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MD2 Opthalmology > Assessment and Diagnosis of Visual Loss > Flashcards

Assessment and Diagnosis of Visual Loss Flashcards

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1
Q

Give 4 examples of causes/signs of visual loss which may suggest a broader life of function threatening problem?

A

Endogenous endeopthalmitis

Panuveitis (including viral retinitis and retinal vasculitis)

Papilloedema

Optic neuritis

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2
Q
A
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3
Q

What is the most common cause for poor vision in humans?

A

Refractive error

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4
Q

Hx: I can’t see very well and my eyes don’t seem to open properly

O/E: bilateral upper lid ptosis

DDx?

A

Neurogenic: CN III palsy, Horner’s syndrome

Myogenic: myaesthenia gravis, myotonic dystrophy

Aponeurotic: involutional

Mechanical causes: orbital tumours, oedema, scarring

Pseudoptosis: contralateral lid retraction

Mitochondrial disease: chronic progressive external opthalmoplegia

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5
Q

Hx: my R eye is red, it waters a lot and the vision is sometimes blurry

O/E: R VA 6/9, slit lamp exam shows punctuate epithelial erosions (PEEs), in this case due to ocular surface exposure

Dx?

A

Transient blurring of vision +/- epiphora (watering) = think tear-film disruption

Causes include trachoma (leading to entropion and pannus trichiasis)

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6
Q

Entropion

A

Eyelid (usually the lower lid) folds inward

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7
Q

How can entropion blur vision?

A

Tear-film disruption

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8
Q

Complications of entropion

A

Corneal scarring

Pannus trichiasis (misdirected growth of eyelashes towards the cornea)

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9
Q

What infective agent causes trachoma?

A

Chlamydia trachomatis

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10
Q

Epidemiology of trachoma

A

Prolific in arid poverty-stricken regions with poor hygiene

84 million people have active disease, 7.6 with trichiasis

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11
Q

Complications of trachoma

A

Scarring of conjunctiva

Entropion

Blindness

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12
Q

Hx: my vision has been gradually getting blurry over months; I’m in my 50s, maybe I have cataracts?

O/E: RVA 6/12, LVA 6/12, pupils equal and reactive to light (PEARL), nil RAPD, IOP normal range

Most likely Dx?

A

Fuch’s endothelial dystrophy

NB There are other corneal dystrophies, however this is the most common

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13
Q

Approach to visual loss: what structures should be considered when thinking about causes of visual loss?

A

Eyelids + tear film

Cornea

Anterior chamber/iris/pupil

Lens

Fundus

The optic nerve (and beyond, i.e. visual field defects)

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14
Q

What is the ice pack test for myaesthenia gravis?

A

Application of ice to eyes for 2-5 mins relieves bilateral ptosis of MG by at least 2mm

It is thought that by cooling the tissues, and more specifically the skeletal muscle fibres, the activity of acetylcholinesterases are inhibited

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15
Q

Pathophysiology of post-op corneal oedema

Signs?

A

Corneal endothelium is vulnerable to insult in cataract surgery

Can see visible folds in Decemet’s membrane

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16
Q

Pathophysiology of Fuch’s endothelial dystrophy

A

Decompensation of corneal endothelial pump leads to corneal oedema (usually bilateral)

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17
Q

Findings on fundoscopy in Fuch’s endothelial dystrophy

A
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18
Q

Mx of Fuch’s endothelial dystrophy

A

Topical 5% sodium chloride (dehydrates cornea)

Definitive Mx: corneal graft surgery (corneal graft of the endothelium only is usually sufficient)

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19
Q

What kind of material in the anterior chamber may decrease visual acuity?

A

RBCs

WBCs

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20
Q

Hx: my vision has been getting blurry again, I’ve had several new pairs of glasses this year but it keeps getting worse

O/E: VA with glasses R 6/12 (pinhole 6/6) and L 6/15 (pinhole 6/6), PEARL, normal IOP, Munson’s sign (V-shaped indentation observed in the lower eyelid when the patient’s gaze is directed downwards; caused by cone-shaped cornea pressing down into the eyelid)

Dx?

A

Keratoconus (progressive thinning, weakness and protrusion of the cornea)

Prevalence ~1 in 2000

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21
Q

What are the layers of the normal cornea?

Which layer is primarily affected in keratoconus?

