Causes of visual loss, pain and painless

1. ACUTE VISUAL LOSS
Fadzlina Zabri
082013100006

3. ACUTE VISUAL LOSS
Central retinal artery
occlusion
Ischaemic central retinal
vein occlusion
Retinal detachment involving
macular area
Massive vitreous hemorrhage
Painless
Acute congestive glaucoma
Acute iridocyclitis
Chemical injuries to the
eyeball
Mechanical injuries to the
eyeball
Painful

4. PAINLESS

5. Central retinal artery occlusion
Obstruction at the level of lamina cribrosa
Profound visual loss will become permanent
within hours
Symptoms
Sudden painless
loss of vision over secs
Amaurosis fugax history
in past

6. Signs
– Visual acuity reduced
– Direct pupillary reflex absent
– Fundus examination shows :
marked narrowing of retinal arteries
retina become milky white due to ischaemic edema
 ‘cherry red spot’ in center of macula
cattle tracking
atrophic changes

8. Treatment
Immediate lowering of IOP
Ocular massage, IV mannitol
Anterior chamber paracentesis
IV acetazolamide 500mg
Vasodilators and inhalation of a mixture of 5% CO2 and 95% O2
Fibrinolytic therapy
IV Steroids – giant cell arteritis
Laser photodisruption
Work up associated systemic condition

10. Central retinal vein occlusion
– 10 times more
common than CRAO
– Painless monocular
loss of vision over
hours to days
– Affect elderly patient
– Vision may improve
through the day
– Ischemic vs. non-
ischemic types

11. Non ischemic CRVO ( venous stasis retinopathy)
– Mild to moderate visual loss
– RAPD absent
– Fewer flamed shape hemorrhage
– May resolve fully or progress to ischemic type

12. Ischemic CRVO (hemorrhagic)
– Severe visual loss
– RAPD+
– Extensive retinal hemorrhage
and cotton-wool spots
– Reduced amplitude of B-wave
of ERG
– Complication
Rubeosis iridis, neovascular
glaucoma

13. Treatment
Systemic and ocular associations
Observation and monitoring
Ocular therapy
Intravitreal anti VEGF
Intravitreal triamcinolone
Pars plana vitrectomy

14. Three –port 20 gauze pars plana vitectomy

15. Risk Factors
Severe myopia (eg. –12 to –15)
Advanced age
Previous cataract surgery
Blunt trauma
Family history
Separation of
neurosensory retina
proper from pigment
epithelium
Retinal detachment

16. Prodromal symptom
– Dark spots - floater
– Sensation of flashes of light – Photopsia
Symptoms of detached retina
– Localised relative loss in the field of vision
– Sudden appearance of dark cloud or veil
– Sudden painless loss of vision
DD of Photopsia
scintillating scotoma of migraine, vitreous detachment, retinal tear, and
retinal detachment.

17. Complication
Proliferative vitreoretinopathy
Complicated cataract
Uveitis
Phtisis bulbi

18. Treatment
Sealing of retinal breaks
Drainage of SRF
Maintenance of chorioretinal apposition
scleral buckling
pneumatic retinopexy
pars plana vitrectomy, internal tamponade
Prophylactic

19. – Occur from retinal vessels
– Present as preretinal or intragel hemorrhage
– Symptoms
• Floaters of a sudden onset
in small hemorrhage
• Sudden painless vision loss
in massive
Massive vitreous hemorrhage

20. Signs

23. Fate
– Complete absorption within 4-8 weeks
– Organization of hemorhage with yellowish – white
debris
– Complications – liquefaction, degeneration, khaki cell
glaucoma
– Retinitis proliferans
Treatment
– Conservative treatment
– Treatment of the cause
– Vitrectomy by pars plana route

24. PAINFUL

25. – Characterized by a sudden rise in IOP in a
susceptible individual with a dilated pupil,
which decompensates the cornea
– Apposition of peripheral iris against the
trabecular meshwork resulting in obstruction
of aqueous outflow by closure of an already
narrow angle of the anterior chamber
Acute congestive glaucoma

28. Signs
– Corneal haziness
& edema
– Conjunctival hyperemia
– Pupil mid-dilated and
fixed
– Iris bowed (bombe’)
forward
– Swollen lids
– Eyeball firm to palpation

29. Treatment
Initial treatment
Systemic hyperosmotic agent: IV mannitol or Acetazolamide
Topical antiglaucoma : timolol, betaxolol 0.5%, latanoprost,
pilocarpine 2% QID
Analgesics and antiemetic
Compressive gonioscopy
Topical steroid eye drops
Definitive treatment
Laser peripheral iridotomy
Filtration surgery
Clear lens extraction

30. Inflammation of uveal tissue from iris and pars
plicata part of ciliary body
Acute iridocyclitis
Symptoms
Pain. Dull aching throbbing
sensation typically worse at night.
Redness.
Photophobia and blepharospasm
Lacrimation
Defective vision.

31. Signs
By slit lamp biomicroscope
Lid edema
Circumcorneal congestion
Corneal edema, KP’s, posterior corneal
opacity
Anterior chamber signs – cells and flares,
hypopyon
Iris sign – nodules, poterior synechiae
Pupillary signs
Changes in lens

32. Treatment
Local therapy
Mydriatic-cycloplegia drug
Corticosteroids
Broad spectrum antibiotic
Systemic therapy
Corticosteroids
NSAIDS
Physical measures
Hot fomentation
Dark goggles

33. Mode of
injury
Domestic accident –
ammonia,
detergent, cosmetic
Agricultural accident
– fertilizer, veg toxin,
insecticide
Chemical laboratory
accident - acid ,
alkali
Deliberate chemical
attack – acid to
disfigure face
Chemical warfare
Self injury -
malingere ,
psycopath
Chemical injuries to the eyeball

34. Alkali burns
– Most severe chemical
injuries known to the
ophthalmologists.
– Common alkalies
responsible for burns
are: lime, caustic
potash or caustic soda
and liquid ammonia
(most harmful).

35. Clinical feature in stages
• Conjuntiva – edema, congested, widespread
necrosis, copius discharge
• Cornea – epithelium sloughing, edema
• Iris – violently inflamed, replaced by
granulation tissue
Acute ischemic
attack
• Epithelium regenerates
• Corneal vascularuzation, inflammation
of iris reduced
Reparation
• Symblepharon, recurrent corneal
ulceration, complicated cataract,
secondary glaucoma
Complication

36. Acid burns
– Less serious than alkali
burns
– Common acids :
sulphuric acid,
hydrochloric acid, nitric
acid
– Causes instant
coagulation of proteins,
act as barrier for deeper
penetrations
Conjunctica will undergo necrosis.
Symblepharon is formed due to
fibrosis

38. Treatment
Prevent further damage
Immediate irrigation with clean water or normal saline
Removal of contaminated and necrotic tissue
Maintenance
Topical antibiotic drops and Steroid eye drop
Cycloplegic
Ascorbic acid : improve wound healiing, collagen formation
Lubricant eyedrop
Treating Complication
Glaucoma : topical timolol, oral acetazolamide
Poor corneal healing : amniotic membrane transplant
Symblepharon : surgical treatment

39. – Extraocular foreign
bodies
– Blunt trauma
– Open globe injuries -
Penetrating and
perforating, intraocular
foreign injuries
Mechanical injuries to the eyeball

41. References
Comprehensive opthalmology , 6th edition by
AK Khurana
Internet