Sudden Vision Loss Flashcards
What are some important history taking points for an acute loss of vision
pain sudden/gradual intermitternt/constatn? flashes/floaters unilateral/bilateral total loss? blurred? (can you see light) central/side vision colour/loss PMH - ocular specifically FHx of eye diseae cardiovascular health
what should always be examined in patients that come in with acute loss of vision
acuity visual fields pupil reactions fundoscopy bloods - CV risk factors, inflammatory markers
What are causes of acute loss of vision
acute corneal disease Giant cell arteritis anterior chamber haemorrhage vitreous haemorrhage optic neuritis/ischaemic optic neuropathy branch retinal vein occlusion central retinal vein occlusion central retinal artery occlusion branch retinal artery occlusion retinal detachment macular haemorrhgae bitemporal hemianopia optic nerve compression via papilloedeme migraine CVA acute angle closure glaucoma anterior uveitis
What are causes of painful loss of vision
Giant cell arteritis Migraine optic neuritis acute angle closure glaucoma anterior uveitis
what does acute corneal disease make the cornea look like
cloudy
when is acute corneal disease not painful
when infected by HSV
what age group is most affected by giant cell arteritis
> 50
what blood test is most indicative of giant cell arteritis, and what values are you looking for
ESR, >50
what are some symptoms of giant cell arteritis
scalp tenderness - particulary over pterygoid visual obscurations jaw claudication (pain on chewing) weight loss decreased appetite proximal myopathy )dif
How should you investigate suspected giant cell arteritis
urgent ESR + CRP
refer to opthal
how do you treat giant cell arteritis
IV steroids 80mg/day
followed by discharge + oral pred 12-18 months (following histology)
if untreated what is the prognosis of giant cell arteritis
can go blind in a few hours
What must be done before giving someone long term steroids for giant cell arteritis
histology sample must be taken from the superficial temporal artery to confirm diagnosis
what can you see histologically that would confirm giant cell arteritis
tunica media thickening
smaller lumen size
commonly giant cells found (hence the name)
what are some features of Temporal Arteritis
> 60, acute visual loss (usually central), pain on chewing/combing hair nad when moving eyes red eye, raised ESR
what should always be done if optic neuritis is suspected
baseline MRI (rule out MS)
what is optic neuritis associated with and what percentage risk is there
MS - 50% lifetime risk, in 15-25% of MS patients optic neuritis is the first presentation
how do you treat optic neuritis
if MRI normal - symptomatic relief with IV steroids (methylprednisolone) if required - speeds recovery but doesnt recover any more vision than it would usually
If 2+ demylelinated lesions seen on MRI then MS is high risk and neurology referral is required for assessment for inteferon-1a or 1b
whats the pathology of optic neuritis
inflammatory demyelination of the optic nerve
optic neuritis prognosis
most regain normal vision in 6 months
if it returns, risk of MS is higher
what is more common, venous occlusion or retinal artery occlusion, and which is worse
venous, aterial is usually worse
what are features of a branch retinal vein occlusion
ventral visual loss - usually on waking
fundoscopy: cotton wool spots + haemorrhages in 1 quadrant of the eye
commonly raised BP and irregularity in routine bloods
what is the treatment for branch retinal vein occlusion
if mild - watch and wait (50% get better with no treatment)
otherwise: if neovascularisation is present, panretinal photocoagulation may be offered
macular laser therapy is offered if the macula is ‘waterlogged’
Anti-VEGF drugs or a dexamethasone implant may be injected into the eye
what are examples of some anti-VEGF drugs
Ranibizumab( Lucentis)
Aflibercept ( Eylea)
Bevacizumab (Avastin)
what are some risk factors for retinal vein occlusion
hypertension diabetes high cholesterol smoking older age glaucoma inflammatory disease of the eye
what is the prognosis of retinal vein occlusion
mild = good extensive = not good, risk of proliferative retinopathy
what are features of central retinal vein occlusion
affects all vision (not just central) variable acuity RAPD present if severe haemorrhages in all quadrants (this varies) swollen nerve - cant see margins filated tortuous veins cotton wool spots
what is a roth spot
a haemorrhage inside a cotton wool spot
what is the prognosis of central retinal vein occlusion
only 10-20% of severe patients recover some vision
how do you treat central retinal vein occlusion
if neovascularisation is present, panretinal photocoagulation may be offered
macular laser therapy is offered if the macula is ‘waterlogged’
Anti-VEGF drugs or a dexamethasone implant may be injected into the eye
treat immediately as waiting is less effective than branch occlusions
what is a severe complication of central retinal vein occlusion
rubeotic glaucoma - neovascularisation involving the iris causing a blockage of the drainage angle
What is the treatment of rubeotic glaucoma
panretinal photocoagulopathy
What sign means there is high risk of rubeotic glaucoma developing in central retinal vein occlusion
RAPD present
what are some features of a central retinal artery occlusion
low acuity to no light perception
afferent pupil defect (decreased constriction when waced with light)
RAPD
carotid bruits
fundoscopy: retinal odema, cherry red spot in macula, retinal arteriole emboli
what investigations should be done for central retinal artery occlusion
BP Fundoscopy carotid USS and doppler neck standard bloods ESR cardiac echo
what treatments for retinal artery occlusion can be done in primary care
rebreathe into paper bag to increased carbon dioxide and dilate vesssels to move emboli into periphery
ocular massage
what treatments for central retinal artery occlusion can be done in secondary care
IV Carbonic anhydrase inhibitor (acetazolamide/diamox) or paracentesis (needle to drop IOP)
What is the urgency of central retinal artery occlusion
12 hours until retina dies so refer to eye casualty immediately - 90 mins until ischemia starts
what are some features of branch retinal artery occlusion
RAPD carotid bruits hypertensive retinopathy fields defects acuity is 6/5 to count fingers
how do you manage branch retinal artery occlusion
BP Fundoscopy carotid USS and doppler neck standard bloods ESR cardiac echo
IV Carbonic anhydrase inhibitor (acetazolamide/diamox) or paracentesis (needle to drop IOP)
what are some features of retinal detachment/vitreous haemorrhage
floaters and flashes with field loss acuity may be lost unless macula stays attached RAPD - only if detached enough abnormal red reflex shadows in visual fields
what is the pathology of retinal detachment
vitreous liquifies and detaches from retina, normally its ok but sometimes the retina comes with it and tears, fluid then gets into the tear and separates the retina from the underlying layers causing further detachment and ischaemia
what is a risk factor for retinal detachment
myopia (short sightedness)
what is the treatment for retinal detachment/vitreous haemorrhage
if there is a tear - laser treatment
detachment - surgery/close breaks and oppose both surfaces
when should you aim to treat by in retinal detachment
before the foeva detaches as this causes significant blindness risk
what are some features of vitreous haemorrhage
blurring of fundoscopy/vision due to bleeding into vitreous
what are some features of macular haemorrhage
acute visual lose with a +ve scotoma, variable acuity, NO RAPD, visual fields should be good, fundoscopy reveals minor/major correlates with acuity
what causes bitemporal hemianopia
pituitary tumour (bitemporal superior quadrantinopia) /growth in superior aspect of rafkes pouch (bitempora inferior quadrantinopia)
if vitreous haemorrhage is seen what scan should be performed and why
Ultrasound B scan to rule out any retinal detachment
