Eye, acute and subacute painless loss of vision

Question 1

Probability diagnosis

Answer 1

Amaurosis fugax

Migraine

Retinal detachment

Acute glaucoma

‘Wet’ macular degeneration

Question 2

Serious disorders not to be missed

Answer 2

Cardiovascular:

• central retinal artery occlusion
• central retinal vein occlusion
• hypertension (complications)
• CVA

Neoplasia:

• intracranial tumour

intraocular tumour:

• — primary melanoma
• — retinoblastoma
• — metastases

Vitreous haemorrhage

AIDS

Temporal arteritis

Acute glaucoma

Benign intracranial hypertension

Question 3

Pitfalls (often missed)

Answer 3

Acute glaucoma

Papilloedema

Optic neuritis

Uveitis

Intraocular foreign body

Question 4

Masquerades checklist

Answer 4

Diabetes (diabetic retinopathy)

Drugs (e.g. quinine, alcohol)

Thyroid disorder (hyperthyroidism)

Question 5

Is the patient trying to tell me something?

Answer 5

Consider ‘hysterical’ blindness, although it is uncommon.

Question 6

Key history

Answer 6

PMHx including risk factors for;

• CVD
• neurology such as migraine and cerebrovascular disease.

FHx and drug history.

Question 7

Key examination

Answer 7

Visual acuity: Snellen chart

Ophthalmoscopic examination, tonometry

Cardiovascular including carotid arteries

Question 8

Key investigations

Answer 8

The vast majority of pts should be referred urgently to an ophthalmological service or stroke unit.

Initial tests are:

• FBE
• ESR/CRP
• blood sugar.

Question 9

Diagnostic tips

Answer 9

The visual disturbance may be the presenting symptoms of a general medical disorder such as TA, hypertension or diabetes.

A cherry-red spot on the macula is pathognomonic of retinal artery occlusion.