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Clinical Optometry 2(i)

Differential Diagnosis 2

“A matter of life and death…?!”

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• loss of transparency of media

• loss of function in neural pathway i.e. retina to cortex

mostly evident from examination!

Sudden Visual Loss

Main Causes

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• Onset!sudden onset or suddenly noticed?Constant or Intermittent

• Laterality• Type of visual loss

blank field, blur, distortion, colour

• Pain?

...again - think horses before zebras

Sudden Visual Loss

HistoryAge of Patient:SVL pts with serious concern have pathology. Diff pathology often related to age & GENERAL HEALTH

Age of Patient:SVL pts with serious concern have pathology. Diff pathology often related to age & GENERAL HEALTH

which hemianopia/altitudinal?which hemianopia/altitudinal?

relation to CHIASM, LE or L hemifield?

relation to CHIASM, LE or L hemifield?

secs/rapid on&off/10-30minsecs/rapid on&off/10-30min

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• VA

• Pupil Examination

• Visual Field

• Anterior Segment

• Fundus examination

again what follows are not exhaustive lists

Sudden Visual Loss

Examination

Both eye’s, habitual correction & pinholeBoth eye’s, habitual correction & pinhole

espec RAPDespec RAPD

confrontationconfrontation

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visual loss can appear like a curtain

cholesterol/calcium

plaque

• Vitreous floaters

Sudden Visual Loss

Temporary Visual Loss (durn < few hours?)

• Postural hypotension• Sub-acute Angle Closure Glaucoma• Papilloedema

• Poor tear film• Migraine• Amaurosis fugax

Transient Ischaemic Attack (TIA)

in order of appearance!

in order of appearance!

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• Trauma• Iritis• Recurrent corneal erosion• Angle closure glaucoma• Radiation damage

Sudden Visual Loss

>24 hours with PAIN

• Optic NeuropathyInflammatory vs De-myelinatingUhthoff’s sign

Generally incomplete healing of wound. Sx worse on waking.Seen with slit lamp

eg: welder’s flash

in order of appearance!

in order of appearance!

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Sudden Visual Loss

>24 hours and PAINLESS• Any age

malingering

• Age 20-40 yearsCentral Serous Chorioretinopathy (CSCR)

Optic neuritis

Macular hole

Retinal Detachment

HIV related infection

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Central Serous Chorioretinopathy

Sx: blurred DV & NV; micropsia; metamorphopsia; central scotoma; poor colour vision

Signs: Rx can show increased hyperopia (due to sub-retinal fluid accumulation); stereo fundoscopy

Manage: refer (often self-limiting, 3-6/52), laser may help

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Macular Hole

Again dramatic sudden loss of VA; associated with metamorphopsia/scotoma

Seen with direct/indirect as full thickness depression in retina

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Retinal Detachment

Sx: curtain falling over vision or localised & persistent flashing lights or increased number of floaters

Schaefer’s sign: ‘Tobacco dust’ in anterior vitreous means retinal tear is present

More in pathology lectures...

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Sudden Visual Loss

>24 hours and PAINLESS• Age 40-60 years

Vitreous Haemorrhage

Retinal Vascular Disease

Diabetic retinopathy

Vein/artery occlusion

Hypertensive retinopathy

Non-Arteritic Ischaemic Optic Neuropathy

Myopic Degenerationrugby player storyrugby player story

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Vitreous Haemorrhage

Common cause of loss of transparency

Found in situations where retina lacks O2 and ‘new’ blood vessels develop

New vessels are thin and weak so easily leak blood into space between retina and vitreous

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Retinal Vein Occlusion

Visual loss depends on site of occlusion (central v branch)

Can have residual vision

?RAPD if central

Ophthalmoscopy: retinal haem’s, oedema, exudates

More in pathology lectures..!new piccy?new piccy?

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Retinal Artery Occlusion

Visual loss depends on site of occlusion (central v branch)

Often total visual loss in affected region

RAPD

Ophthalmoscopy: ‘cherry red’ spot at macula

?Preceded by Amaurosis Fugax

More in pathology lectures..!

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Sudden Visual Loss

>24 hours and PAINLESS

• Age 60+ years

Retinal Vascular Disease

Retinal Detachment

Subretinal neovascular membrane

‘wet ARMD’, Sx: similar to CSCR

Cerebral Vascular accident, (CVA)

Arteritic Ischaemic Optic Neuropathy

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Ischaemic Optic Neuropathy

Infarction of the anterior optic nerve due to blockage of the short posterior ciliary arteries

Two main types:

Non-arteritic: variable reduction in vision, altitudinal hemianopia, swollen optic disc

Arteritic: sudden, profound(HM), permanent visual loss, swollen pale optic disc, RAPD. Preceded by Amaurosis fugax.

2nd can be linked to CVAs

More in pathology lectures..!

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A Case Study

Optometry Today, Oct 22, 1999

• 56 year old male ‘disturbed’ RE vision• VA R:6/9 L:6/5, Ocular exam normal

referred to GP

• Vision drops over 3 daysPt self reports to casualty

• VA R:CF L:6/5, • Exam:

right RAPD,

VF: R dense central scotoma, L normal

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• backed by RAPD, colour perception• Central VF defect - most GC fibres from

macula• Differential diagnosis

in: inflammation, disturbed blood supply, glioma

on: retrobulbar neuritis, or as in this case...

A Case Study

• Normal R fundus & full L visual field

implies R optic nerve problem

Optometry Today, Oct 22, 1999

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A Case Study

Optometry Today, Oct 22, 1999

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History• Onset• Age• Monocular vs Binocular

are there more than two images?

• TypeHoriz, vertical, oblique

• Frank diplopia or ghosting?• Constant?

Associated with specific task / eye position?

Diplopia

Q: What proportion of us have diplopia?