Visual Disturbance

Question 1

What are the presentations of visual disturbance?

Answer 1

1. Visual loss
2. Eye pain
3. Diplopia
4. Reduced colour vision
5. Positive visual symptoms - flashing lights, zigzag, patterns (migraine, vitreous/retinal detachment, occipital SOL, occipital epilepsy)
6. Eye redness
7. Ptosis
8. Headache and scalp pain

Question 2

History taking for visual loss

Answer 2

1. Onset - acute or gradual?
2. Unilateral or bilateral - one or both eyes?
   - Unilateral: ocular and optic nerve pathology
   - Bilateral: posterior to optic chiasm
3. Extent of loss
   A. Which part is affected?
   - Monocular: complete loss in 1 eye - optic nerve lesions anterior to optic chiasm
   - Central scomata: optic neuropathy, ARMD
   - Altitudinal (upper or lower half) - AION
   - Peripheral/homonymous hemianopia

B. Progression and spread - from outside extending into centre
- Rhegmatogenous retinal detachment

Question 3

Causes of acute vs gradual onset visual loss

Answer 3

Question 4

History taking for eye pain

Answer 4

1. Site
   - In the eye or around the eye?
   - Describe the characteristic of pain
   > Deep/dull retrobulbar pain worse on moving the eye: optic neuritis, closed angle glaucoma, iritis, thyroid opthalmopathy, cluster headache
   > Gritty/burning pain: dry eyes, keratitis, conjunctivitis, blepharitis, corneal ulceration, thyroid opthalmopathy
2. Worse on eye movement

Question 5

History taking in diplopia?

Answer 5

See Case 29 double vision (OST)

Question 6

Associated neurological condition in relation to eye symptoms

Answer 6

Headache
1. Generalised - SOL, trauma, tension headache
2. Frontal and facial - refractive error, sinus disease, ocular, intraocular
3. Facial pain, paresthesia, numbness - trigeminal nerve involvement, cavernous sinus lesion
4. Temporal headache, scalp tenderness - giant cell arteritis
5. Sudden onset headache - GCA, ICH, menignitis
6. Aggravated by postural change, straining, coughing, vomiting - raised ICP

Other neurological symptoms to localise lesions
Trauma

Question 7

Medical and family history in visual disturbance

Answer 7

1. Vascular risk factors: IHD, AF, stroke
2. Diabetes mellitus, hypertension
3. Personal history of multiple sclerosis, malignancy, thyroid, genetics, congenital
4. Dietary history - B12/folate deficiency
5. Family history of eye disease - LHON, retinitis pigmentosa
6. Medication side effect: isoniazid, ethambutol, vincristine, cisplatin, ciclosporin, amiodarone, antiepileptics
7. Smoking, alcohol consumption, sexual history
8. Occupation and exposure to toxin - lead, carbon monoxide

Question 8

Action plan for visual disturbance

Answer 8

1. Involvement of multidisciplinary team
2. Bloods: FBC, RP, LFT, TFT, B12/folate
3. ACE and ANCA - granulomatous disease (sarcoidosis, Wegener)
4. Syphilis serology
5. Mitochondrial DNA analysis - LHON
6. Temporal artery biopsy - GCA
7. Ach-R Ab - myasthenia gravis
8. Neuroimaging - orbital pathology, MS
9. No driving or high risk activities until proven safe

(non-exhaustive list)