Acute Painless Vision Loss Flashcards
Describe important points to ask in any opthalmology history?
Vision loss: -duration -both eyes?
- distortion, halos, floaters
- flashing lights
- momentary field loss
- field defects
- When vision loss occurred?
- Gradual/sudden.
- Any obvious cause.
Diploplia
Pain/discomfort
Discharge
Change in lacrimation
Change in appearance
What would you examine in a patient presenting with acute painless visual loss?
Acuity in both eyes. Visual fields. Pupils. Anterior segment. Fundoscopy.
What are the differentials of monocular APVL? (think anatomically when forming differentials)
Acute corneal disease (usually painful so less likely)
Anterior chamber haemorrhage (rare)
Acute cataract (rare)
Vitreous haemorrhage
Posterior vitreous detachment
Retinal tear, detachment
Retinal vein/artery occlusion
Macular haemorrhage
Optic neuritis (giant cell artiritis)
Ischaemic optic neuritis
What are the causes of binocular APVL (less common)?
Compression of the optic chiasm (pituitary adenoma)
Optic nerve damage: Infiltrative (infection, rare non hodgkins lymphoma)
Optic neuritis
Severe papilloedema
Describe the care pathway aka (history, examination, investigations/treatment) for ‘branch retinal vein occlusion’
H: Monocular vision loss on waking, centrally blurry (variable presentation depending on which vein is blocked)
E: variable degrees of intraretinal hemorrhage, cotton wool spots, macular oedema, collateral vessels (chronic), iris and retinal neovascularization, dilated and tortuous veins.
I: BP, Bloods (glucose, FBC, ESR)
T: Refer to outpatient department
Describe the care pathway aka (history, examination, investigations/treatment) for ‘central retinal vein occlusion’
H: On waking, global monocular visual loss
E: Acuity can vary between 6:6 and finger counting
If severe may have a relative afferent pupillary defect
Retinal signs: haemorrhage, cotton wool spots, macular oedema, collateral vessels, neovascularisation.
I: BP, Bloods (FBC, glucose, ESR), IOP
T: Refer to eye casualty.
New treatments may be useful in early stages. Can also treat with anti-VEGF drugs and pan retinal photocoagulation to prevent worsening and complications such as total vision loss.
Describe the care pathway aka (history, examination, investigations/treatment) for ‘central retinal aa occlusion’
H: Curtain coming down vision loss
E: Acuity finger counting to no perception of light
Pupils: Afferent pupillary defect or RAPD
On retinoscopy: retinal oedema, cherry red spot, emboli Other: Carotid bruits
I: Primary Care BP Secondary Care: ESR, Carotid US, Cardiac echo
T: Refer to eye casualty. Re-breathe through a paper bag, ocular massage, acetazolamide, paracentesis
Describe the care pathway aka (history, examination, investigations/treatment) for ‘branch retinal aa occlusion’
H: Can occur at any time a sectoral or central vision loss
E: Acuity Normal to finger counting.
Field defect
Pupils: may have RAPD
Fundoscopy: embolus, signs of hypertensive retinopathy, pale infarcted area
Carotid bruits
I: BP, Carotid US, Cardiac echo and routine bloods
T: Refer to eye casualty for confirmation, further investigations and treatment.
Describe the care pathway aka (history, examination, investigations/treatment) for retinal detachment or vitreous haemorrhage.
H: Retinal detachment causes a visual field loss Haemorrhage: floaters +/- flashes
E: Acuity will be normal if macula is intact.
Field loss pattern
RAPD if extensive loss
Red reflex abnormality
Can see detachment on fundoscopy
I: Nil
T: Refer to eye casualty will need an op.
Describe the care pathway aka (history, examination, investigations/treatment) for macular haemorrhage in (macular degeneration, diabetic retinopathy, macroaneurysm)
H: distortion, positive scotoma (an area of lost or depressed vision within a visual field. A positive scotoma usually appears as a dark spot)
E: Variable acuity, No RAPD, full peripheral field, central haemorrhage on fundoscopy.
I: BP
T: Refer to eye casualty.
Which of the following does the image show: retinal detachment, branch venousretinal aa occlusion, branch retinal vv occlusion, central retinal aa occlusion, central retinal vv occlusion, macular degeneration
Branch retinal vein occlusion
Haemorrhage in the peripheral vessels due to an occlusion
Which of the following does the image show: retinal detachment, branch venousretinal aa occlusion, branch retinal vv occlusion, central retinal aa occlusion, central retinal vv occlusion, macular degeneration
Central retinal vein occlusion
Sunset appearance with engorged central vessels and haemorrhages alongside them
Which of the following does the image show: retinal detachment, branch venousretinal aa occlusion, branch retinal vv occlusion, central retinal aa occlusion, central retinal vv occlusion, macular degeneration
Retinal Detachment
Which of the following does the image show: retinal detachment, branch venousretinal aa occlusion, branch retinal vv occlusion, central retinal aa occlusion, central retinal vv occlusion, macular degeneration
Branch retinal aa occlusion
Pale area is infarcted retina from the occlusion
Which of the following does the image show: retinal detachment, branch venousretinal aa occlusion, branch retinal vv occlusion, central retinal aa occlusion, central retinal vv occlusion, macular degeneration
Central retinal aa occlusion
Characteristic cherry spot and pale optic disk indicating ischaemia
Which of the following does the image show: retinal detachment, branch venousretinal aa occlusion, branch retinal vv occlusion, central retinal aa occlusion, central retinal vv occlusion, macular degeneration.
Wet macular degeneration with a macular haemorrhage
