Loss of Vision and Ophthalmic Emergencies Flashcards
If loss of vision is painful what structures are likely to be involved?
Anterior of the eye is associated with painful loss of vision- these structures have a rich innervation
Iris, cornea, sclera
If loss of vision is painful what structures should be considered?
Posterior components of the eye-
Lens, Vitreous, Retina
Note- optic neuritis can cause pain of movement of the eye due to inflammation of the nerve
If vision loss is sudden what sort of causes should you consider?
Vascular causes are acute onset
If someone presents with loss of history what should you ask about?
When did this happen?
Painful
Painless
How quickly did this come on? Was it sudden?
How is your vision at the moment?
Has the loss been permanent since onset or has it been transient?
Have you lost central vision or peripheral vision?- Struggling to read or bumping into things
One of both eyes affected?- Processes such as diabetic retinopathy cause bilateral damage
Any other associated symptoms? E.g. Headache, polydipsia, polyuria
When a patient presents with loss of vision what should always be checked?
Check Visual Acuity- Could be OSCE so learn this
What is an RAPD?
It is a sign of an optic nerve lesion. There is consensual reflex but no direct as there has been loss of sensory input to the affected side. Therefore appears to dilate when the light is shone into the affected eye.
If someone presents with painless loss of vision which part of the eye is likely to be affected?
Structures from the lens backwards- back of the eye
Except for optic neuritis which causes pain on eye movement
If loss of vision is sudden what causes should you consider?
Vascular causes:
Retinal Vein Occlusion
Retinal Artery Occlusion
May affect central retinal vessels or branches of the vessels
How are vessel arcades spilt in the eye?
Superior or inferior
Nasal or Temporal
What do you see on fundoscopy with a branch retinal vein occlusion?
Haemorrhages confined to the affected area
What do you see with a central retinal vein occlusion?
Fairly severe picture
Wide spread haemorrhages throughout the retina
Swollen disc
What do you see with a branch retinal arteriolar occlusion?
Pallor of the retina in the area supplied by the vessel- it looks less pink than the surrounding area
May be able to see embolic area in the vessel- pale
What are the most common causes of branch arteriolar occlusion?
Emboli- often either cardiac or carotid source
What do you see on fundoscopy with a central retinal artery occlusion?
Pallor of the entire retina
Cherry red spot at the macula
Aim to treat within 8 hours- IV acetazolamide, ocular massage, re-breath into paper bag, anterior chamber paracentesis, refer to stroke/TIA clinic
What are some causes of sudden painless loss of vision?
Central Retinal Artery or Vein Occlusion
Anterior Ischaemic Optic Neuropathy (arteritis or non arteritic (embolic))
Retinal detachement
Vitreous Haemorrhage
What is anterior ischaemic optic neuropathy?
Ischaemia to the anterior optic nerve and optic disc
What are the two categories of causes for anterior ischaemic optic neuropathy?
Arteritic- GCA/Temporal Arteritis
Non Arteritic- Embolic (Cardiac or Carotid source)
What are the features of anterior ischaemic optic neuropathy seen on fundoscopy?
Pallor of the optic disc
Blurring of the edges of the optic disc (loss of sharp border)
Often also have altitudinal visual field defect
What must be ruled out in patients with anterior ischaemic optic neuropathy? How might this be done?
Giant cell arteritis
History of headaches, scalp tenderness, pain when brushing hair, fatigue, lethargy. Bloods- raised ESR and CRP
What is a leading cause of vitreous haemorrhage?
Proliferative diabetic retinopathy causes fragile vessels to form which are prone to bleeding, these can then bleed into the vitreous humour.
Bleeding causes a disruption of clear optical media and so there is vision loss.
Why is an increase in the number of floaters more concerning for a diabetic patient?
Could be a sign of bleeding vessels, causing vitreous haemorrhage. These need to be checked out.
Fragile vessels for due to proliferative diabetic retinopathy.
Describe the process that can cause retinal detachment?
PVD can pull on the retina and cause retinal tears. Fluid can then track underneath the retina leading to retinal detachment.
What are the symptoms of retinal detachment?
Flashes and Floaters (sx of PVD)
Loss of vision, central vision is lost if the macula becomes involved.
What are some causes of retinal detachment?
