Subjective Visual Complaints

Question 1

what are positive visual phenomena?

Answer 1

patients see “things” due to disease of the orbit, optic nerve and/or brain
they can be illusions or hallucinations

Question 2

what is an illusion?

Answer 2

an abnormal perception of real objects

Question 3

what is a hallucination?

Answer 3

a visual sensation that does not correspond to a real object
simple = flashing lights
complex = image of a person

Question 4

what are some positive visual phenomena due to eye disease?

Answer 4

halos around lights, metamorphopsia (illusion) and flashes (simple hallucination)

Question 5

what positive visual phenomena are seen in optic nerve disease?

Answer 5

simple hallucinations = flashes/sparkles (compressive, optic neuritis, NAION, AION)

Question 6

what can cause an illusion in the brain?

Answer 6

a tumor or stroke

Question 7

what can cause a hallucination in the brain?

Answer 7

migraine (simple - most common), brain tumor, metabolic disease, dementia (complex)

Question 8

what are some causes of simple metamorphopsia illusions?

Answer 8

macular disease or corneal disease (disappears when covering one eye)

Question 9

what are some causes of complex metamorphopsia illusions?

Answer 9

parietal tumor/stroke, parietal seizures, migraine (persists when covering one eye)

Question 10

what are the 3 types of complex illusions that can cause diplopia?

Answer 10

polyopia, palinopsia, and akinetopsia

Question 11

what is polyopia? what causes it?

Answer 11

moving objects leave multiple still images or a blurred trail
parieto-occipital tumor/stroke

Question 12

what is palinopsia? what causes it?

Answer 12

persistent visualization of an object after stimulus has been removed
parieto-occipital tumor/stroke or drug abuse

Question 13

what is akinetopsia? what causes it?

Answer 13

smoothly moving objects look stationary or jump from place to place (motion blindness)
bilateral occipito-temporal lobe tumor/stroke

Question 14

what can cause a simple hallucination?

Answer 14

retinal disease (PVD, RD, tear), optic nerve disease, migraine

Question 15

what can cause a complex hallucination?

Answer 15

dementia, metabolic disease, illegal drug use, occipital tumor/stroke, occipital epilepsy, Charles Bonnet syndrome

Question 16

what are negative visual phenomena?

Answer 16

dimming or loss of vision

due to disease of orbit, optic nerve, cerebral vascular supply, neck and heart

Question 17

what are causes of monocular negative visual phenomena?

Answer 17

CRAO, CRVO, retinal vasospasm (ocular migraine), GCA, papilledema (IIH), amaurosis fugax (most common) and calcium emboli

Question 18

what are causes of binocular negative visual phenomena?

Answer 18

migraine (most common), papilledema (IIH), verebrobasilar insufficiency and postural hypotension

Question 19

what is amaurosis fugax?

Answer 19

sudden onset of severe vision loss in one eye, painless, lasts for seconds - minutes and completely resolves in 10 minutes
fellow eye is unaffected and no other neurological symptoms

Question 20

who typically gets amaurosis fugax?

Answer 20

50+ year olds with cardiovascular risk factors

Question 21

what are the examination findings for amaurosis fugax?

Answer 21

normal ocular exam in both eyes, normal perimetry and pupils
may see a Hollenhorst plaque in retinal arteriole

Question 22

what causes amaurosis fugax?

Answer 22

ICA stenosis, ICA dissecting aneurysm (will have miosis), GCA, or cardiac valvular disease (younger patients)

Question 23

what is the work-up needed for amaurosis fugax patients?

Answer 23

blood-work = CBC with diff, ESR, CRP and check for clots
carotid artery doppler
MRI/MRA
echocardiogram

Question 24

what is ocular ischemic syndrome and what can cause it?

Answer 24

entire eye suffers from hypoperfusion (ophthalmic artery)
severe ICA stenosis or occlusion
GCA

Question 25

what are the symptoms for ocular ischemic syndrome?

Answer 25

transient monocular vision loss or blur and orbital ache (improved with laying down), transient neurologic symptoms (contralateral weakness or numbness)

Question 26

what are the signs for ocular ischemic syndrome?

Answer 26

decreased BCVA, IOP, mild anterior uveitis, retinal venous engorement/tortuosity, mid-peripheral retinal hemorrhages, iris neovascularization and cataract

Question 27

what are the treatments for ocular ischemic syndrome?

Answer 27

carotid endarterectomy (70-99% stenosis) or carotid angioplasty and stenting (at least 70% occlusion)

Question 28

what is vasospastic monocular TVL?

Answer 28

aka retinal migraine
choroidal circulation transiently undergoes a vasospasm
same eye is affected every time

Question 29

who typically gets vasospastic monocular TVL and how long does it last?

Answer 29

young adults

poor vision up to 5 minutes, full recovery after 5 minutes and no associated neurological signs

Question 30

what is the treatment for vasospastic monocular TVL?

Answer 30

can try calcium channel blockers to reduce frequency of spasm

Question 31

what is vertebrobasilar insufficiency?

Answer 31

sudden bilateral vision loss (recovers within minutes) and transient neurological symptoms are present

Question 32

what causes vertebrobasilar insufficiency?

Answer 32

atherosclerosis, embolism, GCA, postural hypotension (more common), cardiac disease
typically 50+

Question 33

what are the transient neurologic symptoms in vertebrobasilar insufficiency?

Answer 33

loss of balance, vertigo, problems walking/talking/swallowing, numbness/weakness on one or both sides of body and they may collapse

Question 34

what are the examination findings in vertebrobasilar insufficiency?

Answer 34

normal ocular exam, normal perimetry and pupils, there may be EOM disturbances (due to hypoperfusion to midbrain structures)

Question 35

when is the typical onset for a migraine?

Answer 35

usually prior to age 40

Question 36

what is a visual aura in a migraine?

Answer 36

expanding scintillating scotoma (positive visual phenomena), area of blurred vision in both eyes on same side, and expands 10-30 minutes