Acute visual disturbance 1 Flashcards
elderly patients with painless loss of vision may commonly have
age-related macular degeneration
giant cell arteritis
middle aged patients with painless loss of vision may commonly have
retinal arterial occlusions
retinal vein occlusions
diabetic macular oedema
vitreous haemorrhages
which common causes of painless vision loss present at any age?
retinal detachment
vitreous haemorrhages
onset of painless loss of vision over minutes
retinal arterial occlusions
retinal venous occlusions
vitreous heamorrhages
onset of painless loss of vision over hours
retinal detachments
onset of painless loss of vision over days
diabetic macular oedema
age related macular degeneration
is acute painless loss of vision usually bilateral?
no this is very rare
sudden loss of vision is usually unilateral
if its bilateral there is usually a central cause and not an ocular cause
what does hard exudate on the fundoscopy indicate
lipid leaking out of damaged blood vessels in people with diabetes may cause this
fluid leaking into the macula = diabetic macula oedema
how the vision loss processes
started in the centre = probably a macula problem ie. either age related macula degeneration or diabetic macular oedema
started on the sides like a curtain = retinal detatchment
progressive red haze = vitreous haemorrhage
progressive peripheral loss like a curtain
retinal detatchment
usual cause of vitreous haemorrhage
diabetes
painless loss of vision with a red haze
vitreous haemorrhage
associated symptom of distortion
straight lines start to look wavy
usually macula cause
age related macula degeneration or diabetic macula oedema
associated symptom of flashes/floaters
retinal detachment or vitreous haemorrhage
associated symptoms of scalp pain or jaw claudication
giant cell arteritis
may have another rheumatological condition
inferior branche retinal artery occlusion looks like
people who are myopic
short sightedness
these people are at an increased risk of retinal detatchment
diabetes causes a higher risk of
diabetic macular oedema
vitreous heamorrhage
ischaemic heart disease, AF and cerebrovascular disease increase risk of
vasculopaths
increased risk of retinal artery occlusion or retinal venous occlusion
polymyalgia rheumatica is associated with
GCA = giant cell arteritis
things you can have a family history of
retinal detachment
age related macular degeneration
steps of examination of the eye
- gross inspection
- optic nerve examination
- slit lamp examination
- eyelid eversion
- ocular motility
what’s included in the optic nerve examination
- visual acuity
- visual fields
- pupil reflexes/reactions
- optic nerve exam (fundoscopy)
- colour vision
what does a normal fundus look like
how do you tell which fundus you’re looking at
the optic nerve is always closer to the nose
bearing in mind you’re looking at the fundus of a person facing you
nerve is nasal
how should the optic nerve look
yellow with a distinct border
range retinal tissue
blood vessels running throughout
darker red for veins and lighter red for arteries
veins are slightly wider than arteries
veins look
fatter and darker
arteries look
thinner and lighter
macula looks
more darkly pigmented than the rest of the retina
temporal to the optic nerve
wet age related macular degeneration means
there is blood = wet
advanced (neovascular)/wet age related macular degeneration
commonest cause of vision loss
painless acute central distortion or central scotoma - usually unilateral
outer retina degenerates
new blood vessels that are abnormal grow up into the retina where they don’t belong
abnormal blood vessels are prone to bleeding and leaking fluid causing vision loss
what might you see on fundus than indicates ARMD
central macular drusen +/- haemorrhage
management of ARMD
urgent referral to ophthalmology
smoking cessation
intravitreal anti-VEGF therapy initially once per month then less frequent
might need it indefinitely
intravitreal anti-VEGF therapy
injected into the eye under anaesthetic - painless
initially the treatment is needed once per month and less frequently thereafter
likely to need treatment for the rest of their lives
most modifiable risk factor for ARMD
smoking
Hx of retinal vein occlusion
painless acute blurring/loss of vision (central and/or altitudinal)
may only be inferior/superior visual field loss
inferior retinal occlusion will cause superior field loss and vice versa
middle aged or elderly, history of HTN, diabetes, hyperlipidaemia
aetiology of retinal vein occlusion
