13. Chronic Visual Loss

Question 1

signficant cause of blindness in the USA, most frequent cause of blindness in African Americans, if treated early medically or surgically blindness can be prevented, insidious with symptoms and visual field loss like scotoma, late vision loss can lead to blindness, can be primary open angle glaucoma, angle-closure, congenital, secondary, triad of elevated intraocular pressure >21 with normal at 10-21 mmHg, optic nerve damage with generally increased cup to disc ratio, and visual field loss, tonometry is done to measure pressure but first anesthetize cornea with proparacaine, separate the lids without pressure, tonopen is an electric device making this less cumbersome, also use pneumotonmetry air puff, Icare, and goldmann tonometer is current gold standard, scotoma worsens visual field over time, primary open angle glaucoma is 2/3 of all glaucoma cases, tends to be familial, bilateral but can by asymmetric, risk factors include being >50 years old, family history, African/American, and myopia, treatment with beta blockers, surgical treatment is by laser trabeculoplasty, filtering surgery, cyclodestructive surgery of the ciliary body, or placement of aqueous drainage devices

Answer 1

glaucoma

Question 2

acute onset, severe ocular pain, mid-dilated fixed pupil, blurred vision, haloes around lights, headache, nausea/vomiting, precipitated by physical or emotional stress, natural dilation of the pupil, dilating drops, sympathomimetic drugs, initiate medical therapy with pilocarpine, acetozolamide, and IV mannitol, then refer to opthalmology

Answer 2

acute angle closure glaucoma

Question 3

common, chronic, no pain but gradual elevation of it, normal pupil, insidious loss of vision, no haloes, no pain, no nausea

Answer 3

open angle glaucoma

Question 4

congenital glaucoma

Question 5

IOP > 21 mmHg, IOP not elevated but with a difference of >5 mmHg, cup to disc ratio >0.5, cup to disc difference > 0.2, symptoms of acute glaucoma

Answer 5

indications for referall to opthalmology

Question 6

occur in 50% of people 65-74 years old, occur in 70% over 75 years old, normal aging process of the lens, very common correctable cause of decreased vision, most successful operation in all of surgery, patient may first notice small blur, increased myopia or second sight when reading without glasses, also monocular diplopia or multiple images or starbursts, decreased colors with things turning browner, yellowed, or duller, many different types, laser surgery can cause it by mistake, to determine if visual loss is secondary to this, measure visual acuity, pupillary reaction will not have dense relative afferent pupillary defect, slit-lamp examination, and opthalmoscopy to evaluate the macula and optic nerve, refer when decreased vision interferes with patients daily activities of living, patient decides if surgery is needed, not the physician, chronic visual loss is associated with increased motor vehicle accidents and falls

Answer 6

cataracts

Question 7

leading cause of blindness in patients >60 years old, recognize and refer since possible laser surgery treatment, often no treatments are effective, important to distinguish from other causes of visual loss, cataracts, or glaucoma, progressive deterioration of vision, risk if patient is over 60, previous family history, smoking, caucasian race, cardiovascular disease, obesity, no treatment if atrophic form, but low vision aid lights, use of magnifiers, talking books, electronic TVs, and motivation, difficulty reading, driving, straight lines may be crooked, advanced disease may have central blind spot, peripheral vision remains good so they will have independent living skills, apperance of a macula is a poor predictor of visual acuity, refer if acute change in vision, recent onset of metamorphopsia, recent onset of scotoma, opthalmoscopic abnormality in macula drusenm RPE changes, subretinal neovascular membrane in 10-15%

Answer 7

macular degeneration

Question 8

gradual loss of vision with drusen hyaline nodules in Bruch’s membrane

Answer 8

atrophic/dry age related macular degeneration

Question 9

sudden loss of vision with subretinal neovascularization and accumulation of fluid and blood

Answer 9

exudative/wet age related macular degeneration

Question 10

monitor vision with amsler grid, smoking cessation, control cardiovascular disease and hypertension, antioxidant vitamin supplementation, UV protection, vitamin C supplementation which was proven in study to be important, periodic dilated exam and optical coherence tomography

Answer 10

minimizing effects of age related macular degeneration

Question 11

treatments are designed to destroy or inactivate abnormal blood vessels that are growing under the retina, treatment options in 2020 include, photodynamic therapy - cold laser, intravitral injection, combination therapy

Answer 11

treatment for wet age related macular degeneration