Transcript Acute Painless Loss of Vision

Acute Painless Loss of Vision
Syed Hasan
Acute Painless Loss of Vision
• The second most common ophthalmic
emergency (after red eye)
Loss of vision
Painless
Few seconds duration
•Unilateral
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Giant cell arteritis
Papilloedema
Impending central retinal vein occlusion
Ocular ischemic syndrome
•Bilateral
– Papilloedema
Loss of vision
Few minutes duration
• Unilateral
– Amaurosis fugax
– Giant cell arthritis
• Bilateral
– Vertebrobasilar artery insufficiency
Up to one hour duration
• Migraine
Loss of vision
Persistent
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Central/Branch retinal artery occlusion
Central/Branch retinal vein occlusion
Retinal detachment/Viterous haemmorhage
Posterior uveitis
Anterior ischaemic optic neuropathy
Optic neuritis
Macular degeneration
Cortical blindness
Functional
Toxins/Drugs
Amaurosis Fugax
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Monocular or Binocular transient visual loss.
Monocular: Anterior to Chiasm
Binocular: At or posterior to Chiasm
Duration: Shorter duration=Thromboembolic, Longer Duration=Migraine.
D/D: Embolism, Retinal vasospasm, CRVO, Optic Neuropathy, migraine,
presyncope, seizure, vertebrobasilar ischemia.
Full neurological and cardiovascular workup, ECG, Echo, Carotid Doppler,
ESR and CRP if age >50
20% ultimately undergo carotid endarterectomy.
High risk of CVA.
Rx: Anticoagulants, Antiplatelet agents, Carotid Endarterectomy.
Retinal Ischemia- Ca channel blockers.
Central Retinal artery occlusion
• Acute, painless, monocular, persistent and nearly complete loss of vision.
• 1-2% Bilateral.
• 60% are hypertensive, 20% with cardiac history and others with
hypercoagulable conditions e.g diabetes.
• 5 year mortality is 1/3rd of age matched controls without CRAO.
• O/E: Pale retina, Cherry red spot, Arteriolar segmentation
• 15-30% Cilio-retinal artery- Good prognosis
• No standard treatment of proven benefit.
• Ocular massage, reduction of IOP, Antiplatelet, Anticoagulant and
Fibrinolytic therapy. Hyperbaric oxygen, Steroids
• R/O GCA
Central/Branch retinal artery occlusion
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Artheroscleotic plaque in the carotid
Embolus from a cardiac valve
Systemic vascular disease
Hyperviscosity syndromes
Trauma – fat emboli
Oral contraceptives
• Systemic diseases – DM, syphilis, sickle cell
• Injections of medications around the head
and neck
• Temporal arteritis
• Drug abuse
Central Retinal Vein Occlusion
• Acute, painless vision typically upon waking up.
• Ischemic or Non ischemic
• High IOP, Diabetes, Hypertension, Cardiovascular Disease,
Hypercoagulable state.
• Reduced visual acuity, RAPD and widespread retinal haemorrages.
• Rx: Underlying condition, Aspirin
• Macular edema: Intravitreal injections of Anti-VEGF agents and Steroids.
• Complications: Rubeotic glaucoma
Central/Branch retinal vein occlusion
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Artherosclerotic vascular disease
Arterial hypertension
Diabetes
Hyperviscosity
Open angle glaucoma, trauma closed angle glaucoma, vascular hypertension
Painless monocular visual loss
Ischaemic optic neuropathy
• Incidence: 10/100,000/yr of over
50 age group.
• 5-10% are Giant Cell arteritis rest
are Non-Arteretic AION.
• ARTERETIC AION
• Sudden loss of vision, Headache, Scalp tenderness, Jaw claudication, Wt
loss, night sweats, myalgia, PMR
• Rapd, Swollen disc, can present as CRAO, BRAO or cranial nerve palsies.
• High ESR, CRP and platelets. TABx 90% sensitivity
• Rx: 3 days of I/V methylprednisolone 1g, followed by oral prednisolone 6080mg/ day. Taper treatment according to response. Aspirin helpful.
• Risk of second eye involvement is 10% in treated case and upto 90% in
untreated cases.
• NON-ARTERETIC AION
• Compromised circulation leads to disc swelling and infarction.
• Major causes are Diabetes, Hypertension, Smoking, Hyperlipedemia,
Hypotension, Aneamia, Obstructive sleep apnoea
• ESR, CRP and PLTs normal.
• No proven treatment
• Second eye involvement 19% over 5 years.
Optic neuritis
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Papillitis, Reterobulbar-Neuritis, Neuroretinitis.
Most common cause is Demylenation
Incidence: 5/100,000/yr, F/M 3:1, usually unilateral.
70% in MS sufferer.
Rapid loss of vision within hours to days, recovery within 2 weeks.
Clinically reduced Contrast sensitivity, color vision, Field loss and
reterobulbar pain. RAPD
Rx: Controversial role for steroids. I/V steroids hastens recovery.
90% show good recovery
Atypical Optic Neuritis.
D/D: SOL, Sarcoidosis, Vasculitis, AION, Toxic, Nutritional, Postviral.
Retinal detachment
• More common in men
• Rate 10 per 100,000 people per
year
• Bilateral in up to one third
• Associated with
a) Degenerative myopia
b) Lattice degeneration
c) Aphakia, Cataract Surgery
d) Diabetes, sickle cell disease
Vitreous haemmorhage
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7 In 100,000 each year
Sudden dramatic painless loss of
vision.
Preceded by floaters.
Diabetes, Hypertension, Sickle cell
disease, macular degeretion, CRAO,
CRVO, Valsalva, Retinal Detachment,
Ocular Trauma, PVD with Tear, Blood
disorders, Warfarin.
B-Scan
Rx: Viterectomy
Toxic/Drugs
• B12, Folate deficiency.
• Amiodrone, Ethambutol, Methanol, CO, Isoniazid, Lead
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