Acute visual loss

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Acute visual loss

  1. 1. Acute Visual Loss Karl D. Bodendorfer, MDAssistant Professor of Ophthalmology University of Florida
  2. 2. Acute Visual Loss Categories• Ocular – Media opacities – Retinal (most are vascular) – Optic nerve (most are vascular)• Non-ocular – Stroke – Functional – Acute discovery of chronic visual loss
  3. 3. Acute Visual Loss Ocular• Media Opacities – Corneal edema - acute angle closure glaucoma, keratitis (corneal infections) – Hyphema – Cataract – Vitreous hemorrhage
  4. 4. Acute Visual Loss Acute 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)
  5. 5. Acute Visual LossAcute Angle Closure Glaucoma
  6. 6. Acute Visual LossAcute Angle Closure Glaucoma
  7. 7. Acute Visual Loss Acute Angle Closure Glaucoma• Symptoms – Severe ocular pain – Frontal headache – Blurred vision with halos around lights – Nausea and vomiting
  8. 8. Acute Visual Loss Acute Angle Closure Glaucoma• Signs – Corneal edema – Conjunctival hyperemia – Pupil mid-dilated and fixed – Iris bowed (bombe’d) forward – Swollen lids
  9. 9. Acute Visual LossAcute Angle Closure Glaucoma
  10. 10. Acute Visual LossAcute Angle Closure Glaucoma
  11. 11. Acute Visual Loss Acute Angle Closure Glaucoma• 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
  12. 12. Acute Visual Loss Acute Angle Closure Glaucoma• Initial treatment – Pilocarpine q 15 min x 2 – Other IOP drops – Acetazolamide PO or IV – Oral glycerine or isosorbide – IV mannitol
  13. 13. Acute Visual Loss Acute Angle Closure Glaucoma• Definitive treatment – YAG laser peripheral iridotomy – Surgical peripheral iridectomy – Cataract extraction
  14. 14. Acute Visual LossAcute Angle Closure Glaucoma
  15. 15. Acute Visual LossAcute Angle Closure Glaucoma
  16. 16. Acute Visual Loss Corneal Ulcer
  17. 17. Acute Visual Loss Hyphema• Blood in the anterior chamber• Usually caused by trauma• Check blacks for sickle cell disease
  18. 18. Acute Visual Loss Hyphema
  19. 19. Acute Visual Loss Hyphema
  20. 20. Acute Visual Loss Hyphema• 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
  21. 21. Acute Visual Loss Cataract• 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
  22. 22. Acute Visual Loss Cataract
  23. 23. Acute Visual Loss Vitreous 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
  24. 24. Acute Visual LossVitreous Hemorrhage
  25. 25. Acute Visual Loss Ocular• 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)
  26. 26. Acute Visual Loss Retinal 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
  27. 27. Acute Visual Loss Retinal Detachment• Symptoms – Flashing lights – Floaters – Loss of vision
  28. 28. Acute Visual LossRetinal Detachment
  29. 29. Acute Visual LossRetinal Detachment
  30. 30. Acute Visual LossRetinal Detachment
  31. 31. Acute Visual LossRetinal Detachment
  32. 32. Acute Visual LossRetinal Detachment
  33. 33. Acute Visual LossRetinal Detachment
  34. 34. Acute Visual Loss Retinal Detachment• 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
  35. 35. Acute Visual Loss Retinal Detachment• 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
  36. 36. Acute Visual Loss Macular 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
  37. 37. Acute Visual LossSub-Macular Neovascularization
  38. 38. Acute Visual LossSub-Macular Neovascularization
  39. 39. Acute Visual Loss Macular Hole
  40. 40. Acute Visual Loss Macular Disease• Symptoms – Sudden loss of vision – Wavy lines (metamorphopsias) – Gray areas
  41. 41. Acute Visual Loss Macular Disease• Exam – Amsler grid (graph paper) - very sensitive – Use direct ophthalmoscope - often see elevated areas of retina, hemorrhage – Fluorescein angiogram
  42. 42. Acute Visual Loss Macular Disease• 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
  43. 43. Acute Visual Loss Retinal 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
  44. 44. 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
  45. 45. Acute Visual LossCentral Retinal Artery Occlusion
  46. 46. Acute Visual LossCentral Retinal Artery Occlusion
  47. 47. 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
  48. 48. 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
  49. 49. Acute Visual LossBranch Retinal Artery Occlusion
  50. 50. Acute Visual LossBranch Retinal Artery Occlusion
