Sudden Painless Loss of Vision

Question 1

What is optic neuropathy? What does it cause?

Answer 1

Damage to the optic nerve produces:
Monocular vision loss with a central scotoma
Afferent pupillary defects (unilateral lesions)
dyschromatopsia (colour blindness)
Papilitis on fundoscopy which eventually progresses to optic atrophy (pale disc, indicates long term damage)

Question 2

Describe anterior ischaemic optic neuropathy. What is seen on fundoscopy?
What are the two main types?

Answer 2

Optic nerve is damaged if posterior vascular supply to the optic nerve is blocked by inflammation or atheroma.

Pale swollen optic disc due to optic nerve damage

Non-Arteritic and arteritic

Question 3

Describe giant cell arteritis

Answer 3

Medium to large vessel systemic vasculitis in patients > 70

New onset headache
Jaw claudication
Tender scalp and temporal arteries (thickened and absent pulses)
Neck pain
Monocular visual loss - may be transient

Question 4

Describe the vision loss in GCA

Answer 4

Amaurosis fugal - transient monocular vision loss like a curtain coming down
Permanent visual loss tends to be preceded by multiple episodes of maeurosis fugax

Question 5

What is GCA associated with?

Answer 5

Polymyalgia rheumatics - hip and shoulder girdle aching with morning stiffness.

Question 6

What tests in GCA?

Answer 6

ESR and CRP
Temporal artery biopsy
within 1 week of starting steroids
May miss sections of artery however - skip lesions

Question 7

What is management of GCA?

Answer 7

Oral prednisolone promptly started

Question 8

What is optic neuritis? Causes? Management?

Answer 8

Unilateral loss of acuity occurs over hours/days
Colour vision is affected
Red desaturation
Eye movement hurts
RAPD
Central scotoma

Causes:
Multiple sclerosis
Diabetes
Syphilis

High dose methylprednisolone then prednisolone
4-6 week recovery

Question 9

Describe visual loss in central retinal artery occlusion. How does the retina appear on fundoscopy?

Answer 9

Dramatic visual loss within seconds of occlusion
RAPD appears within seconds and may precede retinal changes

Retina appears white with a cherry red spot at the macula.

Question 10

How do you manage central retinal artery occlusion?

Answer 10

Stroke management
Occlusion is often thromboembolic

Look for signs of atherosclerosis, AF, heart valve disease, diabetes, smoking of hyperlipidaemia

Reduce intraocular pressure by ocular massage
Surgical removal of aqueous from the anterior chamber
Intraocular hypotensive Treatment

Reduce CVS risk factors for primary prevention