Temporal artery biopsy within 1 week Non-Arteritic (NAAION) • Presumably atherosclerotic • Treatment – Follow-up for atherosclerotic risk factors – ASA Case 5 SUDDEN, PARTIAL LOSS, ONE EYE • 60 yo M with migraine history complains of painful blurry vision in one eye over a few minutes. • No trauma. Unlike past migraines • Significant nausea, vomiting, diaphoresis • Findings – Red eye – Only hand motion visual acuity one eye – Unable to examine further because of photophobia Case 5 SUDDEN, PARTIAL LOSS, ONE EYE • 60 yo M with migraine history complains of painful blurry vision in one eye over a few minutes. Acute Angle Closure Glaucoma • Aqueous humor produced in posterior chamber • Blockage of normal drainage and circulation to anterior chamber • Increasing IOP worsens outflow as iris pushed forward – Often 40-80 mm Hg Acute Angle Closure Glaucoma • History – Sudden onset – Precipitant • • • • • Bending forward Dark environment Illness or sympathetic overdrive Dilating drops Anticholinergic med (even benadryl!) Acute Angle Closure Glaucoma • History – – – – – Pain (eye, head, ear, sinuses, or teeth) Photophobia Vision: blurry, halos or starbursts around lights Nausea / Vomiting Diaphoresis ** May mimic migraine, heart, or GI disease because of systemic complaints • Exam – Decreased visual acuity – Red eye – Pupil • Sluggish mid-dilated • Can be irregular (eg. slightly oval) – Corneal haziness – Eyeball firm to palpation http://www.emguidemaps.homestead.com/files/redeye.html www.kocmut.com/assets/ images/glaucoma.JPG Acute Angle Closure Glaucoma • Exam – Anterior chamber • Shallow • “Shadow sign” • Cells and flare www.opt.indiana.edu/riley/HomePage/Direct_Oscope/Text_Direct_Oscopt.html www.hypertension-consult.com/Secure/textbookarticles/Primary_Care_Book/126.htm Acute Angle Closure Glaucoma • Treatment – – – – Immediate ophtho consult Treat pain and nausea Avoid dilating drops! Lower IOP Acute Angle Closure Glaucoma • Treatment – Block aqueous production • Beta blocker (eg. Timolol 0.5% 1 drop) – Onset 30 mins, peak 1-2 h – Caution if asthma, heart failure, heart block • CAI (eg. Acetazolamide 500 mg IV/PO/IM) – Avoid in sulfa allergy, renal insufficiency • Alpha-2 agonist (eg. Apraclonidine 1 drop) – Additive effect Topical Eye Drops 1. Nasolacrimal occlusion 2. Eyelid closure – Simple techniques – Decrease systemic absorption (by 60%) – Increases bioavailability Improving the therapeutic index of topically applied ocular drugs. Zimmerman TJ, et al. Archives of Ophthalmology. 102(4):551-553, 1984. Acute Angle Closure Glaucoma • Treatment – Reduce vitreous volume • Hyperosmotic agents (eg. Mannitol 1-2 g/kg IV) Acute Angle Closure Glaucoma • Treatment – Improve aqueous outflow • Supine position – May help iris fall back posteriorly • +/- Miotic agent (eg. Pilocarpine 1 drop q15 mins) – Often requires IOP < 40 mm Hg before effective – Beware… WORSENS certain AACG types Case 6 ACUTE, PARTIAL LOSS, ONE EYE • 30 yo F with recent URI noticed pain and decreased vision in one eye over a few days. • No trauma, or N/V • Findings: – Red eye and painful EOM – RAPD+ – (N) Acuity – (N) Fundoscopy Optic Neuritis • Key Points – Relatively common and important cause of visual loss – Usually in young adults, esp. caucasian women – Commonly first manifestation of MS – Presumably autoimmune reaction with demyelinating inflammation of optic nerve Optic Neuritis • History – May have preceding viral illness, or previous episodes – Usually monocular – Pain • Variable degree • Worse on eye movement – Vision loss • Exacerbated by heat or exercise (Uhthoff phenomenon) • Central scotoma or altered color/brightness/depth perception Optic Neuritis • Exam – – – – Visual acuity variable RAPD + Field defects (central scotoma, altitudinal, arcs) Fundoscopy • Often normal (retrobulbar in 2/3) • +/- Pale or swollen disc Optic Neuritis • Management – Consult ophtho and neurology – Steroids? Beck RW, Cleary PA, Anderson MM, et al: A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. N Engl J Med 1992;326:581-588. Optic Neuritis Study Group: The 5-year risk of multiple sclerosis after optic neuritis: experience of the Optic Neuritis Treatment Trial. Neurology 1997;49:1403-1413. Optic Neuritis • Optic Neuritis Treatment Trial (ONTT) – Vision • Speeds recovery • No effect on visual outcome at 5 yrs – AVOID oral steroids due to increased recurrence – Multiple Sclerosis • IV steroids may help decrease short-term risk of MS • No long term protection Summary 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 Acute Angle Closure Glaucoma Yes +/- Painful red eye, hazy cornea, irregular pupil, “shadow sign”, firm globe Optic Neuritis Yes Yes Painful EOM, young female pt Summary Urgency Can wait till AM? ED Treatment CRAO CALL IMMEDIATELY Only if subacute (Many days old) Orbital massage Lower the IOP CRVO CALL when convenient Yes, wait ASA RD CALL IMMEDIATELY At their discretion Bed rest supine Eye shield AION CALL if TA, severe Yes, wait sx, uncertain dx, can wait if not TA Steroids if TA Acute Angle CALL Closure IMMEDIATELY Glaucoma No Lower the IOP Treat N/V Optic Neuritis Yes, for ophtho AVOID oral steroids CALL THANK YOU Traumatic Optic Neuropathy • Mechanism: – Hemorrhage of optic nerve sheath – Avulsion optic nerve – Most cases retrobulbar (no external or ophthalmoscopic evidence of injury) • Difficulties: – Poor correlation between severity of impact and degree of visual loss. – Visual deterioration immediately or after several hours Traumatic Optic Neuropathy • Management: – Controversial – Anecdotal evidence for steroids – Role and timing of surgical tx unclear (reserved for those who fail to improve, or deteriorate despite steroids?) Acute visual loss and other disorders of the eyes. Laskowits et al. Neurology Clinics of North America. 16 (2) p. 323-49. May 1998.