Visual problems Flashcards by Emily Roberts

What questions should you ask in a visual problems history?

What is the visual problem?
Eye movements? Pain?
Exacerbating/relieving factors?
Onset?
Course?
Associated symptoms? - redness, trauma, headache, other focal neurology?
PMH?
Happened before? Treatment? Did it work?
Quality? 
Any previous trauma?
FHx?
Age? Weight?
Monocular/binocular?

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What does monocular partial field loss suggest?

Subtotal retinal detachment
Ischaemic optic neuropathy
Branch retinal vascular occlusion

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What does bilateral vision loss suggest?

Retrochiasmal visual pathway disorder

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What does monocular vision loss suggest?

Issue before optic chiasm

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What eye examinations should you do?

Fundoscopy
MRI
CN examination for those related to eye

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What related to the aqueous humour can cause unilateral vision loss?

Acute angle glaucoma

Primary open angle glaucoma

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What is acute angle glaucoma?

Sudden onset painful red eye and blurred vision due to occlusion of drainage of aqueous humour causing a rapid rise in IOP - iris pushed forwards against trabecular mesh

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What are the symptoms of acute angle glaucoma?

N&V
Sudden onset painful red eye
Blurred vision
Headache
Eye injected, tender, feels hard
Cornea hazy
Pupil semi-dilated

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What is the treatment of acute angle glaucoma?

Bright room
Pilocarpine (constricts pupil)
Timolol drops (beta-blocker)
Surgical intervention
IV acetazolamide 500mg (reduced IOP)

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What is primary open angle glaucoma?

Most common glaucoma
Reduced outflow of aqueous humour
Gradual, insidious, painless loss of peripheral visual fields = normal blind spot with scotomas
Tends to only be discovered when extremely advanced or on a routine examination of eyes

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What are the risk factors for getting primary open angle glaucoma?

Increasing age
Black African heritage
FH
Myopia

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How is primary open angle glaucoma treated?

Beta blockers
Prostaglandin analogues
Carbonic anhydrase inhibitors
Selective laser trabeculoplasty

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What related to the vitreous humour can cause vision problems?

Vitreous haemorrhage

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What is are the symptoms of vitreous haemorrhage?

Flashes/floaters with decrease in vision
Tends to be unilateral
Red tinge to vision
Blurring of vision

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What is vitreous haemorrhage associated with?

Diabetic retinopathy
CRVO
Macular degeneration

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What related to the retina can cause vision problems?

Retinal detachment

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What is retinal detachment?

Retina pulled away from underlying surface

Often due to trauma eg RTA

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What are the symptoms of retinal detachment?

Painless, progressive visual field loss

Flashes/floaters with decrease in vision

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How is retinal detachment treated?

Surgical repair

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What vascular problems can cause vision loss?

Central retinal artery occlusion
Central retinal vein occlusion
Anterior ischaemic optic neuropathy

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What is central retinal artery occlusion?

Infarction of inner 2/3 of retina

Ophthalmic emergency

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What are the symptoms of CRAO?

Sudden, painless loss of vision
Arteries narrow and retina opaque and oedematous
Cherry red spot at fovea

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How is CRAO treated?

Ocular massage
IV acetazolamide
Breathing into paper bag - builds up CO2 so acts as vasodilator to dislodge emboli

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What are the symptoms of CRVO?

Dilatation of branch veins
Multiple retinal haemorrhages
Cotton wool patches
Retinal oedema

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How is CRVO treated?

Mild - no treatment | Anti-VEGF/steroid injections

What can cause anterior ischaemic optic neuropathy?

Arteritis (GCA) or non-arteritic

What are the symptoms of anterior ischaemic optic neuropathy?

Papilloedema

What is anterior ischaemic optic neuropathy?

Occlusion of posterior ciliary artery - supplies optic nerve | Check ESR

What amaurosis fugax?

Central retinal artery occlusion

What nerve problems can cause vision loss?

Optic neuritis | Papillitis

What other inflammation can cause vision loss?

Keratitis | Uveitis

What is keratitis?

Corneal inflammation

What can cause keratitis?

HSV Contact lens-associated infection Blepharitis

What are the symptoms of keratitis?