PVD- Causing retinal tear and fluid tracks underneath the tear
Myopia- Longer eye ball means there is a thinner retina more prone to breaking
Trauma- stretching and compressing of the globe occurs with blunt trauma that can cause tears and detachment
What are some signs of retinal detachment?
Fundoscopy- blurring of vessels and retina appears to be coming towards you
Visual field defect depending upon the area affected
Loss of central vision if the macula is involved
What is the management for retinal detachment?
Urgent referral to ophthalmology
Surgical management- Vitrectomy and re-attaching the retinal (maybe with laser)
What is a PVD?
Posterior vitreal detachment- normal process of ageing is that the vitreous shrinks. can cause retinal tear. Sx of flashes and floaters.
What should you do for sudden onset flashes and floaters?
Refer to ophthalmologist as could be retinal detachment
Once macula is involved unlikely to regain central vision
What are some causes of gradual loss of vision?
Cataract (accelerated- tends to be more slow) Age related macular degeneration Diabetic retinopathy Primary Open Angle Glaucoma Papilloedema (bilateral raised ICP)
What can cause a cataract to develop rapidly?
Trauma to the eye- blunt trauma or any foreign object coming into contact with the eye
Why form of macular degeneration can cause fairly rapid loss of vision?
Wet Macular Degeneration- new vessels that form are unstable and can result in bleeding into the macula.
Treated with VEGF inhibitors
what kind of visual loss does macular pathology cause?
Central vision loss
Central scotoma
(Macula is responsible for central vision not peripheral)
What is the cup? What is a normal ratio?
Axons of the nerve entering the disc- this is effectively dead space. Normal is cup to disc ratio is less than 0.3
What conditions cause cupping of the optic disc?
Glaucoma- raised pressure within the eye leads to damage to the optic nerve which limits peripheral vision
What is papilloedema?
Bilateral optic disc swelling due to raised ICP.
Loss of clear margins, loss of pink healthy appearance, difficult to see blood vessels overlying the disc
What are two causes of papilloedema?
Raised ICP (Always do MRI Head) Idiopathic Intra-cranial Hypertension
What kind of visual loss does papilloedema cause?
Loss of peripheral vision
If a patient describes misty, foggy or glare in the vision what should be considered?
Cataract-
Disturbance in clear optical media such as cornea and aqeous/vitreous too
If a patient describes distortion of central vision or central scotoma what should be considered?
Macular pathology
For any issue with central vision think macula
If a patient describes flashes and floaters what should be considered?
PVD
Retinal Detachement
What condition needs to be ruled out if someone has anterior ischaemic optic neuropathy?
GCA- ESR, CRP, Temporal Headaches, Scalp Tenderness
Treat first with high dose steroids and then investigate
What features in a history might you find in a patient with GCA?
Temporal headaches Scalp tenderness Pain on brushing hair Fever Lethargy Weight loss Jaw claudication PMR- Association causing shoulder and hip pain Sudden loss of vision- Anterior ischaemic optic neuropathy
What blood tests should be requested for patients with suspected GCA?
ESR (Goes up)
CRP (Goes up)
Platelets (Goes up)
How might the temporal artery appear in patients with GCA?
Large
Boggy
Non-pulsatile
Tender
What are some causes of central retinal artery occlusion?
Embolic- Carotids or cardiac source
Atherosclerotic disease
Raised IOP
Arteritis- GCA
What are the symptoms of central retinal artery occlusion?
Painless loss of vision or a visual field defect (if branch)
Preceded amaurosis fugax
Note- Painless as it is the back of the eye that is affected
What are some signs of central retinal artery occlusion?
RAPD Pale retina Cherry red spot (macula) Visual field defect No perception of light
What is the management for central retinal artery occlusion?
IV Acetazolomide
Re-breath into paper bag
Occular massage
Anterior chamber paracentesis
Start aspirin and refer to TIA/stroke clinic
Why should you check inflammatory markers for central retinal artery exclusion?
To rule out GCA as this is very serious is not treated urgently with high dose steroids
What is keratitis?
Inflammation of the cornea
What are some causes if keratitis?
Bacterial- Gram positive or negative
Viral- Herpes Simplex Virus (Causes a dendritic ulcer)
Acanthamoeba- associated with use of tap water to clean contact lenses
What signs may be seen with bacterial keratitis?
