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MD2 Ambulatory Care and Emergency Medicine > Approach to Visual Loss > Flashcards

Approach to Visual Loss Flashcards

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1
Q

What does initial stabilisation involve?

A

Is there a life-threatening problem concurrent to visual loss?
Does the visual loss suggest a broader life/function threatening problem?

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2
Q

What are the important points in a visual loss history?

A 
HOPC
Unilateral/bilateral
PHx
Past ocular Hx
FHx
SHx
Rx
Allergies
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3
Q

What are the important points in a visual loss examination?

A

Visual acuity
Pupil reactions
Intraocular pressure

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4
Q

Which structures are most likely to be involved in visual loss?

A

Structures within visual axis

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5
Q

What is the most common cause of poor vision?

A

Refractive error

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6
Q

What are some neurological causes of ptsosis?

A

CN III palsy

Horner’s syndrome

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7
Q

What are some myogenic causes of ptosis?

A

Myaesthenia gravis

Myotonic dystrophy

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8
Q

What are some aponeurotic causes of ptosis?

A

Involutional

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9
Q

What are some mechanical causes of ptosis?

A

Orbital tumours
Oedema
Scarring

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10
Q

What is a cause of pseudoptosis?

A

Contralateral lid retraction

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11
Q

What mitochondrial disease can cause ptosis?

A

Chronic progressive external ophthalmoplegia

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12
Q

What should you think of when there’s transient blurring of vision, with or without epiphoria?

A

Tear film disruption

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13
Q

How can entropion blur vision?

A

Tear film disruption

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14
Q

Over time, what can entropion cause?

A

Corneal scarring

Pannus trichiasis

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15
Q

What is pannus trichiasis?

A

Misdirected growth of eyelashes towards cornea

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16
Q

What causes trachoma?

A

Chlamydia trachomatis

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17
Q

What are the complications of chronic trachoma?

A

Scarring of conjunctiva
Entropion
Blindness

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18
Q

What is the clinical presentation of Fuch’s endothelial dystrophy?

A

“My vision has been gradually getting blurry over months”
Corneal oedema
Descemet’s membrane folds
Same findings in contralateral eye

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19
Q

What is Fuch’s endothelial dystrophy?

A

Decompensation of corneal endothelial pump > corneal oedema

Usually bilateral

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20
Q

What is the treatment for Fuch’s endothelial dystrophy?

A

Topical 5% NaCl > dehydrates cornea
Corneal graft surgery
- Graft of endothelium only usually sufficient

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21
Q

What is the clinical presentation of keratoconus?

A 
"My vision has been getting  blurry again. I've had several new pairs of glasses this year, but it keeps getting worse"
FHx
Young age
Visual acuity corrected with pin hole > not always, though
PEARL
Normal intraocular pressure
Irregular curvature of cornea
Munson's sign
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22
Q

What is Munson’s sign?

A

V shape in lower lid when looking down due to irregular shape of cornea

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23
Q

What is keratoconus?

A

Progressive thinning, weakness, and protrusion of cornea

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24
Q

Which layer of the cornea is primarily affected in keratoconus?

A

Stroma

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25
Q

What is the management of keratoconus?

A

Hard contact lenses
Cross-linking
Corneal transplant

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26
Q

What is the clinical presentation of acute angle closure glaucoma?

A

Few hours of painful unilateral red eye and worsening vision
Cloudy oedematous cornea
Mid-dilated pupil
Raised intraocular pressure

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27
Q

What is the emergency management for acute angle closure glaucoma?

A

Reduce intraocular pressure
Acetazolamide oral and IV STAT
Topical beta-blocker
Topical steroids

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28
Q

What is the clinical presentation of a cataract?

A 
Gradual worsening of vision
Glare
Colours not as bright anymore
Usually in older people
Visual acuity not improved with pin hole
PEARL
Normal intraocular pressure
Sclerosis of lens
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29
Q

What are the different types of cataract?

A

Cortical
Nuclear
Subcapsular

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30
Q

What are causes of cataracts?

A 
Age-related
Drugs
- Steroids
- Amiodarone
Trauma, including intraocular surgery
Systemic diseases
- Diabetes
- Myotonic dystrophy
- Wilson's disease
- Atopic dermatitis
Ocular diseases
- Uveitis
- Myopia
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31
Q

What is the treatment for cataracts?

A

Lens removal and introcular lens insertion

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32
Q

What is the pathophysiology of a dislocation of the lens?

A

Zonular pathology

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33
Q

What is lens dislocation associated with?

A

Connective tissue disorders, including Marfan syndrome

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34
Q

What is the clinical presentation of vitreous haemorrhage?

