Acute painless loss of vision Flashcards by Fred Kelting

What investigations are indicated in the pt w/ APVL?

Visual acuity test
Visual fields
Pupil exam
Fundocopy (+ red reflex + anterior segment inspection using torch)

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How are the causes of acute painless loss of vision (APVL) grossly split?

Monocular causes
Binocular causes
Retinal causes

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What are the monocular causes of APVL

1) Acute corneal disease
2) Anterior chamber haemorrhages (cause hyphaema)
3) Vitreous heamorrhage
4) Optic neuritis/ischemic optic neuropathy
5) Acute cataract (rare)

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What are the signs + symptoms of acute corneal disease?

Pain (painless if due to HSV)
Cloudy cornea (∴ visual loss)

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What are the causes of acute cataract?

Being struck by lightening (very acute)
Porous lens (over a few weeks)

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What are the common causes of vitreous heamorrhage

1) proliferative diabetic retinopathy
2) retinal tears
3) posterior vitreous detachment

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What is special about ischemic optic neuropathy?

It will never cross the midline unless there are multiple pathologies.

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What are the retinal causes of APVL?

1) Vein occlusion:
Branch retinal
Central retinal
2) Arterial occlusion
Branch retinal
Central retinal
3) Retinal detachment
4) Macular haemorrhage

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What are binocular causes of APVL?

1) Optic chiasm pathology (such as pituitary adenoma)
2) Optic nerve pathology
3) Cortex pathology (such as migraine)

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What signs occur with APLV due to pituitary adenoma?

Bilateral afferent pupil defect

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What are common causes of optic nerve pathology that causes binocular APLY?

1) Infiltrative disease
2) Severe papilloedema
3) optic neuritis (such as sarcoid)

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What are some cortical causes of APLV?

1) migraine which is more common with age (35+)

CVA

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What visual signs do you get with migraine?

Temporary – scintillating scotoma just off to left or right of central vision

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What visual signs do you get with CVA?

occipital lobe – homonymous hemianopia

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What is the presenting complaint of branch retinal vein occlusion?

Variable degree of central vision

blurring on waking in the morning (note that if the vein occlusion is not central it will not be nocticed by pts)

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On examination of branch retinal vein occlusion, what will be seen?

haemorrhage
cotton wool spots (damaged to nerve fibers)

which are both limited to one area of the retina

What are the common causes of branch retinal vein occlusion?

High BP

Irregularities in blood

What investigations/management for branch retinal vein occlusion?

FBC, ESR, blood glucose
BP
Not an emergancy so refer to outpatients for anti-VEGF

What is the prognosis for branch retinal vein occlusion?

If extensive –> generally not good.
There is the risk of development of new blood vessels in the future (i.e. in diabetic retinopathy).

If mild –> generally good prognosis.
Resolution and development of collaterals.

What is the presenting complaint of central retinal vein occlusion?

Global blurry vision present on waking but is variable

What are the signs present in central retinal vein occlusion?

VA varying from 6/6 to counting fingers (CF)

RAPD may develop if severe

Varies from a few–>extensive haemorrhages, raided IOP

What should you remember to check on fundoscopy with central retinal vein occlusion?

Check for haemorrhages

Check “good” eye optic disk to check for raised IOP.

What investigations/management should be done for central retinal vein occlusion?

FBC, ESR, blood glucose
BP
IOP
Emergancy send to eye casualty for anti-VEGF use + pan retinal photocoagulation if rubeosis occurs

What are the complications of central retinal vein occlusion (CRVO)?

Permanent severe visual loss

Rubeosis (new vessel growth on iris) leading to rubeotic glaucoma

What is an early sign of rubeotic glaucoma secondary to CRVO?

Relative afferent pupillary defect (RAPD)

What are the symptoms of central retinal artery occlusion (CRAO)?

absolute loss of vision down to no perception of light may describe it as a curtain going down over the eye

What are the signs of CRAO?

Acuity will be CF to no perception of light (NPL) APD if no perception of light or RAPD if any perception Fundoscopy: retinal oedema, cherry red spot in the macula, emboli in the retinal arterioles carotid bruits on neck

What investigations are indicated in CRAO?

BP in 1ry care ESR (for arteritis) in 2ry care Carotid ultrasound in 2ry care Cardiac echo in 2ry care

What is the treatment for CRAO in 2ry care?

acetazolamide (carbonic anhydrase inhibitor) and paracentesis. Both to lower IOP to cause dilation of artery. Refer to eye casualty as max 12 hours until retina dies.

What management is indicated in CRAO in 1ry care?

Rebreathe into paper bag to raise CO2 to dilate vessels to remove emboli Ocular massage to remove emboli Refer to 2ry care emergancy

What is the difference between CRAO and branch retinal arterial occlusion (BRAO)?

It will only involve a patch, but can occur central or more peripheral. Otherwise its s/s, Dx, Ix, Mx are mostly the same.

What is the relationship between vitreous haemorrhages and retinal detachment?

The vitreous gel due to ageing breaks into pockets of fluid which coalesce. The vitreous then detaches posterioly pulling the blood vessels on the surface of the retina causing haemorrhage --> vitreous haemorrhaes. Normally this is a benign event and the floaters will settle If the retina itself is torn can then lead to retinal detachment as the vitrous goes through the tear and peels off the retina. Faster superior as gravity aids peeling Inferiorly slower --> weeks to years.

What are the symptoms of vitreous haemorrhages/retinal detachment?

flashes +/- floaters due to vitreous haemorrhages and visual field loss if retinal detachment occurs

What are the signs of retinal detachment?

Acuity is normal if macula is not affected and vis versa Field loss variable due to amount of retina detached. RAPD if sufficient retina is detached. Abnormal red reflex

What is the management for retinal detachment?

Refer to 2ry care | Urgent surgery

How does the pathology change with a retinal detachment if the tear is superior or inferior?

Faster superior as gravity aids peeling Inferiorly its slower --> weeks to years.

Macular haemorrhage if one of the causes of retinal APVL, what are the causes of macular haemorrhage?

AMD (dry or wet) diabetic retinopathy macroanneurysm

What are the signs of macular heamorrhage?

Varying acuity NO RAPD as only a small area of retina is affected so nerve can still fire On fundoscopy there will be varying amount of central haemorrhage, with periphery spared.

What investigations/management are appropriate with macular haemorrhage?

BP | Mx = referral to eye casualty