Visual problems Flashcards
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?
What does monocular partial field loss suggest?
Subtotal retinal detachment
Ischaemic optic neuropathy
Branch retinal vascular occlusion
What does bilateral vision loss suggest?
Retrochiasmal visual pathway disorder
What does monocular vision loss suggest?
Issue before optic chiasm
What eye examinations should you do?
Fundoscopy
MRI
CN examination for those related to eye
What related to the aqueous humour can cause unilateral vision loss?
Acute angle glaucoma
Primary open angle glaucoma
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
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
What is the treatment of acute angle glaucoma?
Bright room Pilocarpine (constricts pupil) Timolol drops (beta-blocker) Surgical intervention IV acetazolamide 500mg (reduced IOP)
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
What are the risk factors for getting primary open angle glaucoma?
Increasing age
Black African heritage
FH
Myopia
How is primary open angle glaucoma treated?
Beta blockers
Prostaglandin analogues
Carbonic anhydrase inhibitors
Selective laser trabeculoplasty
What related to the vitreous humour can cause vision problems?
Vitreous haemorrhage
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
What is vitreous haemorrhage associated with?
Diabetic retinopathy
CRVO
Macular degeneration
What related to the retina can cause vision problems?
Retinal detachment
What is retinal detachment?
Retina pulled away from underlying surface
Often due to trauma eg RTA
What are the symptoms of retinal detachment?
Painless, progressive visual field loss
Flashes/floaters with decrease in vision
How is retinal detachment treated?
Surgical repair
What vascular problems can cause vision loss?
Central retinal artery occlusion
Central retinal vein occlusion
Anterior ischaemic optic neuropathy
What is central retinal artery occlusion?
Infarction of inner 2/3 of retina
Ophthalmic emergency
What are the symptoms of CRAO?
Sudden, painless loss of vision
Arteries narrow and retina opaque and oedematous
Cherry red spot at fovea
How is CRAO treated?
Ocular massage
IV acetazolamide
Breathing into paper bag - builds up CO2 so acts as vasodilator to dislodge emboli
What are the symptoms of CRVO?
Dilatation of branch veins
Multiple retinal haemorrhages
Cotton wool patches
Retinal oedema
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
