Acute visual loss

Acute Visual Loss

Karl D. Bodendorfer, MDAssistant Professor of Ophthalmology

University of Florida

Acute Visual LossCategories

• Ocular– Media opacities– Retinal (most are vascular)– Optic nerve (most are vascular)

• Non-ocular– Stroke– Functional – Acute discovery of chronic visual loss

Acute Visual LossOcular

• Media Opacities– Corneal edema - acute angle closure glaucoma,

keratitis (corneal infections)– Hyphema – Cataract– Vitreous hemorrhage

Acute Visual LossAcute Angle Closure Glaucoma

• Characterized by a sudden rise in IOP in a susceptible individual with a dilated pupil, which decompensates the cornea

• Aqueous humor (produced behind the iris by the ciliary body) cannot get into anterior chamber to reach trabecular meshwork (drain of the eye)




• Symptoms– Severe ocular pain– Frontal headache– Blurred vision with halos around lights– Nausea and vomiting


• Signs– Corneal edema– Conjunctival hyperemia– Pupil mid-dilated and fixed– Iris bowed (bombe’d) forward– Swollen lids




• Acute glaucoma is the “great masquerader” of the red eye syndromes

• Recognize it and refer quickly - profound visual loss can result from a delay in treatment


• Initial treatment– Pilocarpine q 15 min x 2– Other IOP drops– Acetazolamide PO or IV– Oral glycerine or isosorbide– IV mannitol


• Definitive treatment– YAG laser peripheral iridotomy– Surgical peripheral iridectomy– Cataract extraction



Acute Visual LossCorneal Ulcer

Acute Visual LossHyphema

• Blood in the anterior chamber• Usually caused by trauma• Check blacks for sickle cell disease




• Treatment– Bedrest with head elevated– Topical atropine– Topical steroids– +/- Oral steroids– Watch the IOP and cornea - evacuate blood, if

necessary– Generally needs urgent referral to

ophthalmology

Acute Visual LossCataract

• Cataract– Can develop or worsen quickly– Usually in association with trauma or metabolic

imbalances– Still, most often this would fall under category

of acute discovery of chronic visual loss

Acute Visual LossCataract

Acute Visual LossVitreous Hemorrhage

• Vitreous hemorrhage– Usually in association with trauma or

neovascularization from diabetes or vascular occlusions

– Most often just wait for blood to clear naturally– Use laser, if appropriate, as soon as retina

visible– Evacuate blood if not clear by 3-4 months

Acute Visual LossVitreous Hemorrhage


• Retinal Causes– Retinal detachment– Macular disease - usually neovascular– Retinal vascular occlusions

• Central retinal artery occlusion (CRAO)• Branch retinal artery occlusion (BRAO)• Central retinal vein occlusion (CRVO)• Branch retinal vein occlusion (BRVO)

Acute Visual LossRetinal Detachment

• Separation of sensory retina from choroid• Usually in conjunction with a predisposing

situation– Vitreous degeneration and detachment– Lattice degeneration (high myopes)– Neovascularization of the retina (diabetes)– Trauma


• Symptoms– Flashing lights– Floaters– Loss of vision








• Exam– Any patient with risk factors should be dilated

and examined– A retinal detachment large enough to cause

“window shade” loss of vision is big enough to see with a direct ophthalmoscope

– Most often, patients with these symptoms should be referred for exam


• Treatment– A number of treatments depending on size and

location• Scleral buckle• Laser• Cryo• Intraocular surgery

– Key point is that the sooner the repair, the better the outcome

Acute Visual LossMacular Disease

• Macula is area of sharp acuity• Small anomaly can cause profound visual

loss• Most common cause is subretinal

hemorrhage from neovascularization seen in macular degeneration

Acute Visual LossSub-Macular Neovascularization

Acute Visual LossSub-Macular Neovascularization

Acute Visual LossMacular Hole


• Symptoms– Sudden loss of vision– Wavy lines (metamorphopsias)– Gray areas


• Exam– Amsler grid (graph paper) - very sensitive– Use direct ophthalmoscope - often see elevated

areas of retina, hemorrhage– Fluorescein angiogram


• Treatment– Often amenable to laser treatment– Occasionally, intraocular surgery to evacuate

the hemorrhage is helpful– Again, the sooner treatment is initiated, the

better the outcome - refer quickly

Acute Visual LossRetinal Vascular Occlusions

• Central retinal artery occlusion (CRAO)– Acute painless loss of vision– Usually embolic or thrombotic

• Check heart - atrial fibrillation, MI, valvular disease• Check carotids - cholesterol plaques• * * Check ESR for giant cell arteritis in patients

over 60

Acute Visual LossCentral Retinal Artery Occlusion• Profound visual loss will become permanent

within hours• Diagnosis made based on appearance

– Acute - vascular stasis and very narrow arterioles

– Hours later - inner retina becomes opaque except for macula - “cherry red spot” appearance

Acute Visual LossCentral Retinal Artery Occlusion

Acute Visual LossCentral Retinal Artery Occlusion

Acute Visual LossCentral Retinal Artery Occlusion• Treatment

– Little to lose in initiating treatment• Press firmly on eye for 10 seconds• Release for 10 seconds• Repeat - try to dislodge embolus/thrombus

– Ophthalmologist may tap anterior chamber to lower IOP to zero - trying to dislodge embolus

– Also, rebreathing CO2, hyperbaric O2, Ca channel blockers - none work well

Acute Visual LossBranch Retinal Artery Occlusion

• Sudden painless loss of vision - severity depends on location of occlusion

• Usually embolic• Look for cholesterol plaques on exam




• Treatment– Little can be done– Try to prevent another plaque-related insult

(stroke)• Check carotids• Lower cholesterol• +/- Aspirin

Acute Visual LossCentral Retinal Vein Occlusion

• Less sudden painless loss of vision– Rarely complete, but often severe

• Usually elderly patients• Often becomes bilateral (10%)


