Acute Painless Loss of Vision

Question 1

How would you structure a history in acute painless loss of vision?

Answer 1

Previous ocular history
General CV disease
FH, DH, eye drops
Symptoms - monocular and/or binocular
Time of event, method of symptoms awareness
Change in symptoms, associated symptoms (flashes and floaters)
Duration/recovery
Visual loss - general, central and associated field, peripheral only, global effect on function

Question 2

How would you examine a patient?

Answer 2

visual acuity in both eyes
visual field loss - central only? central and peripheral? 
altitudinal? 
hemianopia?
pupils 
anterior segment 
red reflex
fundoscopy

Question 3

What investigations would you carry out?

Answer 3

Bloods
CT
MRI

Question 4

What are the monocular causes of acute painless loss of vision?

Answer 4

acute corneal disease - rare to be painless (HSV)
anterior chamber haemorrhage - rare
acute cataract - rare
vitreous haemorrhage - less rare –> proliferative diabetic retinopathy, retinal tear, post vitreous detachment
- optic nerve - optic neuritis, ischaemic optic neuropathy retina
- branch vein occlusion, central retinal vein/artery occlusion, branch retinal artery occlusion,
- retinal detachment
- macular haemorrhage

Question 5

What are the binocular causes of APVL?

Answer 5

Chiasm - pituitary apoplexy, rapidly expanding pituitary tumour

Optic nerve - infiltrative, severe papilloedema, optic neuritis

Cortex - migraine, CVA - patterns of field loss

Question 6

What is the primary care pathway for common retinal causes of monocular APVL?

Answer 6

History
Examination
Investigations/acute treatment
Referral

Question 7

How would Branch Retinal Vein Occlusion (BRVO) present and be managed?

HEIR

Answer 7

H - on waking, central blur visible

E - nil except retinal signs - check other eye for asymptomatic BVO

I - BP, bloods - FBC, ESR, Glucose

R - Routine to OP dept

Question 8

How would Central Retinal Vein Occlusion present and be managed?

HEIR

Answer 8

H - on waking, global - variable

E - acuity variable from 6/6 to CF, may have RAPD if severe, variable retinal signs other eye for disc exam

I - BP, bloods

R - Eye casualty

Question 9

How would Central Retinal Artery Occlusion (CRAO) present and be managed?

HEIR

Answer 9

H - intermittent prodromal phase - shutter effect

E - acuity to CF and NPL, pupils - APD/RAPD.
Signs - retinal oedema, cherry red spot, emboli, carotid bruits

PRIMARY CARE
I - BP/nil
T - rebreathe into paper bag and ocular massage

SECONDARY CARE
I - ESR, Carotid US, Cardiac Echo
T - rebreathe, ocular massage, acetazolamide, paracentesis

R - Eye Casualty

Question 10

How would Branch Retinal Arterial Occlusion present and be managed?

HEIR

Answer 10

H - any time - sectoral or central

E - Acuity 6/5 to CF, may have RAPD, carotid bruits, field defect

I - BP, Carotid US, Bloods, Carotid echo

R - Eye casualty

Question 11

How would retinal detachment/vitreous haemorrhage?HEIR

Answer 11

H - floaters +/- flashes or field loss

E - acuity normal if macula on, field loss pattern, RAPD if extensive, red reflex abnormality, fundoscopy

I - Nil in primary care

R - Eye casualty

Question 12

How would macular haemorrhage (AMD, diabetic retinopathy, macroannerysm) present and be managed?HEIR

Answer 12

H - distortion, positive scotoma

E - acuity variable, no RAPD, full peripheral field, central haemorrhage on fundoscopy and sings of peripheral disease

I - BP

R - Eye casualty

Question 13

Look at

Answer 13

images on PP

fundoscopy