Redness Hypopyon- pus in the anterior chamber Photophobia Painful eye Watering of the eye Reduced visual acuity due to haze
What is leading cause for bacterial keratitis?
Contact lens misuse- e.g. poor hand hygiene, wearing them at night
What are the findings of keratitis due to HSV?
Dendritic ulcer on fluorescein staining
Presentation tends to be less severe than a bacterial infection. If patient also wears soft contact lenses consider acanthamoeba which causes more severe symptoms with similar signs.
What is uveitis?
Inflammation of the uvea (iris, ciliary body and choroid)- non-specific
What is a key associated of acute anterior uveitis?
Associated with sero-negative arthropathies which are associated with HLA-B27 +Ve status e.g. Ankylosing Spondylitis
What are some signs/symptoms of uveitis?
Photophobia- inflamed iris painful when causing pupil constriction
Posterior Synechiae- inflammatory exudate makes aqueous humour sticks and adhesions for between iris and anterior surface of the lens
Hypopyon- Pus/Inflammatory material in the anterior chamber
Red eye
What is a posterior synechiae and what causes it?
Iris is adhered to the anterior surface of the lens. This occurs in uveitis because the inflammatory exudate makes the iris stick to the lens.
What is a hypopyon?
Inflammatory exudate in the anterior chamber of the eye which collects under gravity
What is acute angle closure glaucoma?
The drainage angle of the aqueous humour becomes acutely obstructed causing large increases in IOP
What are some risk factors for developing acute angle closure glaucoma?
Hypermetropic/Long sighted as the shorter eyeball means there is less space and structures are closer together
Night time- more likely to obstruct the angle when the iris is dilated
What are the signs/symptoms of acute angle closure glaucoma?
Extremely painful
Red eye
Unilateral headache
Fixed mid-dilated pupil
Associated nausea and vomiting due to the pain
Haloes around bright lights due to corneal oedema with increased IOP
What are some signs of acute angle closure glaucoma?
Corneal oedema- speckled appearance
Red eye
Fixed mid-dilated pupil
Decreased visual acuity
What is the management of acute angle closure glaucoma?
Urgent referral to ophthalmology
Medical Therapy- IV Acetazolomide, Beta Blockers, Mannitol, Topical Pilocarpine to constrict pupil
Surgical- Iridectomy
What are some of the symptoms of optic neuritis?
Often unilateral Loss of vision Pain on eye movement Reduced colour vision Central scotoma Red desaturation
What is optic neuritis associated with?
Multiple sclerosis- do work-up for this
How does the colour red change with optic neuritis?
Red desaturation
What signs may be present for optic neuritis?
Decreased colour vision Red de-saturation Central scotoma Optic disc may look normal RAPD- Optic nerve lesion, pupil on affected side appears to dilate
What are some causative organisms of microbial keratitis?
Staph
E.coli
Pseudomonas
What is the management for microbial keratitis?
Refer to ophthalmology Scrapings for MC and S Topical Intensive Abx- e.g. Ofloxacin Dilator Eye drops to reduce pain Avoid wearing contact lenses
If someone presents with a lid laceration what is the main priority?
To check the integrity of the globe- are there any scleral or corneal lacerations. If so refer to ophthalmology?
When should a lid laceration be referred to opthamology?
If it involves the lacrimal apparatus If it involves the medial canthus If it involves the levator complex If it involves the lid margin If there has been any globe perforation
What should be done for simple lid lacerations?
Tetanus prophylaxis
Repair with 6/0 monofilament
What is a peri-orbital haematoma?
Occurs following blunt trauma to the eye
Bruising that surrounds the eye
What should be done for any blunt trauma to the eye?
Check the globe for any damage- sclera or corneal lacerations
Perform fundoscopy- trauma can cause retinal detachment, vitreous haemorrhage
Check visual acuity
If suspecting any bony-fractures X-ray or CT
What is a hyphaema?
Blood in the anterior chamber- can occur following trauma
What is the treatment for peri-orbital haematoma?
Analgesia and cold compress
What is a blow-out fracture?
Fracture of the orbital wall, floor or roof
What are some symptoms of a blow-out fracture?
