Visual loss Flashcards by Shehnaz Hussain

What are the causes of sudden visual loss?

Vascular (central retinal artery/ vein occlusion) 
Vitreous haemorrhage
Retinal detachment
ARMD - wet 
Closed angle glaucoma
Optic neuritis
Stroke

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What is the arterial supply to the eye?

All arises from the ophthalmic artery
Posterior ciliary artery supplies the optic nerve head
Central retinal artery supplies the retina

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What are the symptoms of central retinal artery occlusion (CRAO)?

Sudden visual loss

Painless

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What are the signs of CRAO?

RAPD
Pale, edematous retina
Thread like retinal vessels
Cannot see top letter on snellen chart

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What are the common causes for CRAO?

Carotid artery disease

Emboli from heart due to vegetations on heart valve

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What will branch retinal artery occlusion cause?

A section of the retina will be pale and ischaemic

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What are the symptoms of amaurosis fugax?

Transient painless visual loss
“Like a curtain coming down”
Lasts 5 mons

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What should be done if someone presents with a history of amaurosis fugax?

Urgent referral to stroke clinic as it can be a pre-warning to a stroke

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What is central retinal vein occlusion (CRVO) associated with?

Endothelial damage e.g. diabetes
Abnormal blood flow e.g. hypertension
Hypercoagulable state e.g. cancer

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What are the symptoms of CRVO?

Sudden visual loss if there is ischaemia

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What are the signs of CRVO?

Retinal haemorrhages
Dilated tortuous vessel
Disc swelling and macular swelling
Cotton wool spots (small infarcts of the nerve fiber layer)

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What can cause ischaemic optic neuropathy?

Occluded posterior ciliary artery

Giant cell arteritis

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What causes ION in GCA?

Posterior ciliary arteries become inflamed with multinucleated giant cells causing a gross thickening of artery wall resulting in visual loss due to ischaemia of the optic nerve head

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What are the symptoms of ION?

Sudden severe visual loss

Irreversible blindness

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What is the sign of ION?

Swollen optic nerve

Pale disc

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What are the symptoms of GCA?

Temporal headache
Jaw claudication 
Scalp tenderness
Amaurosis fugax
Malaise

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What is vitreous haemorrhage?

Bleeding from abnormal neovascularization bleeds into vitreous causing floaters

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When will neovascularization occur in the retina?

Retinal ischaemia in diabetes or retinal vein occlusion sends out VEGF resulting in abnormal, fragile blood vessels to form which are susceptible to bleeding

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What are the symptoms of vitreous haemorrhage?

Loss of vision

Floaters

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What are the signs of vitreous haemorrhage?

Loss of red reflex

Haemorrhage on fundoscopy

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What are the symptoms of retinal detachment?

Painless loss of vision

Sudden onset of flashes/ floaters

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What are the signs of retinal detachment?

RAPD

Tear on ophthalmoscopy

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What is wet ARMD?

New blood vessels grow under the retina resulting in leakage causing a build up of fluid/ blood and eventual scarring

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What are the symptoms of wet ARMD?

Rapid central vision loss

Distortion (metamorphopsia)

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What are the signs of wet ARMD?

Pale macula Exudates at the periphery of macula Small haemorrhages

What is glaucoma?

Progressive optic neuropathy mostly due to high IOP 2 different types End result is optic nerve damage and visual loss

What causes closed angle glaucoma?

Aqueous humour has increased resistance through iridocorneal angle which results in an increase pressure pusing iris forward obstructing the trabecular meshwork

What are the symptoms of acute closed angle glaucoma?

``` Painful Red eye Sudden visual loss Headache Nausea and vomiting ```

What are the signs of acute closed angle glaucoma?

Red eye Cloudy cornea Dilated pupil

When will gradual visual loss present early and late?

Presents early if reduction in visual acuity | Presents late if decreased visual field

What are the causes of gradual visual loss?

``` Cataract ARMD - dry Refractive error Glaucoma Diabetic retinopathy ```

What is cataracts?

