transient visual symptoms Flashcards
characteristics of transient visual symptoms
Transient visual symptoms are usually:
Short lived
Lasting seconds or less than 30 minutes
Positive, negative or both
Monocular, binocular, hemianopic
Associated with other symptoms
Headache, nausea, vertigo, pain
May be precipitated by
Eye position, activity, eye movement, light
negative symptoms
Loss of vision may be:
Transient monocular visual loss (TMVL)
Without pain
With pain
Transient obscurations (very shortlived)
Transient binocular visual loss (TBVL)
Transient homonymous hemianopia (THH)
transient monocular vision loss without pain
what is the diagnostic criteria for amourosis fugax
Monocular loss of vision
Negative symptoms only
Abrupt onset
Resolution within 1 hour
No associated or antecedent symptoms (occasionally headache, no loss of consciousness)
No clinical signs after recovery
No signs on CT scan (unless a previous event)
Infrequent occurrence
why is it important to ask questions about TMVL without pain
Important to ask patient about…….
Other TIAs:
Aphasia, hemiparesis, hemianaethesia, vertigo
Cardiovascular history
Stroke, hypertension, diabetes, peripheral vascular disease
History of
Smoking, diabetes, family history of stroke
what should you do in a patient with TMVL without pain
Usually normal examination, but check….
VA, pupils and fields
Fundus examination
Retinal emboli (significance?)
Optic disc (swelling, atrophy)
Neurological examination
Pulse, heart
Splinter haemorrhages in skin
Splinter hemorrhages in skin may suggest problems like infective endocarditis, vasculitis etc that can all cause emboli in retinal vessels.
what investiagations are done in amourosis fugax
General
Blood tests
Hb, FBC, U&E, urinalysis, BS, cholesterol
BP
Aetiology
ECG, CT scan, Doppler, (MRA) (bruit)
what is the management for TMVL without pain
Management
Reassurance and explanation
Risk of further TIAs/stroke increased by
Weight, BP, diabetes, lipids
Carotids, heart
CT (other vascular events)
Risk reduction strategies
Aspirin, clopidogrel, dipyridamole, warfarin
Statin, BP control, blood sugar
Weight, smoking
Advice on what to do if further episodes
risks of having an emboilic transient ishacemic attack
If someone has an embolic visual TIA their risk of stroke is…..
15% at 12/12, 54% at 7 years
Highest risk is within 1 month of TIA
And 63% have evidence of CVA at diagnosis
TMVL without pain what conditions to consider
Conditions to consider……
Carotid dissection
Horner’s syndrome, trauma, Marfan’s etc
Retinal migraine (no positive symptoms)
Angle closure
Giant Cell Arteritis (AION)
Ocular ischaemia
what are transient obscurations
These are short lived (lasting seconds only)
The vision seems to switch off and switch on
It can be monocular/binocular
Conditions to consider…….
Papilloedema
Disc drusen
Central retinal vein occlusion
Ocular ischaemia
Severe hypertension
Very high IOP
Giant cell arteritis
Paraneoplastic retinopathy
what are different conditons associated with transient visual loss
Transient visual loss on eye movement…
Optic nerve tumour
Transient visual loss with activity
Steal syndromes (food)
Uthoff’s phenomenon (temperature)
Occipital lobe hallucinations
Exercise (benign spasm)
Transient visual loss with position (standing)
Vertebro-basilar insufficiency
Postural hypotension
Light induced transient visual loss
Carotid disease/CAR
transient binocular vision loss chracteristics
Total loss of vision (both eyes)
Often noticed as progressive tunnel vision
Can be severe transient blurring
Associated with brain stem and cerebellar symptoms e.g.
Nausea, vertigo, ataxia, perception
Consider……
Systemic hypotension (low blood pressure)
Hypoglycaemia (low blood sugar)
Vertebrobasilar artery migraine
transient homonymous heminaopia what to consider
It may be difficult for a patient to differentiate THH from TMVL
Caused by occlusion of the posterior cerebral artery or
Middle cerebral artery (when there would be associated symptoms e.g. same sided weakness)
what are other conditions that can cause transient visual disturbance
These conditions can cause transient visual disturbance….
Spontaneous hyphaema
Pigment dispersion syndrome (exercise)
Intermittent angle closure (pain, haloes)
Poor tear film (improves with blinking)
IOL problems (movement, displacement)
Fuch’s dystrophy (corneal problem, worse in morning)
what are postive symptoms
Scintillations
Entoptic phenomena
Vitreous opacities
Hallucinations
scintillations
Multiple bright flickering lights, caused by.
Retinal disease
Fundal white dot/big blind spot syndromes
Vitreo-retinal disease
Traction/Posterior Vitreous Detachment/Retinal Detachment
Fortification spectra (zig-zag edge)
migraine
what is entopic phenomnea
Phosphenes
Flashes and coloured spots seen in dim illumination
Caused by mechanical stimulation of the retina by the extraocular muscles
Moore’s lightning streaks
Blue field entoptic phenomena (white blood cells against a blue sky)
what are virtoeus opacities
Floaters in vision caused by
Vitreous condensation with age, myopia
Posterior vitreous detachment
Asteroid hyalopathy
Blood (vitreous haemorrhage)
White cells
Inflammation, infiltration
Amyloidosis of vitreous
Fuch’s heterochromic cyclitis
what are hallucinations/seizures
Occipital lobe epilepsy, associated with..
Simple partial seizures: elementary objects, in one hemi-field, with marching progress
Stereotyped symptoms
Complex images if it involves the temporal lobe
Sometimes oculoclonic movements
Occasional generalisation to loss of consciousness (grand mal)
what are combined and postive symptoms
Classic migraine aura
Young patients with family history of migraine
Positive aura, fortification (zig-zag) spectra
Homonymous, lasts <60 minutes
Expands, and moves
Associated with other symptoms
Scotoma, heminanopia
Often followed by headache, nausea, photophobia
combined postive and negative symptoms
Classic migraine aura
Young patients with family history of migraine
Positive aura, fortification (zig-zag) spectra
Homonymous, lasts <60 minutes
Expands, and moves
Associated with other symptoms
Scotoma, heminanopia
Often followed by headache, nausea, photophobia
what does postive and negative symptoms refer to
positive = These are symptoms that involve the presence of abnormal sensations or experiences that are not normally present.
negative = Negative Symptoms: In contrast, negative symptoms involve the absence or reduction of normal sensory experiences.
combined postive and negative symptoms =
PVD/retinal tear
Optic neuropathy
