Poor Vision
+
Healthy Eyes

Dr. Anthony
28 Nov, 2013
What if?
-cornea clear
-lens transparent
-vitreous intact
-retina intact
-optic nerve healthy
-refraction corrected

- vis...
DDx
-Functional (migraine, hysteria,
amblyopia)
-Blood supply problems (amaurosis fugax,
vertebrobasilar artery insufficie...
Migraine
Migraine
Classic signs:
Pain
Photophobia, phonophobia
Nausea, vomiting
Presiding visual aura

R (1)
Migraine aura
Migraine
Types:
without aura (80%)
with aura (10%)
aura without pain
retinal migraine
Migraine
Precipitating factors:
birth control pills, pregnancy,
menopause, dietary (thyranine,
phenylalanine, alcohol, nit...
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 ...
Hysteria
Hysteria
Classic signs:
Visual loss / blindness
no ocular pathology
no neuropathology
normal pupillary reaction
Hysteria
Important DDx:
Simulation, Aggravation
Hysteria
Exclude simulants:
NLP: torch test
test near visual acuity
test approximate visual field
use a “strong” drops in ...
Hysteria
Basic Treatment:
no treatment available
psychiatrist referral may be indicated
patient often benefits from promis...
Amblyopia
Crucial Signs:
no ocular changes
no neurological changes
decreased visual acuity with refraction
corrected
Amblyopia
DDX:
diagnosis of exclusion
collect history
Amblyopia
Types:
strabismic
refractive anisometropic
deprivation
Amblyopia
Basic Treatment:
correction of refractive error
patching of the best eye
penalization of the best eye

adults ca...
Amblyopia
Amaurosis Fugax
(Transient Vision Loss)

Classic signs:
no ocular changes
visual loss, scotomas (seconds - hours)
monocula...
Amaurosis Fugax
Amaurosis Fugax
(Transient Vision Loss)

DDx:
migraine w/o pain
Ischemic optic neuropathy
vertebrobasilar artery insuffici...
Amaurosis Fugax
(Transient Vision Loss)

Etiology:
embolus
arteriosclerotic disease (hypoperfusion)
hypercoagulable/hyperv...
Amaurosis Fugax
(Transient Vision Loss)

Work-Up:
ESR, CRP, platelet count
visual field test
carotid auscultation, ultraso...
Amaurosis Fugax
(Transient Vision Loss)

Tx:
carotid surgery
BP, sugar control
follow-up with physician
R (1)
Vertebrobasilar artery
insufficiency
Classic signs:
no ocular changes
blurred vision (seconds)
bilateral
combined with ata...
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...
Ischemic Optic
Neuropathy
Anterior ischemic optic neuropathy –
occlusion of short posterior ciliary
artery – infarction of...
Ischemic optic neuropathy
Ischemic disc appearance
Normal optic neuropathy
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...
Cataract extraction
to Csar, blind
elephant in US

Thank you
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Poor vision healthy eyes

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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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Poor vision healthy eyes

  1. 1. Poor Vision + Healthy Eyes Dr. Anthony 28 Nov, 2013
  2. 2. What if? -cornea clear -lens transparent -vitreous intact -retina intact -optic nerve healthy -refraction corrected - visual functions strongly decreased
  3. 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. 4. Migraine
  5. 5. Migraine Classic signs: Pain Photophobia, phonophobia Nausea, vomiting Presiding visual aura R (1)
  6. 6. Migraine aura
  7. 7. Migraine Types: without aura (80%) with aura (10%) aura without pain retinal migraine
  8. 8. Migraine Precipitating factors: birth control pills, pregnancy, menopause, dietary (thyranine, phenylalanine, alcohol, nitrates, nitrites, glutamate), fatigue, emotional stress, bright lights
  9. 9. Migraine Work-up: collect proper history do CT scan in atypical case check BP and blood sugar
  10. 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. 11. Hysteria
  12. 12. Hysteria Classic signs: Visual loss / blindness no ocular pathology no neuropathology normal pupillary reaction
  13. 13. Hysteria Important DDx: Simulation, Aggravation
  14. 14. Hysteria Exclude simulants: NLP: torch test test near visual acuity test approximate visual field use a “strong” drops in children
  15. 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. 16. Amblyopia Crucial Signs: no ocular changes no neurological changes decreased visual acuity with refraction corrected
  17. 17. Amblyopia DDX: diagnosis of exclusion collect history
  18. 18. Amblyopia Types: strabismic refractive anisometropic deprivation
  19. 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. 20. Amblyopia
  21. 21. Amaurosis Fugax (Transient Vision Loss) Classic signs: no ocular changes visual loss, scotomas (seconds - hours) monocular
  22. 22. Amaurosis Fugax
  23. 23. Amaurosis Fugax (Transient Vision Loss) DDx: migraine w/o pain Ischemic optic neuropathy vertebrobasilar artery insufficiency
  24. 24. Amaurosis Fugax (Transient Vision Loss) Etiology: embolus arteriosclerotic disease (hypoperfusion) hypercoagulable/hyperviscocity state
  25. 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. 26. Amaurosis Fugax (Transient Vision Loss) Tx: carotid surgery BP, sugar control follow-up with physician R (1)
  27. 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. 28. Cerebral Arterial Circle
  29. 29. Vertebrobasilar artery insufficiency DDx, Tx Like in amaurosis fugax R (1)
  30. 30. Cortical blindness Clinical signs: severe vision loss bilateral normal pupillary reactions
  31. 31. Cortical Blindness
  32. 32. Cortical blindness Etiology: infarction tumor infection toxic
  33. 33. Cortical blindness Work-Up: exclude functional vision loss exclude meningitis BP, ECG refer
  34. 34. Cortical blindness Tx: treat underlying cause
  35. 35. Ischemic Optic Neuropathy Certain types of ischemic optic neuropathy are “invisible” during fundoscopy: posterior ischemic optic neuropathy.
  36. 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. 37. Ischemic optic neuropathy
  38. 38. Ischemic disc appearance Normal optic neuropathy
  39. 39. Ischemic Optic Neuropathy Signs Monocular vision loss Sudden Painless Dischromatopsia Scotoma
  40. 40. Ischemic Optic Neuropathy Work-Up BP blood glucose fasting lipid profile refer
  41. 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. 42. Cataract extraction to Csar, blind elephant in US Thank you
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