Ophthalmology: Visual Loss

Question 1

What 4 conditions present with GRADUAL visual loss?

Answer 1

Cataracts

Age-Related Macular Degeneration

Diabetic Retinopathy

Chronic Open Angle Glaucoma

Question 2

How does the character of visual loss differ between the causes of gradual visual loss?

Answer 2

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

Question 3

Blot haemorrhages, vascular bulging/beading and cotton wool spots are indicative fundoscopic findings of which condition?

Answer 3

Diabetic retinopathy

Question 4

What fundoscopic finding is there in cataracts?

Answer 4

Loss of red reflex

Question 5

What is the treatment for cataracts?

Answer 5

Phacotomy with IOL insertion

Give IV antibiotics if complicated by endopthalmitis

Question 6

What is the first and second line investigation for ARMD?

Answer 6

1st: Slit lamp fundus exam or OCT

2nd line: Fluorescene angiogram

Question 7

What is the treatment for dry ARMD?

Answer 7

No treatment

Modify risk factors (Diet and smoking)

Blind registration

Question 8

What is the difference between dry and wet ARMD

Answer 8

Symptoms of wet are more sudden

Due to neovascularisation of retina, leading to microhaemorrhage

Question 9

What is the treatment for wet ARMD?

Answer 9

Anti-VEGF medications: -zumabs, pegaptanib within 3 months of onset

Question 10

Outline the pathogenesis of diabetic retinopathy?

Answer 10

Hyperglycaemia damages microvasculature leading to:

Leakage (blot haemorrhages, bulging/beading)

Nerve damage (cotton wool spots)

Question 11

What is the treatment of diabetic retinopathy?

Answer 11

Anti-VEGF medications

Laser photocoagulation of vessels

Vitreoretinal surgery

Question 12

Gradual peripheral visual loss with intermittent blurred vision and halos around lights is suggestive of which condition?

Answer 12

Chronic open angle glaucoma

Question 13

How do you investigate chronic open glaucoma?

Answer 13

Fundoscopy shows optic disc cupping

Goldmann applanation for raised IOP

Question 14

What is the first line treatment for chronic open angle glaucoma? What is done if this method is not effective?

Answer 14

Lantaprost: Increases uveoscleral flow to reduce pressure on eye

Trabeculectomy if ineffective

Question 15

What are the 5 causes of sudden, painless visual loss?

Answer 15

Central retinal artery occlusion (CRAO)

Central Retinal Vein Occlusion (CRVO)

Ischaemic optic neuropathy

Retinal detachment

Vitreous haemorrhage

Question 16

What are the 3 causes of sudden, PAINFUL visual loss?

Answer 16

Acute angle closure glaucoma

Giant Cell Arteritis

Optic Neuritis

Question 17

What condition has:

Sudden onset of profound visual loss

Relative Afferent Pupillary Defect

Cherry red spot at macula

Answer 17

Central retinal artery occlusion

Question 18

How can CRAO be differentiated from CRVO?

Answer 18

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

Question 19

What are the characteristic symptoms of retinal detachment?

Answer 19

Painless

Persistent flashing lights

Bursts of floaters

Creeping peripheral loss

Question 20

How is retinal detachment treated?

Answer 20

Urgent (<24 hour) referral to ophthalmologist

Scleral buckle/vitrectomy

Question 21

What are the three causes of Sudden, Painful visual loss?

Answer 21

Acute angle closure glaucoma

Giant cell arteritis

Optic neuritis

Question 22

Since both acute angle glaucoma and giant cell arteritis have blurred vision, how can you differentiate them?

Answer 22

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

Question 23

How can optic neuritis be distinguished from ACAG and GCA?

Answer 23

Central loss of vision rather than blurred

Loss of colour discrimination

Question 24

What condition is most associated with optic neuritis? what should you therefore consider on first presentation?

Answer 24

Multiple sclerosis

MRI: >3 white matter plaques –> 50% risk of MS in 5 years

Question 25

Outline the initial and secondary management of ACAG

Answer 25

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

Question 26

What is the pathogenesis of acute closed angle glaucoma?

Answer 26

Increased ocular pressure pushes iris to block drainage of aqeuous humour. This propagates the increase in IOP

Question 27

What is the first line and confirmatory investigation for GCA?

Answer 27

1st line: ESR will be >50ms/hour

GS: Temporal biopsy shows multinucleated giant cells

Question 28

What is the management of giant cell arteritis?

Answer 28

Prednisilone 40-60mg

+ Aspirin 75mg for stroke risk

Remember DONTSTOP for steroids

DONT stop steroids suddenly

Sick day rules

Treatment card

Osteoporosis prevention

PPIs

Question 29

What are the features of optic neuritis?

Answer 29

Unilateral loss of vision that is sudden and painful

Loss of colour discrimination

Pain worse on movement

Question 30

What is the treatment for Optic neuritis?

Answer 30

High dose steroids

4-6 weeks to recovery