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Poor vision healthy eyes


There are certain situation, when ophthalmologist is unhappy. He is unhappy when the diagnosis is not obvious. Presentation deals with the situations, when we have completely healthy eye with …

There are certain situation, when ophthalmologist is unhappy. He is unhappy when the diagnosis is not obvious. Presentation deals with the situations, when we have completely healthy eye with decreased visual acuity and no signs of pathology.

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  • 1. Poor Vision + Healthy Eyes Dr. Anthony 28 Nov, 2013
  • 2. What if? -cornea clear -lens transparent -vitreous intact -retina intact -optic nerve healthy -refraction corrected - visual functions strongly decreased
  • 3. DDx -Functional (migraine, hysteria, amblyopia) -Blood supply problems (amaurosis fugax, vertebrobasilar artery insufficiency, ischemic optic neuropathy) - CNS damage (cortical blindness, chiasmal tumor, epilepsy)
  • 4. Migraine
  • 5. Migraine Classic signs: Pain Photophobia, phonophobia Nausea, vomiting Presiding visual aura R (1)
  • 6. Migraine aura
  • 7. Migraine Types: without aura (80%) with aura (10%) aura without pain retinal migraine
  • 8. Migraine Precipitating factors: birth control pills, pregnancy, menopause, dietary (thyranine, phenylalanine, alcohol, nitrates, nitrites, glutamate), fatigue, emotional stress, bright lights
  • 9. Migraine Work-up: collect proper history do CT scan in atypical case check BP and blood sugar
  • 10. Migraine Basic Treatment: • avoid precipitating factors • treat pain (NSAIDs, ergotamines, selective serotonine receptors agonists – triptans) • treat prophylactically in severe cases (betablockers, Ca-channel blockers, antidepressants, antinausea) • review in 4-6 weeks
  • 11. Hysteria
  • 12. Hysteria Classic signs: Visual loss / blindness no ocular pathology no neuropathology normal pupillary reaction
  • 13. Hysteria Important DDx: Simulation, Aggravation
  • 14. Hysteria Exclude simulants: NLP: torch test test near visual acuity test approximate visual field use a “strong” drops in children
  • 15. Hysteria Basic Treatment: no treatment available psychiatrist referral may be indicated patient often benefits from promise of good vision by next visit review in 1-2 weeks R (1)
  • 16. Amblyopia Crucial Signs: no ocular changes no neurological changes decreased visual acuity with refraction corrected
  • 17. Amblyopia DDX: diagnosis of exclusion collect history
  • 18. Amblyopia Types: strabismic refractive anisometropic deprivation
  • 19. Amblyopia Basic Treatment: correction of refractive error patching of the best eye penalization of the best eye adults can be treated R (2)
  • 20. Amblyopia
  • 21. Amaurosis Fugax (Transient Vision Loss) Classic signs: no ocular changes visual loss, scotomas (seconds - hours) monocular
  • 22. Amaurosis Fugax
  • 23. Amaurosis Fugax (Transient Vision Loss) DDx: migraine w/o pain Ischemic optic neuropathy vertebrobasilar artery insufficiency
  • 24. Amaurosis Fugax (Transient Vision Loss) Etiology: embolus arteriosclerotic disease (hypoperfusion) hypercoagulable/hyperviscocity state
  • 25. Amaurosis Fugax (Transient Vision Loss) Work-Up: ESR, CRP, platelet count visual field test carotid auscultation, ultrasound CBC, fasting blood sugar, lipid profile ECG
  • 26. Amaurosis Fugax (Transient Vision Loss) Tx: carotid surgery BP, sugar control follow-up with physician R (1)
  • 27. Vertebrobasilar artery insufficiency Classic signs: no ocular changes blurred vision (seconds) bilateral combined with ataxia, vertigo, dysarthria, dysphasia, perioral numbness, hemiparesis, hemisensory loss
  • 28. Cerebral Arterial Circle
  • 29. Vertebrobasilar artery insufficiency DDx, Tx Like in amaurosis fugax R (1)
  • 30. Cortical blindness Clinical signs: severe vision loss bilateral normal pupillary reactions
  • 31. Cortical Blindness
  • 32. Cortical blindness Etiology: infarction tumor infection toxic
  • 33. Cortical blindness Work-Up: exclude functional vision loss exclude meningitis BP, ECG refer
  • 34. Cortical blindness Tx: treat underlying cause
  • 35. Ischemic Optic Neuropathy Certain types of ischemic optic neuropathy are “invisible” during fundoscopy: posterior ischemic optic neuropathy.
  • 36. 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)
  • 37. Ischemic optic neuropathy
  • 38. Ischemic disc appearance Normal optic neuropathy
  • 39. Ischemic Optic Neuropathy Signs Monocular vision loss Sudden Painless Dischromatopsia Scotoma
  • 40. Ischemic Optic Neuropathy Work-Up BP blood glucose fasting lipid profile refer
  • 41. 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)
  • 42. Cataract extraction to Csar, blind elephant in US Thank you