A

“I lost vision in one eye today. It was like a curtain came down over my vision”
Affected eye VA: 6/60
PEARL
Nil RAPD

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35
Q

What are some important causes of vitreous haemorrhage?

A

Retinal detachment
Proliferative diabetic retinopathy
Trauma

36
Q

What is the management for vitreous haemorrhage?

A

Often resolves slowly over weeks/months
Can need vitrectomy to clear blood
Risk of re-bleed

37
Q

What is the clinical presentation of retinal detachment?

A 
Flashes of light in one eye = traction of retina
Floaters in one eye
RAPD with extensive retinal detachment
Retinal detachment with fundoscopy
- Difficult to see in peripheries
- Need to dilate pupil
38
Q

What is the management for retinal detachment?

A

Urgent ophthalmological review

Surgical repair

39
Q

What is a Weiss ring a sign of?

A

Posterior vitreous detachment

40
Q

What is the clinical presentation of a central retinal artery occlusion?

A 
Sudden, painless, unilateral loss of vision
RAPD
Pale retina
Arteriolar attenuation
Cerry red spot
41
Q

How quickly does irreversible ischaemic damage to the retina occur?

A

After 90 min

42
Q

What are the common causes of central retinal artery occlusion?

A

Atherosclerosis
Emboli
Haematological disorders
Inflammatory; eg: giant cell arteritis

43
Q

What is the emergency management of central retinal artery occlusion?

A 
Urgent priority to rule out GCA
- ESR
- CRP
Lie patient flat
Ocular massage
Decrease introcular pressure > acetazolamide 500 mg IV STAT
44
Q

What is the clinical presentation of central retinal vein occlusion?

A 
Sudden, painless, unilateral loss of vision
RAPD
Retinal haemorrhages
Macular oedema
Cotton wool spots
45
Q

What atherosclerotic associations are there with central retinal vein occlusion?

A

HTN
Diabtes
Hyperlipidaemia
Smoking

46
Q

What inflammatory diseases are associated with central retinal vein occlusion?

A

Sarcoidosis
Behcet’s disease
SLE
Polyarteritis nodosa

47
Q

What blood dyscrasias are associated with central retinal vein occlusion?

A

Protein C and S deficiency
Antithrombin deficiency
Antiphospholipid syndrome
Multiple myeloma

48
Q

What ophthalmic conditions are associated with central retinal vein occlusion?

A

Glaucoma

Orbital mass

49
Q

How does central retinal vein occlusion cause rubeosis iridis?

A

Blood vessels grow into iris

50
Q

What is the treatment for central retinal vein occlusion?

A

Lifestyle changes
Intraocular pressure control
Intravitreal steroids
Anti-VEGF agents

51
Q

What is the clinical presentation of a macular hole?

A

“I can’t focus on anything with one eye. When I try and look at something, it disappears”

Visual fields by confontration normal

52
Q

What is the management for a macular hole?

A

Vitrectomy
Removal of macular traction
Insertion of gas

53
Q

What is the clinical presentation of dry age-related macular degeneration?

A 
Gradual decrease in central vision
Central scotoma
FHx of macular degeneration
Drusen
Geographic atrophy = coalesced drusen
54
Q

What is the pathophysiology of dry age-related macular degeneration?

A

Loss of retinal pigment epithelium/photoreceptors
Associated with
- Increasing age
- Smoking

55
Q

What is the management for dry age-related macular degeneration?

A 
Predominantly supportive care
Smoking cessation
Vitamin supplementation > thought to reduce oxidative stress in retina
- Vitamin C and E
- Zinc
- Copper
56
Q

What is the clinical presentation of wet age-related macular degeneration?

A 
Rapid decrease in central vision - weeks-months
Metamorphopsia
Central scotoma
Drusen
Geographic atrophy
Lipid exudate
Intra-retinal haemorrhage
57
Q

What is the pathophysiology of wet age-related macular degeneration?

A

Choroidal neovascularisation = growth of abnormal leaky vessels in RPE

58
Q

What is the management of wet age-related macular degeneration?

A

Investigate with fluorescein angiography and optical coherence tomography
Anti-VEGF intra-vitreal injections

59
Q

What is the biggest risk factor for diabetic retinopathy?

A

Duration of diabetes

60
Q

What are other risk factors for diabetic retinopathy?

A 
Poor glycaemic control
Poorly controlled HTN
Hypercholesterolaemia
Nephropathy
Pregnancy
Obesity
61
Q

What is the most common cause of visual impairment in diabetic retinopathy?

A

Diabetic macular oedema

62
Q

What are some features of diabetic retinopathy on fundoscopy?

A 
Circinate ring
Lipid (hard) exudates
Intra-retinal haemorrhage
Micro-aneurysms
Venous beading
Intra-retinal vascular abnormalities
Neovascularisation of disc
Neovascularisation everywhere
Vitreous haemorrhage
63
Q

What is the epidemiology of retinitis pigmentosa?

