Vision Loss and Blindness

Question 1

List all causes of sudden vision loss.

Answer 1

Vascular aetiology
Retinal detachment
Age related macular degeneration (ARMD) -wet type
Closed angle glaucoma	
Optic neuritis
Stroke

Question 2

What provides the major blood supply to the eye?

Answer 2

various branches of OPHTHALMIC ARTERY

Question 3

What vascular causes can lead to acute vision loss?

Answer 3

Occlusion of: - retinal circulation
- optic nerve head circulation

Haemorrhage from: - abnormal blood vessels (eg diabetes, wet ARMD)
- retinal tear

Question 4

What are the signs of central retinal artery occlusion?

Answer 4

RAPD (relative afferent pupil defect)

Pale oedematous retina, thread-like retinal vessels

Question 5

What are causes of central retinal artery occlusion?

Answer 5

Carotid artery disease

Emboli from the heart (unusual)

Question 6

What is central retinal artery occlusion a type of?

Answer 6

stroke

Question 7

How should you manage central retinal artery occlusion?

Answer 7

Ophthalmic management:
If presents within 24 hours,
Ocular massage (try to convert CRAO to BRAO)

Vascular management:
Establish source of embolus – carotid doppler

Question 8

What are the 2 further variants of central retinal artery occlusion?

Answer 8

Branch retinal artery occlusion

Amaurosis fugax

Question 9

What are the symptoms of Amaurosis fugax?

Answer 9

transient painless visual loss
‘like a curtain coming down’
lasts~5mins with full recovery

Question 10

How should you manage Amaurosis fugax?

Answer 10

Immediate referral TIA clinic

Aspirin

Question 11

Name the ocular cause of central retinal vein occlusion.

Answer 11

raised IOP (venous stasis)

Question 12

What are the clinical signs of central retinal vein occlusion?

Answer 12

Retinal haemorrhages
Dilated tortuous veins
Disc swelling and macular swelling

Question 13

What may be required in central retinal vein occlusion to avoid complications from new vessels formed eg vitreous haemorrhage)?

Answer 13

laser treatment
or more recently,
anti- VEGFs used

Question 14

What is Occlusion of optic nerve head circulation also known as?

Answer 14

Also known as ‘Ischaemic optic neuropathy’

Question 15

What happens in Occlusion of optic nerve head circulation?

Answer 15

Posterior ciliary arteries (PCA) become occluded, resulting in infarction of the optic nerve head
(PCA not end arteries)

Question 16

What are the two types of Ischaemic Optic Neuropathy (ION)?

Answer 16

Arteritic 50% - inflammation (Giant Cell Arteritis)
Non-arteritic 50% - atherosclerosis
(Both cause sudden, profound visual loss with swollen disc)

Question 17

What happens in arteritic ION?

Answer 17

Medium to large sized arteries inflamed (multinucleate giant cells)
Lumen of artery becomes occluded (posterior ciliary arteries)
Visual loss from ischaemia of optic nerve head

Question 18

What is a sign of ION?

Answer 18

Pale, swollen disc

Question 19

What are the visual symptoms of ateritic ION?

Answer 19

Sudden visual loss
Profound (CF – NPoL)
Irreversible blindness

Question 20

What are symptoms of giant cell arteritis?

Answer 20

Headache (usually temporal)
Jaw claudication
Scalp tenderness (painful to comb hair)
Tender/enlarged 
   scalp arteries
Amaurosis fugax
Malaise
Very High ESR , PV and CRP
Temporal artery biopsy may help diagnosis

Question 21

What can prevent the other eye going blind in ateritic ION?

Answer 21

Immediate high dose systemic steroid may prevent other eye going blind.

Question 22

What is bleeding from retinal vessels usually associated with?

Answer 22

retinal tear

Question 23

What is bleeding from abnormal vessels usually associated with?

Answer 23

with retinal ischaemia and new vessel formation eg after retinal vein occlusion or diabetic retinopathy

Question 24

What are the symptoms of a Vitreous Haemorrhage?

Answer 24

vision loss

floaters

Question 25

What are the signs of Vitreous Haemorrhage?

Answer 25

Loss of red reflex | No RAPD – unless associated with other pathology

Question 26

What are the symptoms of retinal tear?

Answer 26

Painless loss of vision | Sudden onset of flashes/floaters (mechanical separation of sensory retina from retinal pigment epithelium)

Question 27

Signs of retinal tear?

Answer 27

May have RAPD | May see tear on ophthalmoscopy

Question 28

What are the two types of macular degeneration?

Answer 28

dry (gradual reduction in vision) | wet (sudden reduction in vision)

Question 29

What happens in wet ARMD?

Answer 29

New blood vessels grow under retina – leakage causes build up of fluid/blood and eventually scarring

Question 30

What are the symptoms and signs of wet ARMD?

Answer 30

Symptoms Rapid central visual loss Distortion (metamorphopsia) Signs haemorrhage/exudate

Question 31

What is the treatment of wet ARMD?

Answer 31

Anti-VEGF treatment – injected into vitreous cavity. Stops new blood vessels growing by binding to VEGF (vascular endothelial growth factor)

Question 32

Is gradual vision loss usually bilateral or unilateral?

Answer 32

bilateral

Question 33

What does CARDIGAN stand for with regard to the causes of gradual vision loss?

Answer 33

Cataract Age related macular degeneration (dry type) Refractive error Diabetic retinopathy (covered in other lecture) Inherited diseases e.g. retinitis pigmentosa Glaucoma Access (to eye clinic) Non-urgent

Question 34

Give 5 causes of cataracts.

Answer 34

``` Age related Congenital – intrauterine infection (importance of checking red reflex in neonates) Traumatic Metabolic – diabetes Drug-induced (steroids) ```

Question 35

What is a Christmas tree cataract?

Answer 35

polychromatic cataract

Question 36

Management of cataracts?

Answer 36

surgical removal with intra-ocular lens implant if patient is symptomatic

Question 37

What are the symptoms and signs of dry ARMD?

Answer 37

Symptoms Gradual decline in vision Central vision ‘missing’ ``` Signs Drusen – build up of waste products below RPE RPE changes – atrophy/ hyperplasia ```

Question 38

What is the treatment for dry ARMD?

Answer 38

no treatment, just supportive management

Question 39

What is Myopia?

Answer 39

short sightedness

Question 40

What is Hypermetropia?

Answer 40

long sightedness

Question 41

What is Astigmatism?

Answer 41

usually irregular corneal curvature

Question 42

Presbyopia

Answer 42

long sightedness with age

Question 43

What happens in open angle glaucoma?

Answer 43

Intra ocular pressure increases gradually Damage of retinal nerve fibres Visual field contracts

Question 44

What are the signs of glaucoma (often no symptoms)?

Answer 44

Increased intraocular pressure Cupped disc Visual field defect

Question 45

Treatment of open angle glaucoma?

Answer 45

pressure-lowering eye drops or occasionally surgery