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Vision Loss: Acute and Chronic
Amit Tandon, MDClinical Assistant Professor
Department of Ophthalmology & Visual Science
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.
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