A

Most common retinal dystrophy
Sporadic/inherited
Affects rods first
Usually in young adults

64
Q

What is the clinical presentation of retinitis pigmentosa?

A 
"I'm concerned about my vision. I've nearly been in a few car accident. My night vision is so bad, that I've stopped driving in the dark altogether. Blindness tends to run in my family"
Normal visual acuity
PEARL
Nil RAPD
Intraocular pressure normal
Annular scotoma
Waxy pallor of disc
Bone-spiculae retinal pigmentation
Retinal arteriolar attenuation
65
Q

What does posterior uveitis include?

A

Retinal vasculitis
Retinitis
Choroiditis

66
Q

What are some causes of posterior uveitis?

A 
Systemic inflammatory disorders
- Behcet's disease
- Sarcoidosis
Viruses
Fungal
Protozoa
Bacterial
Lymphoma
67
Q

What is the management of posterior uveitis?

A 
Investigate cause
Assess risk of bilateral vision loss
Antimicrobials if infective cause
Topical steroids
Intraocular antimicrobials and steroids
Systemic therapies
68
Q

What is the clinical presentation of idiopathic (benign) intracranial hypertension?

A

Overweight, female, 20s
Headaches
Blurry vision
Bilateral swollen optic discs = papilloedema

69
Q

What are the investigations for idiopathic intracranial hypertension?

A

Urgent neuroimaging

Lumbar puncture if cause not clear

70
Q

What is the treatment for idiopathic intracranial hypertension?

A 
Weight loss
Medical Rx
- Acetazolamide
- Other diuretics
- Corticostreoids
Surgical Rx
- Optic nerve sheath fenestration
- Lumbar-peritoneal shut
71
Q

What is the clinical presentation of optic neuritis?

A

“I woke up this morning and have very poor vision in one eye”
RAPD in affected eye
Normal intraocular pressure
Reduced colour saturation in affected eye
Blurred optic disc margin
Swollen, inflamed, disc = papillitis

72
Q

What is the management for optic neuritis?

A

MRI brain and referral to neurologist to investigate for multiple sclerosis
High dose prednisolone

73
Q

What are the causes of bilateral disc swelling?

A

Generally papilloedema
Malignant HTN
Pseudopapilloedema

74
Q

What are causes of raised intracranial pressure due to mass effect?

A

Haemorrhage
Haematoma
Tumours

75
Q

What are the causes of raised intracranial pressure due to increased CSF production?

A

Choroid plexus tumour

76
Q

What are the causes of raised intracranial pressure due to reduced CSF absorption?

A

Venous sinus thrombosis
Aqueduct/foramen stenosis
Idiopathic intracranial hypertension

77
Q

What are the causes of unilateral disc swelling?

A

Arteritic anterior ischaemic optic neuropathy
Non-arteritic anterior ischaemic optic neuropathy
Optic neuritis
Tumours
Infections

78
Q

What are the causes of unilateral disc swelling reated to raised intracranial pressure?

A

Foster-Kennedy syndrome

Raised ICP where 1 optic disc already atrophic

79
Q

What are the causes of pseudopapilloedema?

A

Optic disc drusen
Hypermetropia = shorter eye axial length > gives disc swollen appearaance
Tilted discs

80
Q

What are the clinical features of giant cell arteritis?

A

Headache
Scalp tenderness
Jaw claudication
Associated polymyalgia rheumatica
Acute unilateral loss of vision
- Usually due to ischaemic optic neuropathy
- Can be due to central retinal artery occlusion

81
Q

What are the investigations for giant cell arteritis?

A

ESR - classically >100
CRP
Temporal artery biopsy

82
Q

What is the treatment for giant cell arteritis?

A

40-60 mg prednisolone (high dose)

83
Q

What is primary open angle glaucoma?

A

Chronic degenerative condition affecting optic nerve

84
Q

What is the progression of visual field loss in glaucoma?

A

Normal fields with blind spot >
Arcuate scotoma - usually not noticed by patient >
Progression of centrally sparing field loss - patient can still be unaware >
Snuff out - can present as acute vision loss

85
Q

What are the signs of primary open angle glaucoma?

A

Increased optic cup-to-disc ratio

Progressive visual field loss

86
Q

What are the risk factors for primary open angle glaucoma?

A

Positive FHx
High myopia
Diabetes
Elevated intraocular pressure

87
Q

What are the most common causes of vision loss?

A 
Refractive error
Cataracct
Diabetic retinopathy
Macular degeneration
Ocular surface disease

MD2 Ambulatory Care and Emergency Medicine (29 decks)

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