  51. 51. Acute Visual LossBranch Retinal Artery Occlusion• Treatment – Little can be done – Try to prevent another plaque-related insult (stroke) • Check carotids • Lower cholesterol • +/- Aspirin
  52. 52. Acute Visual Loss Central Retinal Vein Occlusion• Less sudden painless loss of vision – Rarely complete, but often severe• Usually elderly patients• Often becomes bilateral (10%)
  53. 53. Acute Visual Loss Central Retinal Vein Occlusion• Associations – Hypertension – Atherosclerotic vascular disease – Glaucoma – Hyperviscosity syndromes
  54. 54. Acute Visual Loss Central Retinal Vein Occlusion• 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
  55. 55. Acute Visual LossCentral Retinal Vein Occlusion
  56. 56. Acute Visual Loss Central Retinal Vein Occlusion• 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
  57. 57. Acute Visual Loss Branch 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
  58. 58. Acute Visual LossBranch Retinal Vein Occlusion
  59. 59. Acute Visual Loss Ocular• Optic nerve disorders – Optic neuritis – Optic nerve edema – Ischemic optic neuropathy (ION) – Giant cell arteritis
  60. 60. Acute Visual Loss Normal Nerve
  61. 61. Acute Visual Loss Optic 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)
  62. 62. Acute Visual Loss Optic Neuritis• Examination - optic nerve usually normal; sometimes hyperemic and edematous• Usually resolves with time• Treatment controversial• Prognosis of a single attack is usually good
  63. 63. Acute Visual Loss Optic Neuritis
  64. 64. Acute Visual Loss Optic Neuritis
  65. 65. Acute Visual Loss Optic 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
  66. 66. Acute Visual Loss Unilateral Optic Nerve Edema• A - AION (acute ischemic optic neuropathy)• T - Tumor• O - Optic neuritis, orbital pseudotumor• U - Uveitis• C - CRVO• H - Hypotony
  67. 67. Acute Visual Loss Bilateral 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)
  68. 68. Acute Visual LossOptic Nerve Edema
  69. 69. Acute Visual LossOptic Nerve Edema
  70. 70. Acute Visual LossOptic Nerve Edema
  71. 71. Acute Visual LossBilateral Optic Nerve Edema
  72. 72. Acute Visual Loss 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
  73. 73. Acute Visual Loss Ischemic Optic Neuropathy• Ischemic optic neuropathy (ION) – Usually painless – Vascular - embolic or thrombotic – Symptoms • Decreased visual acuity • Decreased color vision • Visual field cut - often altitudinal
  74. 74. Acute Visual Loss Ischemic Optic Neuropathy• Signs – Acutely - hyperemic, swollen nerve - sometimes sectoral – Later - pallid nerve• Important: – Check ESR for giant cell arteritis in patients over 60
  75. 75. Acute Visual LossIschemic Optic Neuropathy
  76. 76. Acute Visual LossIschemic Optic Neuropathy
  77. 77. Acute Visual Loss Ischemic Optic Neuropathy• Treatment – Little can be done – Consider: • Checking carotids • Checking heart • +/- Aspirin
  78. 78. Acute Visual Loss Giant 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
  79. 79. Acute Visual Loss Giant Cell Arteritis• Symptoms – Jaw claudication – Headache – Scalp tenderness – Myalgias – Fever – Acute visual loss***
  80. 80. Acute Visual Loss Giant Cell Arteritis• 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
  81. 81. Giant Cell Arteritis:Ischemic Optic Neuropathy
  82. 82. Giant Cell Arteritis:Central Retinal Artery Occlusion
  83. 83. Giant Cell Arteritis:Third Nerve Palsy
  84. 84. Giant Cell Arteritis Pathology
  85. 85. Acute Visual Loss Giant Cell Arteritis• Diagnosis - prompt diagnosis and treatment are critical – History – Stat ESR – +/- Fluorescein angiogram – Temporal artery biopsy
  86. 86. Acute Visual Loss Giant Cell Arteritis• If GCA suspected, start steroids immediately• Don’t wait for biopsy• Sometimes immunosuppressive therapy is needed
  87. 87. Acute Visual Loss Non-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
  88. 88. Acute Visual Loss Stroke, 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
  89. 89. Acute Visual LossRight Homonymous Hemianopia
  90. 90. Acute Visual LossRight Homonymous Hemianopia
  91. 91. Acute Visual Loss Non-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
  92. 92. Acute Visual Loss Non-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
  93. 93. The End

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