Approaches to Visual Loss and Retinal Disorders

Question 1

General approach to visual loss

Answer 1

-Confrontational visual field (monocular vs binocular vision)
-Visual acuity (normal/ reduced)
-Pupil reactions (RAPD)
-Fundoscopy (diagnosis)

Question 2

Questions for visual loss

Answer 2

-Demographic details
-Onset: sudden, gradual
-Uni or binocular-Associated symptoms: pain, photopsia, floaters, field loss, red eye, epiphora
-First episode or recurrent
-If possible let patient describe in his own words

Question 3

Histories to take for visual loss

Answer 3

-Ocular
-Medical
-Current medication
-Family

Question 4

Symptoms of presenting complaint to explore

Answer 4

-Pain
-Change in vision
-Swelling
-Watering/ discharge
-Itchy/ gritty
-Floaters
-Redness

Question 5

Features of presenting complaint history

Answer 5

-Duration
-Timescale
-Frequency
-Laterality
-Full or part of visual field
-Exacerbating or relieving factors
-Associated features

Question 6

Features of past ophthalmic history

Answer 6

-Glasses and contact lenses
-Similar symptoms
-Previous ocular trauma
-Previous ocular surgery
-Previous treatments including laser

Question 7

Conditions in past medical history

Answer 7

-Allergic eye disease & atopy
-Herpetic disease & cold sores
-Uveitis & inflammatory conditions
-Choroidal masses & malignancy
-Vascular occlusions & general risk factors

Question 8

Medications in drug history

Answer 8

-SSRI
-TCA
-Steroids
-Oculotoxicity= hydrocholoquine, ethambutol, tamoxifen

Question 9

Features of family history

Answer 9

-Visual impairment
=Retinal dystrophies e.g. RP
=Corneal dystrophies
-Glaucoma
-General medical FH (Diabetes, IHD, HTN)

Question 10

Types of retinal disorders

Answer 10

-AMD
-Vitreo retinal disorders
-Vascular disorders
-Tumours
-Inherited retinal conditions

Question 11

Examples of vitreo-retinal disorders

Answer 11

-Macular hole
-Retinal tear/ detachment/ vitreous haemorrhage
-Vitreous floaters

Question 12

Eye tumours

Answer 12

-Retinoblastoma
-Choroidal melanoma

Question 13

Inherited retinal conditions

Answer 13

-Retinitis pigmentosa
-Stargardts disease

Question 14

Examples of media opacities

Answer 14

-Cataract
-Vitreous haemorrhage

Question 15

Which conditions are more likely in short-sightedness?

Answer 15

-Eyeball too long
=light converges in front of retina
=Retinal detachment as more stretched

Question 16

Which conditions are more likely in long-sightedness?

Answer 16

-Eyeball too short
=Light converges behind the eye
=acute angle closure as more bunched up

Question 17

Describe macular hole

Answer 17

-Presentation: central distortion, scotoma
-Investigation: OCT
-Management: vitrectomy

Question 18

Describe retinal detachment

Answer 18

-RF: DM, myopia, age, previous surgery for cataracts, eye trauma
-Presentation: flashes, floaters (=pigment cells in vitreous/ traction on retina), sudden painless and progressive visual field loss (curtain/ shadow, depends where if macula is spared), RAPD if optic nerve involved
-Investigation: fundoscopy (red reflex lost, retinal folds pale opaque or wrinkled), slit lamp, indirect ophthalmoscopy for pigment cells and VH
-Management: vitrectomy after urgent referral

Question 19

Describe retinal tear

Answer 19

-Management: laser surgery

Question 20

Describe retinoblastoma

Answer 20

AUTOSOMAL DOMINANT
-Presentation: leukocoria (white pupil), absence of red-reflex, strabismus, visual problems
-Investigation: OCT, fundoscopy, MRI head
-Management: enucleation, external beam radiation therapy, chemotherapy and photocoagulation

Question 21

Describe choroidal melanoma

Answer 21

-Presentation: eye irritation, lumps, bulging, vision loss, dark patch, blurred vision shadows and flashes
-Investigation: ultrasound, fluorescein angiogram, fundoscopy
-Management: brachytherapy (tiny radioactive plates in tumour), radiotherapy, surgery, enucleation

Question 22

Describe retinitis pigmentosa

Answer 22

ABNORMAL PHOTORECEPTORS, INHERITANCE (X-linked or dominant)
-Presentation: night blindness (loss of rods), tunnel vision (loss of peripheral retina) black dots, macular sparing, waxy pale optic nerve
-Investigation: fundoscopy (black bone spicule-shaped pigmentation in peripheral retina, mottling of retinal pigment epithelium
-Management: visual aids, vitamin A supplementation, fish oils, lutein