arteriosclerosis leading to vein occlusion at AV junction
sclerosis of an artery which at the junction of the artery and vein leads to obstruction of the vein
leakage of blood and other fluids into the retina
macula swells leading to loss of vision
retinal vein occlusion on examination
haemorrhages and dilated/tortuous veins, macula oedema
+/- RAPD (relative afferent pupillary defect caused by CRVO central retinal vein occlusion), cotton wool spots, disc swelling
severe central retinal vein occlusion will cause
relative afferent pupillary defect
two types of retinal vein occlusion
CRVO = central retinal vein occlusion (whole retina)
BRVO = branch retinal vein occlusion (semi-retina)
management of retinal vein occlusion
systemic vascular risk factors (especially hypertension)
urgent referral to ophthalmology
intravitreal anti-VEGF or steroid therapy +/- retinal laser
difference between retinal vein or artery occlusion
retinal vein occlusion produce blood
retinal artery technically can too but not as likely
retinal artery occlusion causes retinal paleness
what does retinal artery occlusion look like
retinal paleness
cherry red spot if central (macula sparing)
cherry red spot indicates
cherry red spot indicates central retinal artery occlusion
Hx of retinal artery occlusion
painless unilateral loss of vision, central and/pr altitudinal
Middle aged/elderly
vasculopathic/cerebrovascular/AF/hyperlipidaemia
retinal paleness indicates
retinal artery occlusion
aetiology of retinal artery occlusion
arteriolar embolus from carotid systemic or cardiac value
examination of retinal artery occlusion
pallor of whole (CRAO) or semi retina (BRAO)
there may be a cherry red spot if it is CRAO
or hemi-field it if is BRAO
+/- RAPD (CRAO), visible emboli
management of retinal artery occlusion
urgent stroke work-up
- CT angiogram head/neck, carotid doppler USS
- trans thoracic echocardiogram, ECG +/- Holter
exclude giant cell arteritis in 60+ year olds (FBC, ESR, CRP), and ask about jaw claudication
urgent ophthalmology referral -> stroke referral -> thrombolysis protocol (tPA)
retina looks like a brain
retinal detatchment
retinais detatched from the choroid is bulging forward into the vitreous
tear in the retina
causes the majority of retinal detachments
tear usually from the vitreous gel tugging on the retina, vitreous fluid gets behind the tear and causes the detachments
retinal detatchment Hx
painless unilateral flashes and floaters
progressive curtain scotoma
middle aged, elderly, myopic, trauma, diabetes
determining if the macula is detached in retinal detatchment
prognosis much worse if the macula is detached
if you operate quickly you can save sight
macula off may been youre not able to regain vision
risk factors for retinal detatchement
myopia
diabetes
trauma
middle aged/elderly
examination for retinal detachment
greys, corrugated looking retina - macula on or off
altitudinal or total field loss
normal fundus and fields possible vitreous detatchement only
management for retinal detatchment
fast and prepare for surgery
urgent referral to opthalmology
vitrectomy (most common) or scleral buckle surgery
vitreous haemorrhage aetiology
- vitreous detachment (normal) can cause sheering of blood vessel causing vitreous haemorrhage (not normal)
- alternatively, diabetes causes abnormal blood vessels which are prone to bleeding (frilly looking blood vessels), may indicate proliferative diabetic retinopathy
vitreous haemorrhage looks like
two main causes of vitreous haemorrhage
- vitreous detatchment
- diabetes
Hx of vitreous haemorrhage
painless unilateral floaters or ‘red haze’
+/- loss of vision
diabetes, trauma, myopia
examination of vitreous haemorrhage
variable change in VA and fields
visible blood on fundoscopy +/- detached retina
treatment for vitreous haemorrhage
vitrectomy surgery or laser surgery
fast for theatre
systemic management for diabetes
diabetic macular oedema Hx
caused by hyperglycaemia
painless central visual blurring
always bilateral but might be asymmetric
onset days to weeks
diabetes, hypertension, hyperlipidaemia
aetiology of diabetic macular oedema
retinal vascular hyperpermeability from chronic hypoerglycaemia
swelling of the macula
examination of diabetic macular oedema
variable change in VA, central field loss
central macular haemorrhages +/- hard exudates
diabetic macular oedema management
optimal metabolic management
semi-urgent referral to ophthalmology
intravitreal therapy (anti-VEGF or steroids) +/- retinal laser
