Acute Vision Loss Flashcards
Acute Vision Loss ?s
Monocoluar/binocular? Pain? Photophobia? Chronology? Other sx?
Pain w/ AVL suggests
cornea, iritis, acute glaucoma, optic neuritis
No pain w/ AVL suggests
retina, retinal vessels, brain
Photophobia w/ AVL suggests
uveitis (iritis/iridocyclitis), acute glaucoma, corneal abrasion/trauma
Eye Hx
Baseline vision w/ correction
Cataracts, glaucoma, mac degeneration, diabetic retinopathy
Traumas, surgeries, amblyopia, eye drops?
Age and Medical Hx
HTN, Dyslipidemia, Diabetes
Rheumatologic (RA, SLE, IBD)
Cancer
Review of systems Hx
Think stroke/TIA
HA, dizziness, numbness, weakness, nausea
PE Tools
Visual acuity chart (best corrected w/ pinhole). Don’t rush.
Flashlight/penlight.
Direct ophthalmoscope
Slit lamp
Eye Vital Signs
External exam VA Pupils Eye pressur Ocular motility Confrontation
Relative afferent pupillary defect (RAPD)
lesions of optic nerve (optic neuritis, ischemic optic neuropathy) or >50% retina (detachment, vascular occlusion)
Slit Lamp Examines what
Cornea, anterior chamber, iris
Extended eye exam
Direct Ophthalmoscope for red reflex, optic nerve (nasal side), vessels
Vascular acute vision loss
diabetes, vascular occlusions, amaurosis
Infectious acute vision loss
HSV/VZV, bacterial keratitis/contact lens use, endophthalmitis
Traumatic acute vision loss
abrasion, ruptured globe, hymphema
Autoimmune acute vision loss
Uveitis, optic neuritis, temporal arteritis
Metabolic acute vision loss
diabetes (lens swelling)
Iatrogenic acute vision loss
psych meds, immune modulators
Neoplastic acute vision loss
Don’t usually create ACUTE vision sx
Degenerative (age-related) acute vision loss
cataracts, glaucoma, AMD
Corneal abrasions
Anterior
Hx: sudden onset, painful, FBS, photosensitivity, tearing, blurred vision, Associated w/ trauma, FB, contact lens
Exam: Decreased acuity, fluorescein uptake, pain improves w/ topical anesthetics (CANNOT GIVE TO TAKE HOME)
Tx: Evert lids to remove foreign body, topical abx (polymixin-trimethoprim gtt or erythromycin for non CTL wearers and Vigamox gtt or Ciloxan ung for CTL wearers)
Epithelium heals quickly, breaks allow infection
Corneal ulcers
Infection of corneal stroma
Hx: untreated abrasion w/ secondary infection
Exam: corneal INFILTRATE (focal opacity in stroma)
Tx: CONSULT ophthalmology for possible culture, abx or antifungal drops
Corneal edema
Opacification, dulling of light reflex
DDx: uveitis/inflammation, increased IOP (angle closure), corneal endothelial dystrophies
Ophtho or opto referral
Herpetic Keratitis
Hx: FBS, eye pain, photophobia, blurred vision; previous or current HSV or VZV; skin vesicles/SKIN RASH
Exam: dec acuity, possible fluorescein uptake (dendritic), possible corneal edema, possible AC cell/flare
Tx: OPHTO consult for dilated exam; treat w/ oral acyclovir/valacyclovir, topical abx to prevent secondary infection, cycloplegic
Hyphema
Blood in anterior chamber
Hx: blunt trauma (most); abnormal iris vessels and neovascularization (ischemic conditions)
Exam: vision variable by hyphema size (normal to LP); IOP possible elevated
Tx: OPHTHO URGENT REFERRAL: No ASA/NSAIDS, bedrest, upright/HOB elevated, eye shield; topical steroid & cycloplegic, +/- IOP drop; Dilated exam or US to r/o retinal detachment; may need to evaluate for sickle cell disease
Anterior Uveitis
Hx: Blurry vision, CONSENSUAL photophobia, redness, pain (does not improve w/ topical anesthetics); Most idiopathic (can be ass w/ conditions or infections)
Exam: decreased acuity, AC cell/flare, typically need to do slit lamp exam to see
Tx: URGENT OPHTHO CONSULT, treat w/ steroid drops once infection ruled out; cycloplegic
Hypopyon
Prurulence in anterior chamber
Hx: recent open eye surgery/trauma (EXOGENOUS ENDOPHTHALMITIS), severe systemic infection (ENDOGENOUS ENDOPHTHALMITIS, rare), severe corneal ulcer (AC rxn), severe eye pain, decreased vision, redness
Exam: red, painful eye, decreased vision, HYPOPYON
Tx: EMERGENT OPHTHO CONSULT, if endophthalmitis, need IV abx or surgical vitrectomy
Uncontrolled Glaucoma
Most commonly angle closure glaucoma (other forms possible); Increased IOP
Hx: HA, Eye pressure/pain, nausea, rainbows/halos, decreased vision, +/- photophobia, may have glaucoma hx
Exam: increased IOP, corneal edema (if sudden), mid-dilated pupil (if sudden), +/- closed/narrow angle, +/- abnormal iris vessels, +/- AC cell/flare
