Sudden painless loss of vision

Question 1

What 5 questions are helpful in sudden painless loss of vision?

Answer 1

HELLP

• Headache associated - Do ESR urgently for possible giant cell arteritis
• Eye movements hurt - optic neuritis
• Lights/flashes preceding visual loss - retinal detachment
• Like a curtain descending - amaurosis fugax - may precede permanent visual loss e.g. from emboli or GCA
• Poorly controlled DM and vitreous haemorhage

Question 2

What sort of signs are seen in optic neuropathies?

Answer 2

This causes monocular visual loss with a central scotoma (area of depressed vision with central loss)
Afferent pupillary defect
Papillitis on fundoscopy that gradually progresses to optic atrophy

Question 3

What is the pathology and signs of anterior ischaemic optic neuropathy?

Answer 3

Most common cause of optic neuropathy in older people. Occurs from atheroma or inflammation blocking the posterior vascular supply. Fundoscopy shows a pale/swollen optic disc due to damage to the optic nerve.

Question 4

What is giant cell arteritis?

Answer 4

This is a medium to large vessel vasculitis

Question 5

What are the symptoms of temporal giant cell arteritis?

Answer 5

New-onset headache, tender and thickened temporal artery, jaw claudication, neck pain

Question 6

What is amaurosis fugax?

Answer 6

This is transient, painless loss of vision in one eye typically described as a curtain descending

Question 7

What kind of visual loss occurs in giant cell arteritis?

Answer 7

Monocular and often transient (amaourosis fugax)

Permanent visual loss is typically preceded by multiple episodes of amaourosis fugax.

Question 8

What tests should be done for giant cell arteritis?

Answer 8

ESR will be >47 and CRP will be >2.5mg/dL

Temporal artery biopsy should be performed 1 week before starting prednisolone

Question 9

What is the treatment for giant cell arteritis?

Answer 9

Oral prednisolone 60mg/24 hours

Higher dose IV prednisolone if visual failure occuring

Question 10

What are the symptoms of optic neuritis and what disease does this often precede?

Answer 10

There is unilateral loss of acuity which occurs over hours/days. Colour vision is affected with red desaturation (red appears less red). Develop an afferent pupillary defect. 50-80% develop MS in the next 15 years.

Question 11

What is the treatment for optic neuritis?

Answer 11

high dose methylprednisolone followed by prednisolone

Question 12

What are the typical causes of transient vision loss?

Answer 12

Always think vascular:
TIA, migraine
Multiple sclerosis
Subacute glaucoma
Papilloedema

Question 13

Which is more common central retinal artery or vein occlusion?

Answer 13

Vein is more common

Question 14

What is the management of central retinal artery occlusion?

Answer 14

Present with sudden visual loss
This is a type of stroke so treat according to local stroke procedures
If seen within 100 min of onset attempt to increase retinal blood flow. This can be done through reducing intracoccular pressure through ocular massage, surgical removal of aqeous from anterior chamber or use of intraocular hypertensive treatment

Question 15

How does the retina appear in central retinal artery occlusion?

Answer 15

white with a cherry red macula spot

Question 16

What are the causes of central retinal vein occlusion?

Answer 16

It is caused by arteriosclerosis, hypertension, diabetes and polycythemia

Question 17

What is the pattern of visual loss in central retinal vein occlusion?

Answer 17

This is slower than in arterial occlusion but can still be percieved as sudden by the patient. It causes painless blurred vision.

Question 18

How can central retinal vein occlusion be further divided and how can this be assessed?

Answer 18

Into ischaemic and non ischaemic causes. The level of ischaemia can be assessed with a fundus flourescein angiogram. Ischaemic changes are likely to lead to neovascularisation and damage.

Question 19

How is central retinal vein occlusion managed?

Answer 19

1st line are VEGF inhibitors followed by dexamethasone implants. Photocoagulation can be used if neovascularisation has started to occur.

Question 20

How does vitreous haemorrhage tend to occur?

Answer 20

This usually arises from retinal neovascularisation.

Question 21

How does vitreous haemorhage tend to present?

Answer 21

Small extravasations of blood produce vitreous floaters.

Question 22

How can a vitreous haemorrhage appear on examination?

Answer 22

With a large enough bleed can get loss of red reflex.

Question 23

How is vitreous haemorrhage managed?

Answer 23

IT usually undergoes spontaneous absorption but in dense haemorrhage then a vitrectomy can be done to remove the blood.

Question 24

What does a stormy sunset appearance on fundoscopy indicate?

Answer 24

Retinal vein occlusion causing there to be haemorrhagic changes