Week 15 - Ocular emergencies posterior eye Flashcards
Which conditions are most common when affecting posterior pole?
• Posterior Eye
- RAO
- RVO
- Retinal Detachment
- Vitreous Haemorrhage
- AION (GCA and NAAOIN)
- Optic Neuritis
• TIA/Stroke
Visual loss causes….
• VITAMINC
V - Vascular
I - Inflammatory
T - Trauma
A - Autoimmune
M - Metabolic
I - Infection
N - Neoplastic
C - Congenital
Ocular emergency categories:
Sudden visual loss?
• No: Trauma, cellulitis, zoster opthalmacus
• Yes…
- Vascular: RAO/RVO, GCA, TIA, STROKE
- Non-vascular: Vit haemorrhage, retinal detachment, optic neuritis, NA ION
CRAO Symptoms and Signs
Symptoms
• Sudden painless monocular loss in vision
Signs
• Profound RAPD present (amaurotic pupil)
• Emboli? - can be massages to improve
• Whitish, oedematous retina
• Cherry red spot (if established)
• Disc pallor
• Retinal vasculature narrowing
BRAO: Symptoms and signs
Symptoms
• Sudden painless monocular drop in vision…. However vision is often unaffected
Signs
• RAPD often present
• Emboli at bifurnication points
• Whitish, oedematous sector of retina
• Retinal vasculature narrowing in area supplied by the affected branch
• Altitudinal or sectoral visual field defect
CRAO: Management
Management:
• College CMG - CRAO if less than 12 hours old same day referral to ophthalmology. Greater Glasgow - CRAO if less than 24 hours old same day referral to ophthalmology
• Initiate Ocular Massage whilst patient lies supine in new cases
Management by ophthalmology
• Acetazolamide
• Intra-arterial fibrinolytic therapy
• Aspirin - antiplatelet properties
GCU
• Follow up to detect neovascular changes
• Dietary advice, smoking cessation, managing blood pressure
BRAO: Management
Management:
• College CMG - CRAO if less than 12 hours old same day referral to ophthalmology. Greater Glasgow - CRAO if less than 24 hours old same day referral to ophthalmology
• Initiate Ocular Massage whilst patient lies supine in new cases
Management by ophthalmology
• Acetazolamide
• Intra-arterial fibrinolytic therapy
• Aspirin - antiplatelet properties
GCU
• Follow up to detect neovascular changes
• Dietary advice, smoking cessation, managing blood pressure
RVO: describe
• Thrombus in the CRV or a branch of the CRV
• Atheriosclerotic aetiology
• Common associations - hypertension, older age, hyperlipidaemia, diabetes, glaucoma, contraceptive pill, smoking
RVO: Management
Optometric Management
• BRVO 5-6 x more common than CRVO
• Referral urgency depends on presentation
- any reduction of vision referred to clinic for 1-2week review for possible Anti-vegF
- If CMO present secondary to BRVO/CRVO then intravitreal anti-vegf will generally be given so referral urgency is usually within 1-2 weeks
What symptoms prompt urgent referral:
Patients should be referred urgently to a TIA clinic for review within 48hrs if they present with the following symptoms
• Amaurosis Fugax of sudden onset within 2 weeks, with no headache or associated pain and no ocular pathology/abnormality present
• Sudden onset previously undiagnosed visual field total scotoma of less than 2 weeks with no ocular pathology (i.e. homonymous hemianopia or quadrantopia)
To refer to a TIA clinic there is a direct phone number available 24 hours a day 7 days a week
Retinal detachment: differentials
• Differential Diagnosis
- Posterior Vitreous Detachment
- Retinoschisis
- Choroidal Mass
• Shaffers sign
• PVD- look for Weiss ring, carefully examining peripheral retina
Retinal detachment vs retinoschisis
• Surface: Corrugated vs smooth, domed
• Haemorrhage or pigment: Present vs absent
• Scotoma: Relative vs absolute
• Reaction to laser : Absent vs generally present
• Shifting fluid: Variable vs absent
Retinal detachment management
Emergency referral
• Retinal detachment
• Pigment in the anterior vitreous (tobacco dust)
• Vitreous, retinal or pre-retinal haemorrhage, or
• Lattice degeneration or retinal break, with symptoms
Vitreous Haemorrhage: Symptoms and Signs
• A sign of another pathology
• Symptoms: Painless, unilateral floaters and variable vision loss
• Signs Depend on aetiology: Dilated fundus exam important, including of the other eye, gonioscopy, visual fields
Mechanisms of vitreous haemorrhage:
• Abnormal Vessels
- Diabetic retinopathy (31-54 percent) of vitreous haemorrhages are caused by diabetes
- Neovascularization from branch or central retinal vein occlusion (4-16 percent)
- Sickle cell retinopathy (0.2-6 percent)
• Rupture of Normal Vessels
- Retinal tear (11-44 percent)
- Trauma (12-19 percent)
- Posterior vitreous detachment with retinal vascular tear (4-12 percent)
- Retinal detachment (7-10 percent)
- Terson’s syndrome (0.5-1 percent)
• Blood From Adjacent Source
- Macroaneurysm (0.6-7 percent)
- Age-related macular degeneration (0.6 4 percent)
