Poor Vision

+

Healthy Eyes

Dr. Anthony28 Nov, 2013

What if?

-cornea clear-lens transparent-vitreous intact-retina intact

-optic nerve healthy-refraction corrected

- visual functions strongly decreased

DDx

-Functional (migraine, hysteria, amblyopia)

-Blood supply problems (amaurosis fugax, vertebrobasilar artery insufficiency,

ischemic optic neuropathy)- CNS damage (cortical blindness,

chiasmal tumor, epilepsy)

Migraine

Migraine

Classic signs:

PainPhotophobia, phonophobia

Nausea, vomitingPresiding visual aura

R (1)

Migraine aura

Types:

without aura (80%)with aura (10%)

aura without painretinal migraine

Migraine

Precipitating factors:

birth control pills, pregnancy, menopause, dietary (thyranine, phenylalanine, alcohol, nitrates,

nitrites, glutamate), fatigue, emotional stress, bright lights

Migraine

Work-up:

collect proper history

do CT scan in atypical case

check BP and blood sugar

Migraine

Basic Treatment:

• avoid precipitating factors• treat pain (NSAIDs, ergotamines, selective serotonine receptors agonists – triptans)• treat prophylactically in severe cases (beta-blockers, Ca-channel blockers, antidepressants, antinausea)• review in 4-6 weeks

Migraine

Hysteria

Hysteria

Classic signs:

Visual loss / blindnessno ocular pathologyno neuropathology

normal pupillary reaction

Important DDx:

Simulation, Aggravation

Hysteria

Hysteria

Exclude simulants:

NLP: torch testtest near visual acuity

test approximate visual fielduse a “strong” drops in children

Basic Treatment:

no treatment availablepsychiatrist referral may be indicated

patient often benefits from promise of good vision by next visit

review in 1-2 weeks

Hysteria

R (1)

Amblyopia

Crucial Signs:

no ocular changesno neurological changes

decreased visual acuity with refraction corrected

DDX:

diagnosis of exclusion

collect history

Amblyopia

Types:

strabismic

refractive anisometropic

deprivation

Amblyopia

Basic Treatment:

correction of refractive errorpatching of the best eye

penalization of the best eye

adults can be treated

Amblyopia

R (2)

Amblyopia

Amaurosis Fugax

(Transient Vision Loss)

Classic signs:

no ocular changes

visual loss, scotomas (seconds - hours)

monocular

Amaurosis Fugax

Amaurosis Fugax

(Transient Vision Loss)

DDx:

migraine w/o pain

Ischemic optic neuropathy

vertebrobasilar artery insufficiency

Amaurosis Fugax

(Transient Vision Loss)

Etiology:

embolus

arteriosclerotic disease (hypoperfusion)

hypercoagulable/hyperviscocity state

Amaurosis Fugax

(Transient Vision Loss)

Work-Up:

ESR, CRP, platelet count

visual field test

carotid auscultation, ultrasound

CBC, fasting blood sugar, lipid profile

ECG

Amaurosis Fugax

(Transient Vision Loss)

Tx:

carotid surgery

BP, sugar control

follow-up with physician

R (1)

Vertebrobasilar artery

insufficiency

Classic signs:

no ocular changesblurred vision (seconds)

bilateralcombined with ataxia, vertigo, dysarthria,

dysphasia, perioral numbness, hemiparesis, hemisensory loss

Cerebral Arterial Circle

Vertebrobasilar artery

insufficiency

DDx, Tx

Like in amaurosis fugax

R (1)

Cortical blindness

Clinical signs:

severe vision loss

bilateral

normal pupillary reactions

Cortical Blindness

Cortical blindness

Etiology:

infarction

tumor

infection

toxic

Cortical blindness

Work-Up:

exclude functional vision loss

exclude meningitis

BP, ECG

refer

Cortical blindness

Tx:

treat underlying cause

Ischemic Optic

Neuropathy

Certain types of ischemic optic neuropathy are “invisible” during fundoscopy: posterior ischemic

optic neuropathy.

Ischemic Optic

Neuropathy

Anterior ischemic optic neuropathy –occlusion of short posterior ciliary

artery – infarction of optic nerve head

Posterior ischemic optic neuropathy –infarction of retrolaminar portion of

optic nerve (pial capillary plexus)

Ischemic optic neuropathy

Ischemic optic neuropathyNormal disc appearance

Ischemic Optic

Neuropathy

Signs

Monocular vision loss

Sudden

Painless

Dischromatopsia

Scotoma

Ischemic Optic

Neuropathy

Work-Up

BP

blood glucose

fasting lipid profile

refer

References:

(1) The Wills Eye Manual Office and Emergency Room Diagnosis and Treatment of Eye

Disease (2008)(2) J. Kanski "Clinical Ophthalmology - A

Systematic Approach" (2011)

Thank you

Cataract extraction to Csar, blind elephant in US