12. Acute Vision Loss

Question 1

medial opacities due to corneal edema, lens changes, vitreous opacities, retinal changes due to retinal detachment, macular age related degeneration dry/wet, or vascular diseases, optic nerve, CNS visual pathways, functional, acute discovery of chronic visual loss

Answer 1

etiologies of acute vision loss

Question 2

commonly caused by intraocular pressure, often caused by acute glaucoma, cornea becomes dull with ground glass appearance, less commonly presents with ulcers, corneal dystrophies, and surgery, any acute infection/inflammation can mimic

Answer 2

corneal edema

Question 3

acute onset, severe ocular pain, mid-dilated fixed pupil, blurred vision, haloes around lights, headache, nausea

Answer 3

acute angle closure glaucoma

Question 4

cataracts, generally develop slowly with associated aging, clear lenses can develop large refractive changes due to osmotic shifts like poor VA which can be improved with refraction

Answer 4

lenticular changes

Question 5

blood in the anterior chamber, decreased visual acuity is dependent on % of it, generally secondary to blunt trauma, less commonly secondary to neovascularization

Answer 5

hyphema

Question 6

bleeding into the vitreous similar to hyphema, but resolves slower, due to diabetic retinopathy with neovascularization, retinal break/detachment, posterior vitreous detachment, or trauma, diagnosis made through dilated pupil

Answer 6

vitreous hemorrhage

Question 7

hallmark of photopsia -flashes of light- and floaters, often followed by a shade in the visual field, generally begins peripherally & dissects posteriorly, diagnosis is through a dilated pupil generally by an opthalmologist

Answer 7

retinal detachment

Question 8

poor vision but generally not relative afferent pupillary defect, sudden visual loss or metamorphopsia from bleeding from a neovascular net, older patients may also have macular degeneration dry/wet - neovascular- or sudden loss of vision due to wet macular degeneration -neovascular-

Answer 8

macular disease

Question 9

temporary arterial obstruction, sudden transient vision loss, monocular dimming of vision, evaluation includes cardiovascular, cerebrovascular, opthalmologic, and migraine (classic vs. opthalmic)

Answer 9

amaurosis fugax

Question 10

scintillating scotoma, amaurosis fugax, transient cortical blindness, homonymous hemianopia, classic or opthalmic

Answer 10

migraine visual symptoms

Question 11

true ocular emergency, sudden painless visual loss, appearance depends on timing, minutes to hours can be due vascular stasis, boxcarring, hours can be opaque retina with a cherry red spot, vision changes can include light perception or worse, pupils can have relative afferent defects, treat with digital massage to compress the eye with the heel of the hand firmly for 10 seconds then release for 10 seconds for 5 minutes, glaucoma medications, and emergency call to opthalmologist, months later may have a blind eye with a pale optic disc but vasculature may be unremarkable

Answer 11

central rentinal artery occlusion

Question 12

only a branch of the central artery is involved, more commonly associated with an embolus, source from cardiac, talc, fat, or vasculitis, vision is variable, scotoma depends on size and location

Answer 12

branch retinal artery occlusion

Question 13

often severe vision loss but subacute onset, blood and thunder appearance meaning disc swelling, diffuse retinal hemorrhages, venous engorgement, and cotton wool spots, generally older patients, can be from hypertension, arteriosclerotic vascular disease, diabetes mellitus, glaucoma, hyperviscosity syndromes, smoking, workup with general medical exam and opthalmology, late complications include neovascular glaucoma

Answer 13

central retinal vein occlusion

Question 14

idiopathic inflammation of the optic nerve, may be associated with multiple sclerosis, relative afferent pupillary defect is a classic sign, prognosis generally good after 1st attachment especially if young, treat with parenteral corticosteroids

Answer 14

optic neuritis

Question 15

subgroup of optic neuritis involving optic nerve therfore the optic nerve is swollen with disc edema, also relative afferent pupillary defect

Answer 15

papillitis

Question 16

young adult with monocular progressive loss of vision over hours to days, pain on ocular movement, opthalmoscopic exam is unremarkable with sharp disc, poor vision, pain on extraocular motion, positive relative afferent pupillary defect, differential diagnosis includes compressive optic neuropathy, if presentation is acute with vision loss, order CT/MRI of the orbits and chiasm to evaluate for compressive lesion

Answer 16

retrobulbar neuritis

Question 17

generally >57 yo patient, sudden monocular loss of vision with 40% of them bilaterally, symptoms include cephalgia, scalp tenderness, jaw claudication, malaise, weight loss, low grade fever, arthrlagias polymagia rheumatica, limb girdle pain

Answer 17

ischemic optic neuropathy

Question 18

arteritic, relative afferent pupillary defect, pale swollen optic nerve and altitudinal visual field defect, long prodrome may precede visual loss, if suspected, STAT erythrocyte sedimentation rate, suggestive if >60 mm/hr, institute high dose systemic steroids, then must obtain temporal artery biopsy, general aim is to preserve the fellow eye or prevent cerebrovascular accident or myocardial infarction

Answer 18

anterior ischemic optic neuropathy

Question 19

concessive forces causeing a shearing of the vascular supply, avulsion of the optic nerve, severe vision loss, optic nerve tears at lamina cribosa as a result of sudden retropulsion followed by anterior displacement, rare

Answer 19

trauma

Question 20

vascular occlusions in the CNS, ischemic or hemorrhagic infarcts of pathways or cortex, homonymous quadranopia or hemianopia, can be macular sparring, cortical -central/cerebral- blindness is rarer and will present blind with normal pupils & fundus

Answer 20

visual pathways

Question 21

hysterical or malingering, incompatibile or inconsistent exam

Answer 21

functional disorders

Question 22

verify by old records or exam

Answer 22

acute discovery of chronic vision loss

Question 23

corneal abrasion/ulcer/edema, iritis, acute glaucoma, optic neuropathy like optic neuritis, giant cell arteritis

Answer 23

painful vision loss

Question 24

retrobulbar neuritis, temporal arteritis

Answer 24

vision loss associated with pain

Question 25

retinal detachment, macular disease, rentinal vascular occlusions like central retinal artery occlusion, branch retinal artery occulsion, central retinal vein occulsion, branch retinal vein occulsion, optic nerve disease like papillitis and ischemic optic neuropathy, cerebral vascular accidents

Answer 25

painless vision loss with clear media

Question 26

cornea edema, hyphema, cataracts, vitreous hemorrhage

Answer 26

painless vision loss without a clear media/cloudy media