Ophthalmology: Visual Loss Flashcards
What 4 conditions present with GRADUAL visual loss?
Cataracts
Age-Related Macular Degeneration
Diabetic Retinopathy
Chronic Open Angle Glaucoma
How does the character of visual loss differ between the causes of gradual visual loss?
Cataracts: Blurring and ‘Starbursts at night time’
Diabetic retinopathy: Blurring and blotching of vision
ARMD: Central visual field loss, reduced acuity and straight lines are wavy
Chronic open angle glaucoma: Peripheral loss until tunnel vision, halos around lights
Blot haemorrhages, vascular bulging/beading and cotton wool spots are indicative fundoscopic findings of which condition?
Diabetic retinopathy
What fundoscopic finding is there in cataracts?
Loss of red reflex
What is the treatment for cataracts?
Phacotomy with IOL insertion
Give IV antibiotics if complicated by endopthalmitis
What is the first and second line investigation for ARMD?
1st: Slit lamp fundus exam or OCT
2nd line: Fluorescene angiogram
What is the treatment for dry ARMD?
No treatment
Modify risk factors (Diet and smoking)
Blind registration
What is the difference between dry and wet ARMD
Symptoms of wet are more sudden
Due to neovascularisation of retina, leading to microhaemorrhage
What is the treatment for wet ARMD?
Anti-VEGF medications: -zumabs, pegaptanib within 3 months of onset
Outline the pathogenesis of diabetic retinopathy?
Hyperglycaemia damages microvasculature leading to:
Leakage (blot haemorrhages, bulging/beading)
Nerve damage (cotton wool spots)
What is the treatment of diabetic retinopathy?
Anti-VEGF medications
Laser photocoagulation of vessels
Vitreoretinal surgery
Gradual peripheral visual loss with intermittent blurred vision and halos around lights is suggestive of which condition?
Chronic open angle glaucoma
How do you investigate chronic open glaucoma?
Fundoscopy shows optic disc cupping
Goldmann applanation for raised IOP
What is the first line treatment for chronic open angle glaucoma? What is done if this method is not effective?
Lantaprost: Increases uveoscleral flow to reduce pressure on eye
Trabeculectomy if ineffective
What are the 5 causes of sudden, painless visual loss?
Central retinal artery occlusion (CRAO)
Central Retinal Vein Occlusion (CRVO)
Ischaemic optic neuropathy
Retinal detachment
Vitreous haemorrhage
What are the 3 causes of sudden, PAINFUL visual loss?
Acute angle closure glaucoma
Giant Cell Arteritis
Optic Neuritis
What condition has:
Sudden onset of profound visual loss
Relative Afferent Pupillary Defect
Cherry red spot at macula
Central retinal artery occlusion
How can CRAO be differentiated from CRVO?
CRVO // CRAO
moderate-severe // profound loss
Typically ‘curtain’ distribution (superior or inferior) // complete
Examination
Both RAPD
Retinal haemorrhages and tortuous vessels // Cherry red spot at macula
What are the characteristic symptoms of retinal detachment?
Painless
Persistent flashing lights
Bursts of floaters
Creeping peripheral loss
How is retinal detachment treated?
Urgent (<24 hour) referral to ophthalmologist
Scleral buckle/vitrectomy
What are the three causes of Sudden, Painful visual loss?
Acute angle closure glaucoma
Giant cell arteritis
Optic neuritis
Since both acute angle glaucoma and giant cell arteritis have blurred vision, how can you differentiate them?
ACAG has red eye with halos around lights
GCA has pain in jaw/scalp and systemic symptoms
Can test for raised ESR (>50mm/hour) and multinucleated giant cells in GCA
How can optic neuritis be distinguished from ACAG and GCA?
Central loss of vision rather than blurred
Loss of colour discrimination
What condition is most associated with optic neuritis? what should you therefore consider on first presentation?
Multiple sclerosis
MRI: >3 white matter plaques –> 50% risk of MS in 5 years
Outline the initial and secondary management of ACAG
Initial
Lie on back to open trabecular meshwork
Pilocarpine (2% blue, 4% brown) to contract iris so meshwork more open
Acetazolamide 500mg to reduce humour production
Secondary
Relieve blockage: Pilocarpine
Reduce humour: Acetazolamide/dorzolamide, glycerol/mannitol
Laser iridotomy
What is the pathogenesis of acute closed angle glaucoma?
Increased ocular pressure pushes iris to block drainage of aqeuous humour. This propagates the increase in IOP
What is the first line and confirmatory investigation for GCA?
1st line: ESR will be >50ms/hour
GS: Temporal biopsy shows multinucleated giant cells
What is the management of giant cell arteritis?
Prednisilone 40-60mg
+ Aspirin 75mg for stroke risk
Remember DONTSTOP for steroids
DONT stop steroids suddenly
Sick day rules
Treatment card
Osteoporosis prevention
PPIs
What are the features of optic neuritis?
Unilateral loss of vision that is sudden and painful
Loss of colour discrimination
Pain worse on movement
What is the treatment for Optic neuritis?
High dose steroids
4-6 weeks to recovery
