Sudden Loss of vision - Vascular causes Flashcards
5 questions to ask about:
- Why do you ask about headaches?
- Why do you ask about painful eye movements?
- Why do you ask about lights/flashes before visual loss?
- Why do you ask if their vision is like a curtain descending?
Headache - for giant cell arteritis
Optic neuritis
Detached retina
Amaurosis fugax which may precede permanent visual loss
Anterior ischaemic optic neuropathy (AION):
What is it?
You get 2 types - arteritic and non-arteritic:
- What causes arteritic AION?
- The mechanism is unclear for non-arteritic AION but what is it related to?
- What age group typically gets non-arteritic AION?
What age group is it common in?
Optic nerve damage if posterior vascular supply to the optic nerve is blocked by inflammation or a clot.
Giant cell (temporal) arteritis
CVD risk factors (diabetes, HTN, cholesterol)
<50 yrs - usually happens when they wake up
The elderly
Giant cell (temporal) arteritis:
What is it?
What age group is it found in?
50% of patients have polymyalgia rheumatica. What is it?
Pain:
- Uni/bi
- Type of headache
- What would pain combing the hair indicate?
- What may happen in the jaw?
- 15% of patients get aortitis. How may it present?
Vasculitis of large and medium vessels in cranial branches of arteries arising from the aortic arch.
Elderly
A condition that causes pain, stiffness and inflammation in the MUSCLES around the shoulders, neck and hips.
Unilateral
Throbbing headache
Scalp tenderness
Jaw claudication - fatigue or discomfort of the jaw muscles during chewing of firm foods such as meat, chewing gum, or prolonged speaking.
Chest or abdo pain
Giant cell (temporal) arteritis:
Other symptoms:
- Systemic symptoms - 2
- What symptoms may indicate polymyalgia rheumatica? - 2
Visual symptoms:
- Do you get pain?
- Uni/bi
- What is amaurosis fugax and what may it lead to?
Malaise
Fever
No
Unilateral but can be bilateral
Transient loss of vision initially but may be permanent as a complication.
Giant cell (temporal) arteritis:
Signs:
- Where is tender?
- What may the pulse be like?
- What would the optic disc look like on fundoscopy?
Investigations:
- Bloods and why?
- What can be done to look for mononuclear/granulomatous infiltration when beginning Rx?
Management:
High dose PREDNISOLONE is used.
- How long are they on them for?
- What can be prescribed if the steroids are ineffective or causing side effects?
- What can be added to reduce the risk of stroke and visual loss?
Temporal artery over the temporal region
Weak or uneven temporal artery pulse
Inflammatory markers - ESR/CRP
FBC - high platelets and low Hb
6-12 months - taper off
Biologics - tocilizumab
Immunosuppressants - methotrexate
Aspirin
Retinal VEIN occlusion:
2nd most common cause of blindness from vascular disease.
Causes and associations?
How is it classified?
2 types?
Arteriosclerosis
HTN
DM
By anatomical location
Central retinal vein occlusion
Branch retinal vein occlusion
Central retinal VEIN occlusion:
What is the visual loss reduced to on this?
Why is it sudden when it is central?
What does branch retinal vein occlusion cause instead of complete visual loss?
Finger counting
Occurs at the level of the optic nerve
Visual deficits according to the area of ischaemia
Central retinal VEIN occlusion:
2 types - ischaemic and non-ischaemic:
Ischaemic:
- What do you see on the retina in ischaemic?
- You can get neovascularisation. Why is this not good?
- What may you see on fundoscopy in simple terms?
Non-ischaemic:
- Why does this one need to be monitored?
Investigations:
- What is a fluorescein angiogram and why is it used?
- What is pan-retinal photocoagulation?
Cotton wool spots - DM
Swollen optic nerve
Macular oedema
Neovascularisation - formation of new blood vessels - the eye can cause a type of glaucoma (neovascularization glaucoma) if the new blood vessels’ bulk blocks the constant outflow of aqueous humour from inside the eye.
Also has a high risk of haemorrhaging.
Looks like blood splatter -- May become ischaemic ---- A medical procedure in which a fluorescent dye is injected into the bloodstream. The dye highlights the blood vessels in the back of the eye so they can be photographed.
A type of laser treatment which treats or prevents neovascularisation
Central retinal VEIN occlusion:
Management:
- Who should they be referred to?
- First-line - Why are they given anti-VEGF?
- Second-line - Why are steroid, such as dexamethasone, given? Route?
Oncall ophthalmologist
For neovascularisation
Dexamethasone - helps macular oedema, therefore, reduces complications
Intravitreal implant
Central retinal ARTERY occlusion:
Why is this not as relevant as vein?
What should this be treated as?
How bad does the vision get?
What can you look for that could indicate there is a thromboembolic occlusion?
Not as common
Stroke - so follow stroke protocol
Finger counting or worse
Bruits in the carotids HTN AF Valve disease DM Smoking High C
Central retinal ARTERY occlusion:
What happens to the pupils?
Fundoscopy:
- How does the retina look?
- What do you see at the macula? - 3 words
Management:
- Since it is managed as a stroke, IOP can be reduced to increase blood flow. How can this be done?
How may this be prevented?
Afferent pupillary defect
Pale - may even look white
Cherry red spot
--- Reduce IOP by: - ocular massage - surgical removal of aqueous fluid - intraocular hypotensives
Address CVS risk factors
Vitreous haemorrhage:
What may cause it?
Floaters:
- What causes it?
- How is it seen by the patient?
What else may the patient see in their vision?
What may you see on fundoscopy with a large bleed?
Management if not complicated
Management if it is a dense VH and there’s neovascularisation?
Neovascularisation (DM, BRVO/CRVO) Retinal tears Retinal detachment Trauma ---- Small extravasations of blood
Small black dots or tiny ring-like forms with clear centres
Haze
Photophobia
Shadows
No red reflex and retina may not be seen
Usually resolves on its own
Vitrectomy
