Vision Loss: Acute and Chronic Amit Tandon, MD Clinical Assistant Professor Department of...

Vision Loss: Acute and Chronic

Amit Tandon, MDClinical Assistant Professor

Department of Ophthalmology & Visual Science

Amit.Tandon@osumc.edu

Learning Objectives

Primary Learning Objectives: utilize symptoms, clinical presentations and examination findings to recognize common causes of chronic and acute vision loss.

Secondary Learning Objectives: interpret the meaning of ocular symptoms differentiate common causes of vison loss recognize ocular manifestations of systemic diseases

Visual loss

- The most important presenting eye problem that you will encounter as a physician.

- Differentiating sight (and life threatening) causes from more benign causes is crucial.

- A number of questions must be answered to arrive at the diagnosis.

Onset Acute – over several minutes, hours or days Chronic – Progressive over weeks to months

Duration Transient, permanent or intermittent

Location Monocular or binocular?

Differentiates brain vs eye problem

History

www.kellogg.umich.edu

Optic Nerve Pathway

History

Previous episodes of visual loss Associated Symptoms:

Diplopia Eye pain/photophobia Red Eye Nausea/emesis Discharge

Previous Ocular History Eye surgery or trauma

Physical – Eye Examination

Visual acuity With correction Each eye separately

Confrontational visual fields Pupillary reactions External/slit lamp examination Tonometry Ophthalmoscopy

Quiz1

Location of Visual Loss

Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical

Refractive error

Must be excluded prior to considering other, more serious, alternatives. Myopia Hyperopia Astigmatism Presbyopia Use of the pinhole

www.tnhealth.org/tsbcsdis.htm

Correction of refractive error

Spectacles Contact Lenses Corneal Refractive

Surgery PRK vs LASIK

Lenticular Refractive Surgery Lensectomy with implant Piggyback IOL

Quiz2

Location of Visual Loss

Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical

Ptosis

Acute eyelid drooping (ptosis) so severe that it obstructs vision is extremely rare

May herald the development of a cerebral aneurysm (posterior communicating artery) causing a third cranial nerve palsy.

Ptosis

Associated with normal vision when the lid is lifted

Other signs of a IIIcn palsy Mydriasis Inability to move the eye

inward, upward, or downward.

Other causes of a third nerve palsy Vascular diseases

(diabetes and hypertension) Vascular disease will often spare the pupil

Trauma Tumor Urgent evaluation of a

third nerve palsy is required

www.neurology.arizona.edu

.

Quiz3

Location of Visual Loss

Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical

Cornea

Any disruption of the tear film or corneal surface will cause blurred vision.

Loss of transparency of the deeper structure of the cornea (stroma) usually indicates edema, infection, inflammation, or scar.

Dry eye

Keratoconjunctivitis sicca is often associated with intermittent blurred vision especially with reading.

The result of break up of the tear film that is the primary optical surface of the eye.

Vision is usually restored temporarily with each blink.

Keratoconjunctivitis Sicca

Corneal abrasion

Severe Pain If central can

dramatically affect vision

Topical anesthetic will relieve the pain immediately

Corneal edema

The most common ACUTE cause of corneal edema (other than surgery or trauma) is angle closure glaucoma.

The high intraocular pressure drives fluid into the cornea.

The patient will also describe colored rainbows around lights due to the light scatter.

Associated with eye pain and nausea. Edema will resolve and vision will clear

rapidly once the intraocular pressure is lowered.

Angle Closure Glaucoma

Corneal Edema

Corneal infiltration or inflammation

This usually occurs in the face of an active infection. Accumulation of the offending organism along with

the induced inflammation causes a localized opacity of the cornea.

Corneal infiltrate

There is usually a predisposing factor such as: Contact lens wear Corneal exposure (Bell’s Palsy) Topical steroid use Herpes simplex keratitis Previous surgery or injury

Corneal scar

Result of a corneal infection or injury and will not be the cause of a true acute loss of vision.

Location of Visual Loss

Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical

Anterior Chamber

Most common – traumatic hyphema

Usually caused by a blunt trauma.

Exclude a globe rupture.

Hyphema will clear within one week in most cases.

Hyphema

Cycloplegia, topical steroids and rest are usually effective.

Aminocaproic acid may be used to decrease the chance of rebleeds in high-risk cases.

Patients at risk for sick cell anemia or trait should be checked because this may complicate recovery.

Main risk of permanent loss of vision is secondary glaucoma.

Location of Visual Loss

Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical

Cataract

The hallmark of most cataracts is slowly progressive loss of vision however there are two instances when they may form acutely.

One is the situation of uncontrolled diabetes with very high glucose levels. A dense cortical cataract may form due to osmotically induced

fluid shifts. These may resolve once the diabetes is under control.

Acute Cataracts

The other situation is with penetrating or blunt trauma. The cataract that forms with ocular injury may be localized and

nonprogressive or may be severe and rapidly progressive.

Location

Cataract

Cortical cataract seen against red reflex

Extremely dense nuclear cataract

Posterior subcapsular cataract

arapaho.nsuok.edu/~fulk/kanski.html

Traumatic Cataract

Location of Visual Loss

Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical

Vitreous

Sudden visual loss in a patient with known diabetic retinopathy may be the result of a vitreous hemorrhage.

This may cause severe visual loss, which may resolve over weeks to months.

Vitreous Hemorrhage

Retinal Tear Diabetic

Retinopathy Central Retinal Vein

Occlusion (CRVO) Branch Retinal Vein

Occlusion (BRVO)

Quiz4

Location of Visual Loss

Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical

Central Retinal Artery Occlusion (CRAO)

Sudden, painless, complete loss of vision in one eye.

