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.

Published in: Health & Medicine

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