• Associations– Hypertension– Atherosclerotic vascular disease– Glaucoma– Hyperviscosity syndromes


• Examination– Use direct ophthalmoscope– “Blood and thunder” appearance

• Many diffuse flame and blot hemorrhages• Cotton wool spots (white patches of retina)• Engorged veins

– Optic nerve head edema



• Treatment– Hemorrhages and cotton wool spots resolve

with time– Vision may improve a little bit– Retina may become ischemic

• Watch for neovascularization - 90 day glaucoma• Needs close followup - may need laser

Acute Visual LossBranch Retinal Vein Occlusion

• Semi-sudden, painless loss of vision -severity depends on location of occlusion

• Same associations as CRVO• Looks like CRVO except for is sectoral• Treat the same way

– Watch for neovascularization – Laser for neovasc or non-resolving macular

edema

Acute Visual LossBranch Retinal Vein Occlusion


• Optic nerve disorders– Optic neuritis– Optic nerve edema– Ischemic optic neuropathy (ION)– Giant cell arteritis

Acute Visual LossNormal Nerve

Acute Visual LossOptic Neuritis

• Inflammation of the optic nerve– Idiopathic - often associated with multiple

sclerosis– Signs and symptoms - decreased vision,

decreased color vision, afferent pupillary defect (APD), pain with eye movements, and visual field cuts (central scotomas)


• Examination - optic nerve usually normal; sometimes hyperemic and edematous

• Usually resolves with time• Treatment controversial• Prognosis of a single attack is usually good



Acute Visual LossOptic Nerve Edema

• Many possible causes - including:– Malignant hypertension– Tumors– Elevated intracranial pressure– Meningitis

• Often need CT/MRI and lumbar puncture• Possibly an ophthalmologic or life

emergency - react quickly

Acute Visual LossUnilateral Optic Nerve Edema

• A - AION (acute ischemic optic neuropathy)• T - Tumor• O - Optic neuritis, orbital pseudotumor• U - Uveitis• C - CRVO• H - Hypotony

Acute Visual LossBilateral Optic Nerve Edema

• M - Mass• M - Malignant Hypertension• M - Meat (pseudotumor cerebri)• M - Mucked up drainage (hydrocephalus, DVO)• M - Meningitis• M - Medicines (vitamin A, tetracyclines)




Acute Visual LossBilateral Optic Nerve Edema


• Papilledema is a term reserved for optic nerve edema, usually bilateral, caused by elevated intracranial pressure

• A definite ophthalmologic or life emergency

Acute Visual LossIschemic Optic Neuropathy

• Ischemic optic neuropathy (ION)– Usually painless– Vascular - embolic or thrombotic– Symptoms

• Decreased visual acuity• Decreased color vision• Visual field cut - often altitudinal


• Signs– Acutely - hyperemic, swollen nerve -

sometimes sectoral– Later - pallid nerve

• Important:– Check ESR for giant cell arteritis in patients

over 60




• Treatment– Little can be done– Consider:

• Checking carotids• Checking heart• +/- Aspirin

Acute Visual LossGiant Cell Arteritis

• A true ocular and sometimes life threatening emergency

• Generalized inflammatory disease of large and medium sized arteries– Nearly all patients over 50 years old– Most at least 60


• Symptoms– Jaw claudication– Headache– Scalp tenderness– Myalgias– Fever– Acute visual loss***


• Ischemic optic neuropathy is most common ocular manifestation

• Central retinal artery occlusion (CRAO) is also common

• Motor nerve palsies can occur• Profound visual loss • Other eye can become involved within

hours or days

Giant Cell Arteritis:Ischemic Optic Neuropathy

Giant Cell Arteritis:Central Retinal Artery Occlusion

Giant Cell Arteritis:Third Nerve Palsy

Giant Cell ArteritisPathology


• Diagnosis - prompt diagnosis and treatment are critical– History– Stat ESR– +/- Fluorescein angiogram– Temporal artery biopsy


• If GCA suspected, start steroids immediately

• Don’t wait for biopsy• Sometimes immunosuppressive therapy is

needed

Acute Visual LossNon-Ocular Causes

• Stroke, cerebral mass, or bleed– Usually painless– Vision loss is bilateral unless insult is anterior

to chiasm– Often, there are associated symptoms

• Numbness• Weakness• Paresthesias• Impaired thinking or talking

Acute Visual LossStroke, Mass, or Bleed

• Most common manifestation is a homonymous visual field defect

• Workup and treatment are urgent or semi-urgent– CT scan– Send patient to ER or primary care physician– DO NOT send patient to ophthalmology - at

least not at first

Acute Visual LossRight Homonymous Hemianopia

Acute Visual LossRight Homonymous Hemianopia

Acute Visual LossNon-Ocular

• Functional visual loss– Hysteria - implies patient truly believes he has

visual loss even though he doesn’t– Malingering - implies patient is aware he has no

visual loss, but is faking it for secondary gain• Money• Enjoy the sick role

Acute Visual LossNon-Ocular

• Acute discovery of chronic visual loss– More common than you’d think– Scenarios

• One day patient decides to cover one eye and discovers other eye has decreased vision

• One day patient decides that lack of new glasses has caused his vision to acutely drop

• One day 80 year old patient decides his dense cataracts that have been building up for 20 years are suddenly causing visual loss

The End

Health & Medicine

Acute visual loss