Retinal vessels are narrow. The retina is pale except the

macular region, which is thin, and choroidal circulation may be seen causing a cherry-red spot.

Central Retinal Artery Occlusion(CRAO)

Workup for carotid and cardiac sources of the embolus is necessary along with screening for temporal arteritis in appropriate patients.

An afferent pupillary defect (APD) is present with a CRAO. APD is typically an optic nerve problem, can occur in severe retinal

problems. Should NOT occur with other types of eye pathology (other than retina/optic nerve).

Technically it is a relative APD or RAPD, but often notated just as an APD.

BRAO

Branch retinal artery occlusion may be asymptomatic unless it occurs near the fovea.

Marcus Gunn Pupil

Central retinal vein occlusion

May also cause sudden painless loss of vision in one eye.

This loss is usually not as extensive as that with CRAO’s.

This may be associated with systemic hypertension and glaucoma.

Neovascularization of the retina and iris may occur.

Neovascular glaucoma may lead to blindness if not aggressively treated.

Central Retinal Vein Occlusion

Retinal detachment

Usually causes a dark shade over the visual field.

It may be heralded by the onset of many floaters and flashing lights. Differentiate flashing lights from migraine

phenomenon because migraine is both eyes, flashing lights from the retina is one eye only.

The detached retina is usually easily seen through a dilated pupil.

Retinal Detachment

www.eyeweb.org

Diabetic Retinopathy

Two types: Nonproliferative diabetic retinopathy (NPDR) Proliferative diabetic retinopathy (PDR)

Diabetic Macular edema is the most common cause of visual loss related to diabetes. Can occur in NPDR or PDR. It may be treated with focal argon laser photocoagulation.

Non Proliferative Diabetic Retinopathy (NPDR)

Dot/blot hemorrhages Flame hemorrhages Microaneurysms

Cotton Wool Spots Hard Exudate

www.southcoasteye.com/

Proliferative diabetic retinopathy(PDR) More severe form of diabetic retinopathy, which

may occur with or without macular edema. Treated with panretinal photocoagulation.

May occur without visual loss therefore routine ocular exams are crucial for diabetics.

Proliferative diabetic retinopathy may lead to vitreous hemorrhage, traction retinal detachment and blindness.

PDR

Neovascularization of the disc (NVD)

NeovascularizationElsewhere (NVE)

medweb.bham.ac.uk/easdec/eyetextbook/dr.htm14.jpg

Age-related macular degeneration (ARMD) Dry age-related macular degeneration

A disease of the retinal pigment epithelium causing slowly progressive loss of vision.

May progress to the more severe form of wet age-related macular degeneration.

Antioxidant vitamins (Vit C, E, beta carotene, and zinc) may decrease the chance of progression of this disease to the more advanced form.

ARMD

Wet macular degeneration is characterized by the development of a subretinal neovascular membrane. Can acutely bleed and have visual loss.

Visual distortion (metamorphopsia) is a hallmark of this disease.

Anti-VEGF medications have improved the outlook of wet ARMD, but still a devastating disease Avastin and Lucentis

Dry ARMD

Wet ARMDSubfoveal Neovascular Membrane

Quiz5

Location of Visual Loss

Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical

Optic Nerve

Glaucoma – the most common cause of optic nerve related visual loss is related to glaucoma. Open angle glaucoma is the most common form of

glaucoma. No symptoms until it is very advanced. Visual loss involves the peripheral visual field. Visual loss is not reversible. Treatment involves lowering of intraocular pressure

through medication and surgery.

Glaucoma

Normal Glaucoma

Angle closure glaucoma

Rare form of glaucoma which may occur in acute or chronic forms.

Chronic angle closure glaucoma presents similarly to chronic open angle glaucoma.

Acute angle closure glaucoma may present with eye pain, blurred vision, and nausea.

Pupil may be fixed and mid dilated. Treatment of angle closure glaucoma is through

the creation of a peripheral iridectomy using a laser.

Neovascular glaucoma

An acute form of glaucoma related to retinal ischemia with diabetic retinopathy or retinal vein occlusions.

Symptoms are similar to that with acute angle closure glaucoma.

Treatment must be directed at both the causative retinal disease and the direct lowering of intraocular pressure.

Ischemic optic neuropathy (ION)

2 types: Arteritic or Non-arteritic Present with an APD Arteritic ischemic optic neuropathy (AION) is

related to underlying inflammatory vascular disease such as temporal arteritis (giant cell arteritis). Elderly patients with concomitant jaw claudication,

scalp tenderness, and proximal muscle pain are at risk.

A sedimentation rate should be performed followed by a temporal artery biopsy if positive.

Treatment is with systemic corticosteroids.

Ischemic Optic NeuropathyNonarteritic

Optic nerve swelling Splinter

hemorrhages Sudden loss of

vision Altitudinal visual

field loss

Ischemic optic neuropathy (ION)

Nonarteritic ischemic optic neuropathy (NAION) causes sudden visual loss in the absence of vascular inflammation.

Underlying diabetes and hypertension predispose to NAION.

Optic neuritis

Sudden visual loss in relatively young people. Pain with eye movements is classic Present with an APD

Commonly a manifestation of multiple sclerosis. Treatment with corticosteroids is controversial

Vision will recover faster but in the long term has no additional benefit.

Quiz6

Location of Visual Loss

Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical

Visual Pathways

Disease involving the visual pathways through the brain will manifest according to the location and type of disease (CVA –sudden, Tumor – slow).

Visual Cortex in Occipital Lobes

Summary

Vision Loss is the most important eye complaint you will encounter as a physician.

Utilize symptoms, clinical presentations and examination findings to recognize common causes of vision loss.

Differentiating acute vs chronic vision loss will help narrow down the diagnosis.

Any Questions?Amit.tandon@osumc.edu

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