Acute Painless Loss of Vision Syed Hasan Acute

Acute Painless Loss of Vision Syed Hasan

Acute Painless Loss of Vision • The second most common ophthalmic emergency (after red eye)

Loss of vision Painless Few seconds duration • Unilateral – – Giant cell arteritis Papilloedema Impending central retinal vein occlusion Ocular ischemic syndrome • Bilateral – Papilloedema

Loss of vision Few minutes duration • Unilateral – Amaurosis fugax – Giant cell arthritis • Bilateral – Vertebrobasilar artery insufficiency Up to one hour duration • Migraine

Loss of vision Persistent • • • Central/Branch retinal artery occlusion Central/Branch retinal vein occlusion Retinal detachment/Viterous haemmorhage Posterior uveitis Anterior ischaemic optic neuropathy Optic neuritis Macular degeneration Cortical blindness Functional Toxins/Drugs

Amaurosis Fugax • • • Monocular or Binocular transient visual loss. Monocular: Anterior to Chiasm Binocular: At or posterior to Chiasm Duration: Shorter duration=Thromboembolic, Longer Duration=Migraine. D/D: Embolism, Retinal vasospasm, CRVO, Optic Neuropathy, migraine, presyncope, seizure, vertebrobasilar ischemia. Full neurological and cardiovascular workup, ECG, Echo, Carotid Doppler, ESR and CRP if age >50 20% ultimately undergo carotid endarterectomy. High risk of CVA. Rx: Anticoagulants, Antiplatelet agents, Carotid Endarterectomy. Retinal Ischemia- Ca channel blockers.

Central Retinal artery occlusion • Acute, painless, monocular, persistent and nearly complete loss of vision. • 1 -2% Bilateral. • 60% are hypertensive, 20% with cardiac history and others with hypercoagulable conditions e. g diabetes. • 5 year mortality is 1/3 rd of age matched controls without CRAO. • O/E: Pale retina, Cherry red spot, Arteriolar segmentation • 15 -30% Cilio-retinal artery- Good prognosis • No standard treatment of proven benefit. • Ocular massage, reduction of IOP, Antiplatelet, Anticoagulant and Fibrinolytic therapy. Hyperbaric oxygen, Steroids • R/O GCA

Central/Branch retinal artery occlusion • • • Artheroscleotic plaque in the carotid Embolus from a cardiac valve Systemic vascular disease Hyperviscosity syndromes Trauma – fat emboli Oral contraceptives • Systemic diseases – DM, syphilis, sickle cell • Injections of medications around the head and neck • Temporal arteritis • Drug abuse

Central Retinal Vein Occlusion • Acute, painless vision typically upon waking up. • Ischemic or Non ischemic • High IOP, Diabetes, Hypertension, Cardiovascular Disease, Hypercoagulable state. • Reduced visual acuity, RAPD and widespread retinal haemorrages. • Rx: Underlying condition, Aspirin • Macular edema: Intravitreal injections of Anti-VEGF agents and Steroids. • Complications: Rubeotic glaucoma

Central/Branch retinal vein occlusion • • • Artherosclerotic vascular disease Arterial hypertension Diabetes Hyperviscosity Open angle glaucoma, trauma closed angle glaucoma, vascular hypertension Painless monocular visual loss

Ischaemic optic neuropathy • Incidence: 10/100, 000/yr of over 50 age group. • 5 -10% are Giant Cell arteritis rest are Non-Arteretic AION.

• ARTERETIC AION • Sudden loss of vision, Headache, Scalp tenderness, Jaw claudication, Wt loss, night sweats, myalgia, PMR • Rapd, Swollen disc, can present as CRAO, BRAO or cranial nerve palsies. • High ESR, CRP and platelets. TABx 90% sensitivity • Rx: 3 days of I/V methylprednisolone 1 g, followed by oral prednisolone 6080 mg/ day. Taper treatment according to response. Aspirin helpful. • Risk of second eye involvement is 10% in treated case and upto 90% in untreated cases. • NON-ARTERETIC AION • Compromised circulation leads to disc swelling and infarction. • Major causes are Diabetes, Hypertension, Smoking, Hyperlipedemia, Hypotension, Aneamia, Obstructive sleep apnoea • ESR, CRP and PLTs normal. • No proven treatment • Second eye involvement 19% over 5 years.

Optic neuritis • • • Papillitis, Reterobulbar-Neuritis, Neuroretinitis. Most common cause is Demylenation Incidence: 5/100, 000/yr, F/M 3: 1, usually unilateral. 70% in MS sufferer. Rapid loss of vision within hours to days, recovery within 2 weeks. Clinically reduced Contrast sensitivity, color vision, Field loss and reterobulbar pain. RAPD Rx: Controversial role for steroids. I/V steroids hastens recovery. 90% show good recovery Atypical Optic Neuritis. D/D: SOL, Sarcoidosis, Vasculitis, AION, Toxic, Nutritional, Postviral.

Retinal detachment • More common in men • Rate 10 per 100, 000 people per year • Bilateral in up to one third • Associated with a) Degenerative myopia b) Lattice degeneration c) Aphakia, Cataract Surgery d) Diabetes, sickle cell disease

Vitreous haemmorhage • • • 7 In 100, 000 each year Sudden dramatic painless loss of vision. Preceded by floaters. Diabetes, Hypertension, Sickle cell disease, macular degeretion, CRAO, CRVO, Valsalva, Retinal Detachment, Ocular Trauma, PVD with Tear, Blood disorders, Warfarin. B-Scan Rx: Viterectomy

Toxic/Drugs • B 12, Folate deficiency. • Amiodrone, Ethambutol, Methanol, CO, Isoniazid, Lead

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