Bony pain and tenderness
Pain on eye movements- due to trapping of ocular fat outside the fracture
Enopathalmus- eye regressed into orbital cavity
Dipolpia- if ROM is reduced
Parasthesia over maxillary area- due to damage to infra-orbital nerve
What is a cause of blow-out fracture?
Typically blunt trauma
What is the management is a blow-out fracture is suspected?
X-Ray/CT
Refer to ophthalmology or max-fax
What is the name of a the sign that can indicate an orbital fracture/blow out fracture on imaging?
Tear drop sign
There is bulging of peri-orbital fat into the normally air-filled sinuses that looks like a tear drop
What is a hyphaema?
Blood in the anterior chamber
What can cause a hyphaema?
Trauma to the eye which causes shearing/damage to blood vessels of the iris resulting in bleeding into the anterior chamber
What are some symptoms fo hyphaema?
Blurring of vision- reduces clarity of aqueous humour
Staining of corneal epithelium also cause blurring of vision
Theres blood in the front of their eye- people will probably complain about that
Photophobia- damage to the iris cause inflammation which makes pupillary constriction painful
What is the management for hyphaema?
As with any trauma to the eye:
Check the integrity of the globe for any other damage
Fundoscopy- vitreous haemorrhage, retinal detachment
Check visual acuity
Refer to opthamology
Topical steroids- reduces inflammation and stabilises the blood aqueous barrier to reduce the risk of re-bleed
Rest- Want to avoid increases in blood pressure that could cause a re-bleed
Reduce Intra-occular pressure if required- blood can clog up trabecular meshwork
What is the management of secondary bleeds causing secondary hyphaema?
As for primary
May require surgical evacuation as red cells adhere to and stain the corneal epithelium
If suspecting an intra-occular foreign body what is important to ask about in the history?
Velocity Eye protection Tetanus vaccination What was the material? How did it happen? Associated symptoms?
What investigations should be done if IOFB suspected?
Fundoscopy to see if any objects can be seen
X-Ray/CT (NOT MRI- unless you want to remove it very fast)
Refer to ophthalmology
Intensive ABx- Ciprofloxacin 750mg BD
What might cause a globe rupture?
Blunt trauma- compressive force
Sharp objects/Lacerations
High velocity objects
What is the management for a globe rupture?
Urgent referral to ophthalmology for surgical repair
Plastic shield- protect and avoid pressure on eye
Tetanus Prophylaxis
Imaging to check for IOFB- X-Ray/CT
Anti-biotics
What are some symptoms of a ruptured globe?
Severe pain
Loss of vision- loss of optical media
Photophobia
May develop infection
What does a scleral laceration look like?
Very dark wedge due to laceration exposing underlying coroid
What may an acutely forming cataract in a young patient be a sign of?
If there has been any perforation of the cornea a foreign object coming into contact with the lens can cause it to opacify
Also blunt trauma
Therefore any acutely forming cataract be aware of IOFB and trauma
What should be done for all chemical burns?
Irrigate
Irrigate
Irrigate
Till neutral pH/pH of normal eye achieved or for at least 30 minutes
Use 0.9% Saline (NaCl).
Refer to opthamology
What are some symptoms of chemical injury to the eye?
Red eye
Pain
Reduced vision (check acuity)
Photophobia
Why is an alkali more concerning than an acid burn to the eye?
Alkalis will progress and erode to cause perforation
Acids cause scarring at site of contact so will not cause perforation
What are some signs of chemical injury to the eye?
Corneal injection Redness Clouding of the cornea Limbal ischaemia (concerning as site of stem cells for cornea) Chemosis
What else can be given for chemical injury except for irrigation?
Dilator eye drops (cycloplegics) and topical steroids to reduce pain
Antibiotics if risk of infection or globe perforation
Vitamin C drops help with healing
Why is plaster dust very worrying if it gets into the eye?
It is an alkali and the dust is difficult to remove from the eye
What is the triad of non-accidental injury?
Sub-dural haematoma
Brain damage
Retinal haemorrhages
What feature should raise concerns regarding non-accidental injury?
Triad- subdural haematoma, retinal haemorrhages, brain damage
Multiple injuries in various stages of heeling.
What is orbital cellulitis?
Cellulitis (infection) within the orbit
