Acute Vision Loss
No laughing matter…
Dr Aaron J Wong
MH Intern
26 April 2012
Ms Smith
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70F with no previous ophthalmic history
Sudden loss of vision in R eye
No improvement over 6hr
What do you do?
Outline
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Ophthalmic emergencies - Acute visual loss
Anatomical sieve to the eye
Causes - immediate, emergent, urgent
History & Exam
Cases
Questions
Ophthalmic emergencies
Most sight-threatening conditions present as:
• trauma, including chemical burns
• acute loss of vision
• +/- painful red eye(s)
reduced vision + red eye = emergency
Vision Loss
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Rapidity is the most important factor
Acute = minutes to hours; Subacute = days
Chronic = weeks to months
Chronic >>> acute, but ACUTE = EMERGENCY
• Acute persistent visual loss (PVL) = a sudden deficit in visual
function in one or both eyes lasting more than 24 hours
• Acute transient visual loss aka. amaurosis fugax
• Ddx for amaurosis fugax are few (temporary vascular
occlusion/carotid artery disease, or temporary neuronal depression
related to seizure or migraine, ?temporal arteritis)
• Ddx of PVL is large.
Approach to Acute Visual Loss
• Sudden loss or blurring of vision is an
emergency > characterize properly
• Always exclude temporal arteritis because of
immediate risk to other eye
• Refer, refer, refer! Stratify by
– Immediate
– Emergent (same day)
– Urgent (24-48hr)
Ddx
• ABCDEFG – ED/Trauma
• Probability – Very common, common,
uncommon, rare
• VITAMIN CD
• Masquerades
• Anatomical
Anatomical Sieve
Ocular
Media
Extraocular
Retinal
Taken from: http://www.garetina.com/about-the-eye
Neural visual pathway
Anatomical Sieve
Ocular
Media
Extraocular
Retinal
Neural visual pathway
Keratitis +/- !endophthalmitis
!Retinal artery occlusion
Corneal edema
Trauma
!AACG
Retinal vein occlusion
Retinal detachment
+/- Vitreous hemorrhage
Hyphema
Optic nerve disease
!Arteritic – GCA
Non-arteritic
Optic neuritis
Chiasmal
Pituitary apoplexy
Acute maculopathy
Lens changes
Uveitis
!Retrochiasmal
Stroke/TIA
Tumor+haemorrhag
e
Other – Drugs/Neoplasia
Effects of Trauma
Ocular
Media
Extraocular
Retinal
Neural visual pathway
Keratitis +/- !endophthalmitis
!Retinal artery occlusion
Corneal edema
Trauma
!AACG
Retinal vein occlusion
Retinal detachment
+/- Vitreous hemorrhage
Hyphema
Optic nerve disease
!Arteritic – GCA
Non-arteritic
Optic neuritis
Chiasmal
Pituitary apoplexy
Acute maculopathy
Lens changes
Uveitis
!Retrochiasmal
Stroke/TIA
Tumor+haemorrhag
e
Other – Drugs/Neoplasia
History (HOPC)
• Timing —sudden onset of visual loss vs. sudden discovery of
preexisting visual loss
• Laterality
– Monocular > anterochiasmal/ocular;
– Bilateral > retrochiasmal/extraocular/systemic
• Quality
– Diffuse/localized
– Across midline
– Severity
• Onset
– Acute (minutes to hours)
– Subacute (days)
– Chronic (weeks to years)
• Progression & Duration
History (Assoc Sx)
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Trauma
Flashes +/- floaters > retinal detachment/haemorrhage +/- PVD
Diplopia
Pain - presence / absence not as useful; unless pain is severe!
– Anterior segment
• Keratitis > sharp superficial pain
• AACG > deep brow ache with N&V
• Endophthalmitis > deep boring pain
– Optic neuritis > pain worse with eye movement
• Redness — Anterior segment disease + uveitis
• Other neurological sx- weakness, numbness/tingling, slurred speech,
vertigo/ataxia
• Headache - rarely due to a refractive cause
• Systemic features - scalp tenderness, jaw claudication, proximal weakness,
fever, night sweats, weight loss
History (Relevant PMHx)
• Ophthalmic history
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Past episodes - amaurosis fugax
Recent cataract surgery > retinal detachment, endopthalmitis
Myopia > retinal detachment; Hypermetropia > AACG
Contact lens use - Corneal ulceration in contact lens wearers
Chronic conditions ie. AMD, Glaucoma > acute on chronic presentation
Family hx - Glaucoma
• Systemic diseases/risk factors
– Diabetes - RVO, neovascularization +/- vitreous haemorrhage, iris
neovasculization > glaucoma, optic neuropathy, myopic lens shifts,
cataracts, corneal abnormalities
– Hypertension > ocular vascular diseases
– Coronoary artery disease, PVD, hyperviscosity states
History (Medications)
• Eye drops vs systemic
• Anticholinergics: loss of accommodation, angle closure
glaucoma
• Topiramate: angle closure glaucoma.
• Sildenafil: blue vision, ischemic optic neuropathy
• Digoxin: yellow vision
• Amiodarone - progressive vision loss
• Bisphosphonates: uveitis
• Rifabutin: uveitis
• Sulfonamides: myopia
• Toxins - methanol consumption
Exam
• ABCDEFG – General Inspection of head and neck for trauma
• Visual acuity –one eye at the time, best corrected +/- 1mm
pinhole; distance & near
• Confrontation visual fields - red object
• Evaluation of EOM
• Pupils - symmetry, reactivity to light, pupillary reflex,
RAPD!!!
