Ophthalmology - Sudden loss of vision

Question 1

A 64yo man presents with sudden painless loss of vision in his left eye.

What is your differential diagnosis?

Answer 1

1. Vitreal haemorrhage
2. Retinal detachment
3. TIA (amaurosis fugax)
4. CRAO
5. CRVO

Question 2

Suggest possible causes for vitreal haemorrhage.

Answer 2

1. proliferative diabetic retinopathy (>50%)
2. PVD
3. AMD
4. ocular trauma

Question 3

A 64yo man presents with sudden painless reduced vision in his left eye + floaters + red hue to vision. On fundoscopy: haemorrhage is seen on vitrous cavity, obscuring the retina.

Name 2 investigations you would perform.

Answer 3

1. USS: to rule out retinal detachment/tear

2. fluorescein angiography: to ID neovascularisation

Question 4

A 64yo man presents with sudden painless reduced vision in his left eye. He is diagnosed with vitreous haemorrhage.

What are the treatment options and when are they indicated?

Answer 4

1. laser photocoagulation +/- intravitreal BEVACIZUMAB (anti-VEGF) infections
   - neovascularisation
   - retinal breaks
2. Early vitrectomy
   - associated retinal detachment
   - non-clearing VH after 2-3/12
   - advanced proliferative retinopathy + non-clearing VH after 6-8/52 with adequate Tx
   - AMD

Question 5

A 73yo woman presents with sudden severe visual loss described as a curtain coming down. Preceded by flashes.

What is the likely diagnosis? What are the Mx options?

Answer 5

Retinal detachment

Mx

1. urgent vitrectomy (can be 7-10/7 later if macula already detached)
2. +/- preceding laser photocoagulation to secure retina

Question 6

What are the risk factors for retinal detachment?

Answer 6

1. PVD
2. myopia
3. prev. cataract surgery
4. trauma + VH
5. DM (tractional RD)

Question 7

How does PVD usually present? What classical sign may be seen on fundoscopy?

Answer 7

1. flashes (photopsia) + shower of floaters

2. Weiss ring

Question 8

What are the symptoms + signs of CRAO?

Answer 8

Symptoms:
- sudden painless loss of vision - often no perception of light (curtain falling)

Signs:

• RAPD
• white, oedematous retina with cherry red spot

Question 9

How would you manage someone presenting with CRAO?

Answer 9

ESR/CRP to rule out GCA.

If presenting within 30mins can attempt to dislodge thrombus:

1. ocular massage
2. paracentesis
3. 500mg IV ACETAZOLAMIDE

Long-term Tx:

1. treat reversible RFs e.g. hypercholesterolaemia, HTN, AF
2. secondary CVD prevention

Question 10

What is your differential diagnosis for acute painful loss of vision?

Answer 10

1. optic neuritis
2. anterior ischaemic optic neuropathy (arteritic or GCA)
3. acute closed angle glaucoma
4. anterior uveitis

Question 11

A 27yo woman presents with reduced vision progressing over 2/7 in her right eye. There is retro-ocular pain and pain with any movement of her right eye. O/E: right RAPD, large central visual field defect.

What is the likely diagnosis? How would you assess + manage?

Answer 11

Optic neuritis - clinical diagnosis if typical features

Rule out arteritic risk factors e.g. BP, HbA1c, CRP/ESR.

No Mx unless known MS, poor vision in other eye or severe pain: IVMP