Cloudiness of the lens - abnormal changes in lens proteins (crystalline) results in their chemical and structure alteration, leading to loss of transparency

What can cause cataracts?

``` Age related Congenital (intrauterine infection) Traumatic Metabolic (diabetes) Drug-induced (steroids) ```

What are the different types of cataract?

Nuclear Posterior subcapsular Christmas tree Congenital

What are the symptoms of cataracts?

Gradual decline in vision (hazy/blurred) that cannot be fixed with glasses Glare

What is the management of cataracts?

Surgical removal with intraocular lens implant if symptomatic

What causes dry ARMD?

Build up of drusen under the retina which will stop nutrients from diffusing from the choroid to the retina The retina will become atrophic and thin

What are the symptoms of dry ARMD?

Gradual decline in vision | Central vision missing - scotoma

What are the signs of dry ARMD?

Drusen - waste products below the RPE | Atrophic patches of retina - scotoma

What is myopia?

Short sighted

What is hypermetropia?

Long sighted

What is astigmatism?

Irregular corneal curvature

What is presbyopia?

Loss of accommodation with aging (pupil dilation, medial convergence and parasympathetic fattening of lens)

What are the symptoms of open angle glaucoma?

NONE | Optician may discover

What are the signs of open angle glaucoma?

Cupped disc Visual field defect May/ may not have high IOP

What is a swollen disc?

Any disc swelling secondary to any cause

What is papilloedema?

Swollen optic disc secondary to raised ICP

What is the golden rule with bilateral optic disc swelling?

All patients with bilateral optic disc swelling should be suspected of having raised ICP due to SOL until proven otherwise RAISED ICP IS A MEDICAL EMERGENCY

What is included in the optic nerve examination?

``` Ophthalmoscopy Visual acuity - snellen chart Pupil exam - direct, consensual and RAPD Visual field assessment Colour vision - ishihara test ```

Where is the CSF fluid in papilloedema?

Subarachnoid space of the meninges

What are the three components of ICP?

Brain 80% Blood 10% CSF 10%

What is the monro-kellie hypothesis?

An increase in one variable of ICP will result in a decrease of one/both other variables as the cranium is rigid and cannot expand

What will occur with an increase in CSF fluid?

Blood vessels compressed causing global brain ischaemia | Swelling with herniation through foramen magnum, brainstem compression and death

CASE: 70yr old male, blurred vision, headaches, VA 6/6 R and L Bilateral swollen discs

Meningioma

``` CASE: 55yr old Smoker Obese C/o blurred vision for 1 week Bilateral grossly swollen discs ```

ALWAYS CHECK BP He has a BP of 240/140 mmHg Malignant hypertension

What are the functions of CSF?

``` Maintains stable extracellular environment for the brain Buoyancy Mechanical protection Waste removal Nutrition ```

What can cause a rise in ICP?

Obstruction to CSF circulation Overproduction of CSF Inadequate absorption

``` CASE: 25 y/o female 6 mnth headaches BMI 40 VA 6/6 R&L Bilateral disc swelling Normal BP Normal head MRI ```

Lumbar puncture showed raised CSF opening pressure | Idiopathic intracranial hypertension

What causes idiopathic intracranial hypertension?

Stenosis of transverse cerebral sinuses Increased abdo pressure, increased cardiac pressure resulting in obstructed venous return from cranium Microemboli in sagittal sinus

What happens if the disc swelling becomes chronic?

Atrophic and pale disc Loss of visual function Blindness

What are the causes of RAPD?

``` Optic neuritis Ischaemic optic disease Severe glaucoma resulting in trauma to the optic nerve Direct optic nerve damage Retinal detachment Severe macular degeneration Retinal infection ```

Symptoms of horners sydrome

Ptosis - loss of innervation to superior tarsal muscle Miosis - loss of symp output to ciliary muscles Anhidrosis

What can cause horner's syndrome?

Carotid artery dissection Pancoast tumour Brachial plexus injury Cavernous sinus thrombosis