Tx: OPHTHO CONSULT >30 and EMERGENT >40mm Hg, start IOP lowering drops +/- oral diamox depending on IOP
Lens change/cataract
Hx: most develop slowly (except traumatic); some pt interpret progression as sudden visual loss (acute discovery of chronic loss)
Exam: Lens opacities
Tx: OUTPATIENT OPHTHO (unless traumatic, then urgent)
Clear lenses? acute hyperglycemia alters lens hydration and shape, causes large change in refractive error
Vitreous hemorrhage
Hx: painless vision loss/darkening, floaters
Can be caused by long-standing ischemic conditions (diabetes, retinal vein occlusions) or seen in retinal tears/detachments
Exam: decreased acuity, POOR RED REFLEX
Tx: URGENT OPHTHO CONSULT for dilated exam and/or US
Posterior Vitreous Detachment
Hx: flashing lights, floaters
Exam: +/- decreased visual acuity
Tx: URGENT OPHTHO CONSULT for dilated exam
Retinal tear/detachment
Hx: same as posterior vitreous detachment +/- shade or curtain in peripheral vision
Risks: myopia, trauma, family hx, age
Exam: Visual field loss, possible poor red reflex, possible detachment/tear on US, visual acuity may be normal
Tx: URGENT OPHTHO CONSULT for dilated exam, possible OR
Age-related Macular Degeneration
Hx: slow loss of central vision for DRY form; SUDDEN METAMORPHOPSIA (distortion of vision, wavy lines) or decreased vision for WET form. DRY can become WET
Exam: macular drusen (yellow subretinal deposits), +/- subretinal hemorrhages
Tx: OPHTHO OUTPT w/in 1 week if suspect new onset WET AMD, needs dilated exam
Retinal artery/vein occlusion
Hx: SUDDEN PAINLESS VISION LOSS IN MIDDLE AGE PATIENT w/ HTN, DM, DYSLIPIDEMIA; or young pt w/ hypercoagulability
Exam: decreased vision or field loss (ARTERY: pale white fundus +/- cherry red spot; VEIN: blood and thunder diffuse hemorrhages and edema)
Tx: STAT OPHTHO CONSULT; may need systemic work-up including carotid US and echo for arterial oclusion
Amaurosis Fugax
Hx: monocular vision loss, painless, transient lasting minutes (often described as a shade that comes down but full vision returns)
MANY potential causes: MOST COMMON = EMBOLIC/HEMODYNAMIC from CAROTID DISEASE
Considered form of TIA & treated as such (may indicate serious vascular disease, such as embolic stroke)
WORKUP: complete PE, Carotid duplex US, echo, +/- head imaging
Optic Neuritis
Hx: younger (female) pt w/ vision loss
Exam: decreased acuity, pain w/ eye movement, color vision change, RAPD, swollen optic nerve (1/3)
Tx: consult ophthalmology, MRI, +/- IV steroids
Ischemic Optic Neuropathy
Hx: Older pt w/ painless vision loss, h/o HTN, DM, HLD
Exam: decreased acuity and/or visual field loss (altitudinal), no pain, RAPD, swollen optic nerve acutely
Tx: consult ophthalmology, screen for TEMPORAL ARTERITIS (>60 yo w/ myopia, jaw pain)
Papilledema
bilateral disc edema due to increased ICP
Hx: HA, tinnitus, no/mild visual disturbance (positional), NV
DDX: IC Mass/bleed, hydrocephalus, pseudotumor cerebri (IIH), meningitis/encephalitis, AVM, venous sinus thrombosis
WORKUP: start w/ imaging, +/-LP, CALL OPHTHO and NEURO
Orbital cellulitis
Posterior problem (optic nerve)
Hx: swelling/redness of eyelids, eye pain, decreased vision, pain w/ eye movement, +/- recent sinusitis or tear duct blockage
Exam: tender, red swollen eyelids, chemosis (swelling of conjunctiva), +/- (decreased vision, APD, color vision change, motility deficits)
Tx: CT, OPHTHO CONSULT POSSIBLE EMERGENT OR, Hospital admission, IV abx
Temporal arteritis
Vasculitis than can cause permanent vision loss from ischemic optic neuropathy
EMERGENT
Hx: transient or permanent vision loss, HA, scalp tenderness, fever, jaw claudication, hip/shoulder pain, typically in pt > 50yo
Exam: optic nerve edema or pallor, artery occlusion also possible
Labs: ESR, CRP
Tx: High dose prednisone STAT (to prevent further vision loss), Consult OPHTHO (or other surgical service) for temporal artery biopsy w/in 1 week
Migraines
Hx: bilateral loss of vision, lasts 1-60 min, often w/ aura, vision recovers completely +/- HA
Exam: transient decrease in VA
Tx: migraine meds, further eval if HA severe or patient has other neuro sx
Stroke
Hx: bilateral loss vision or visual field, older pt w/ field loss or neglect, often w/ other neuro sx
Exam: decreased vision or loss visual field bilaterally (often hemianopia)
Tx: imaging, NEURO OR NEUROSURG CONSULT