Sensation of foreign body or pain Photophobia Lacrimation Vision reduced if ulcer affecting visual axis

What is uveitis?

Inflammation of uveal tract (iris, ciliary body, choroid)

What are the different types of uveitis?

Anterior Intermediate Posterior Panuveitis

What is anterior uveitis?

Inflammation of iris or both iris and ciliary body

What are the symptoms of anterior uveitis?

``` Redness Pain Photophobia Normal/blurred vision IOP normal/raised ```

How is anterior uveitis treated?

Topical steroids 0.1% dexamethasone | Cyclopentolate 1% for dilating pupil and preventing formation of posterior synechiae

What is intermediate uveitis?

Inflammation of vitreous

What are the symptoms of intermediate uveitis?

Painless blurred vision Floaters Both eyes commonly affected

What is the treatment for intermediate uveitis?

Combination of treatment for anterior and posterior depending on severity of different areas

What is posterior uveitis?

Inflammation of choroid, optic nerve head, retina

What are the symptoms of posterior uveitis?

``` Painless, blurred vision Can progress to severe visual loss Floaters Scotomata Blind spots ```

What is posterior uveitis associated with?

Systemic autoimmune conditions

How is posterior uveitis treated?

Oral steroids Treat underlying condition Immunosuppressants - ciclosporin, azathioprine

What is panuveitis?

Inflammation affecting all of uveal tract

What are the signs and symptoms of optic neuritis?

``` Reduced visual acuity over a few days Pain on eye movements Exacerbated by heat or exercise Relative afferent pupillary defect Dyschromatopsia - deficiency in colour vision ```

What can cause optic neuritis?

``` Inflammation of optic nerve MS/CIS Infection - Lyme/syphilis/HIV B12 deficiency Arteritis ```

What is the course of optic neuritis?

Recovery of vision usually occurs within 6 weeks

What is the treatment of optic neuritis?

Steroids to help reduce pain and hasten recovery

What is the relation of optic neuritis to MS?

``` May prove to be first manifestation of MS 15 year risk of developing MS 40% Higher if lesions on MRI - If MRI normal 10 year risk 11% - If MRI abnormal 10 year risk 83% ```

What are the signs and symptoms of GCA?

``` Medical emergency Jaw claudication Scalp tenderness Fatigue Anorexia Anaemia Age > 70 Elevated ESR/CRP No arteriosclerotic risk factors ```

What is GCA linked to?

Polymyalgia rheumatica

What is a relative afferent pupillary defect?

One eye responds to light and the other doesn't | Loss of direct response

What can cause relative afferent pupillary defects?

``` Ischaemic optic neuritis Optic neuritis Optic nerve compression Asymmetric glaucoma Trauma ```

What is cataracts?

Most common cause of preventable blindness

What can cause cataracts?

Age-related opacification of lens Congenital - maternal infection, familial Age - elderly Metabolic - diabetes, galactosaemia, hypocalcaemia, Wilson's disease Drug-induced - corticosteroids, phenothiazines, miotics, amiodarone Traumatic - post-intraocular surgery Inflammatory - uveitis Disorder-associated - Down syndrome, dystrophia myotonica, Lowe syndrome

What are the clinical features of cataracts?

Gradual painless deterioration of vision | Other symptoms depends on type

What investigations should you do with someone with cataracts?

Blood glucose Serum calcium LFTs

What is management of cataracts?

Surgery | Laser treatment

How common is macular degeneration?

Most common cause of visual impairment in patients over 50

What can cause age-related macular degeneration?

Genetic mutations

What are the risk factors for age-related macular degeneration?

``` Increasing age Smoking Hypertension Hypercholesterolaemia UV exposure ```

What are the 2 types of macular degeneration?

Non-exudative (dry) | Exudative (wet)

What are they symptoms of dry macular degeneration?

Painless, progressive loss of central vision Focal RPE detachment Visual distortion and blurring Lipofuscin deposits found between retinal pigment epithelium

What is wet macular degeneration?

Abnormal subfoveal choroidal neovascularisation of region of macula and causes severe central vision loss

How is macular degeneration managed?

Anti-VEGF with intravitrial injections