• Fundoscopy +/- slit lamp
• +/- Fluorescein application
• +/- Intraocular pressure testing (by tonometry or palpation)
RAPD
Mx (Stratification)
• Immediate referral
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Acute central retinal artery occlusion – 8hr window
?GCA – save the remaining eye
IOP > 40 mm Hg + eye pain ie. AACG
intracranial pathology (stroke, tumor, bleed, or elevated ICP) r/f to
neurological/neurosurgical.
• Emergent referral (same day)
– Retinal detachment
– Infectious keratitis +/- Endophthalmitis
– Hyphema
• Urgent referral (24 – 48hr)
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Central retinal vein occlusion.
Acute maculopathy.
Vitreous hemorrhage.
Optic neuritis
Non-infectious uveitis
Case 1 – Ms Smith
• 70F with no previous ophthalmic hx
• Hx
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Sudden loss of vision in R eye <6hr ago
Painless, no redness
Transient blurring of vision 2wk ago but recovered
PMHx – IHD, diabetes (on meds)
• O/E
– VA (R eye) <6/60
– VA (L eye) 6/9
– RAPD
Case 1 – Ms Smith
Case 1 – CRAO
• Hx
– Rapid onset, painless
• O/E
– Pale retina
– Arterial narowing
– Cherry red macula (>4hr)
– Embolus may be seen
– Optic disc not pale or swollen
Case 1 – CRAO
• Mx
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Exclude GCA – Hx & urgent CRP/ESR
Immediate referral to ophthal; <8hr window
Lower IOP - azetazolamide 500mg stat
Ocular massage
• Use index fingers of each hand
• [5s pressure, 5s release] x20
– Start aspirin
– Investigate for TIA
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Cardiac exam
Carotid US
Echocardiogram
Lipids, fasting BSL (CV RF)
Case 2 – Ms Lee
• 70F with no previous ophthalmic hx
• Hx
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Ongoing diplopia & blurred vision
Sudden loss of vision in R eye
Painless, no redness
Temporal headache, scalp tenderness
Jaw claudication, myalgia, fatigue
Fever/night sweats, anorexia, weight loss
PMHx – polymyalgia rheumatica
• O/E
– VA (R eye) hand movements
– VA (L eye) 6/6
– RAPD
Case 2 – Ms Lee
Case 2 – GCA
• Mx:
– Immediate referral
– Corticosteroids
• Methylprednisolone 1 g IV, daily for 3 days
• Prednis(ol)one 40 to 60 mg orally, daily in the morning for 2
to 4 weeks.
• at weekly intervals reduce the daily dose by a maximum of
10%—provided the ESR and CRP levels remain normal
– Aspirin 100 mg orally, daily
– Ix
• Urgent ESR, CRP
• Temporal artery biopsy (3-5cm)
Case 3 – Mr Yao
• 70M basketball player from China
• Hx
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Reduced vision in R eye
SEVERELY painful – deep brow ache/headache, red eye
Haloes around lights, photophobia
Abdo pain, N&V
Ophthal hx – hypermetropia, +3.0 D
• O/E
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Diffusely red eye
VA (R eye) 6/24
VA (L eye) 6/6
Mid-dilated, oval pupil
Dulled & irregular light reflex
Cloudy cornea
IOP 40mmHg, firm globe
Case 3 – Mr Yao
Case 3 – AACG
• Mx
– Immediate referral
– Lower IOP
– Medical
• Pilocarpine 4% eye drops, 1 drop q5min for 1st hr
• Acetazolamide 500mg po/IV, then 250mg po q6hr
• Other eye drops ie. timolol, brimonidine, latanoprost
– Laser perpiheral iridotomy to relieve pupil block;
– May require trabeculectomy
Case 4 – Mr Wong
• 40M amateur boxer, received blow to head
• Hx
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Sudden, marked visual loss in R eye
Rapidly progressive
Preceding flashes and floaters
No redness
Ophthal hx – myopic, uses contacts; -8.0 D
• O/E
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Bruise to head
VA (R eye) 6/60
VA (L eye) 6/6
VF (R eye) abnormal inferior hemisphere
Dulled red reflex
?RAPD
Case 4 – Mr Wong
Case 4 – Retinal detachment
• Mx
– Urgent ophthal referral
– Check the other eye! BL in 10%
– Rhegmatogenous (primary) vs.
tractional vs. exudative vs. haemorrhagic
– Pre-detachment – Cryopexy or laser retinopexy
– Scleral buckling + cryopexy/laser
– Vitrectomy + cryopexy/laser
– Pneumatic retinopexy
Case 5 – Mr Schmoe
• 60M, recent cataract surgery
• Hx
– Reduced vision over 2 days in R eye
– Painful, red
– Eyelid edema, congested eye
• O/E
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Diffusely red eye
Sediment in anterior chamber
VA (R eye) 6/24
VA (L eye) 6/6
Case 5 – Mr Schmoe
Case 5 – Endopthalmitis
• Mx
– Urgent ophthal referral
– Ideally, Gram stain from hypopyon at surgery
directs Abx regimen
– If significant delay, give empirical Abx
• Ciprofloxacin 750mg po stat
• Vancomycin up to 1.5g IV stat
• DO NOT USE TOPICAL ANTIBIOTICS, AS PRESERVATIVES
ARE TOXIC TO INTRAOCULAR CONTENTS
Keratitis
Vitreous haemorrhage
Acute maculopathy
CRVO
Optic neuritis
Occipital Cortex infarct
Questions?
Sources
• BMJ Best Practice – Vision Loss
• UpToDate - Approach to the adult with acute
persistent visual loss
• Therapeutic guidelines - Ophthalmic
emergencies, acute vision loss
• RVEEH - Golden eye rules
• Dr. Mark Daniel - Sudden Visual Loss
• Dr Shueh Wen Lim – Acute Vision Loss