A
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22
Q

Mx of keratoconus

A

Hard contact lens

Cross-linking

Corneal transplant

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23
Q

Hx: 2/24 of painful unilateral red eye with worsening vision

O/E: IOP 60mmHg

Dx?

A

Acute angle closure glaucoma (this is a sight-threatening emergency!)

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24
Q

What signs are seen on inspection of the eye in acute angle closure glaucoma?

A
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Mx of acute angle closure glaucoma
IOP reduction: Acetazolamide STAT (IV and oral) Topical B blocker (e.g. timolol) Topical steroids Once IOP reduced: peripheral iridotomy (LPI eliminates pupillary block by allowing the aqueous to pass directly from the posterior chamber into the anterior chamber, bypassing the pupil)
26
Hx: my vision has been getting progressively more blurry, I experience glare and colours don't seem as bright anymore O/E: VA 6/18 (no improvement with pinhole), PEARL, no RAPD, IOP normal, slit lamp exam revealed nuclear sclerosis (centre of lens appears white) Dx? Types and causes?
Dx: cataract Types: cortical, nuclear, subcapsular Causes: age-related, drugs (e.g. steroids, amiodarone), trauma (including intra-ocular surgery), systemic diseases (e.g. DM, myotonic dystrophy, Wilson's disease, atopic dermatitis), ocular diseases (uveitis, myopia)
27
What kind of VA is seen in mature cataracts?
28
What has happened to this lens?
Lens dislocation (usually due to zonular pathology) Associated with CTDs, including Marfan's syndrome
29
Hx: I lost vision in my L eye today, it was like a curtain came down over my vision O/E: L VA \<6/60, PEARL, no RAPD Dx? Important causes?
Vitreous haemorrhage Important causes include retinal detachment, proliferative diabetic retinopathy and trauma
30
Mx of vitreous haemorrhage
Often resolves slowly over weeks/months Can require vitrectomy to clear blood Risk of re-bleed
31
Hx: flashes of light and floaters in the visual field of my L eye O/E: PEARL, slit lamp and dilated fundus exam performed Dx?
Retinal tear and associated peripheral retinal detachment (note the peripheral location of the break - these can be hard to find!) NB RAPD will be present when retinal detachment is extensive
32
Mx of retinal detachment
Suspicion of retinal detachment requires urgent r/v by opthalmologist (within 24 hrs) Mx is surgical repair
33
What does this slit lamp examination show?
Weiss Ring (sign of posterior vitreous detachment, PVD)
34
Hx: sudden, painless unilateral loss of vision O/E: R VA \<6/60, R RAPD, fundal examination performed What are the findings of the fundal exam? Dx?
Fundal exam shows pale retina, arteriolar attenuation and a "cherry red spot" Central retinal artery occlusion (this is a sight threatening emergency; irreversible ischaemic damage to the retina occurs after ~90 mins)
35
Common causes of central retinal artery occlusion
Atherosclerosis Embolic sources Haematological disorders (e.g. hypercoagulable states) Inflammatory causes (e.g. GCA in ~3% of cases)
36
Emergency Mx of central retinal artery occlusion
Urgent priority to rule out GCA (ESR, CRP) Lie patient flat (to help maintain circulation) Ocular massage (direct pressure for 5-15 secs/min for 15 mins) Decrease IOP (e.g. with acetazolamide 500mg IV stat)
37
Prognosis of central retinal artery occlusion
POOR 35% achieve VA of 6/60 or better 20% achieve VA of 6/12 or better
38
Hx: sudden painless unilateral loss of vision O/E: R VA \<6/60, R RAPD, fundal examination performed Findings on fundoscopy/inspection of eye? Dx?
Central retinal vein occlusion
39
Clinical associations with central retinal vein occlusion
Atherosclerosis: HTN, DM, hyperlipidaemia, smoking Inflammatory diseases: sarcoidosis, Behcet's, SLE, polyarteritis nodosa Blood dyscrasias: protein C and S deficiency, antithrombin deficiency, antiphospholipid syndrome, multiple myeloma Opthalmic: glaucoma, orbital mass
40
Mx of central retinal vein occlusion
Lifestyle changes IOP control Intra-vitreal steroids and anti-VEGF agents
41
Hx: I am unable to focus on anything with my R eye, when I try to look at something it disappears O/E: R VA 6/48 (eccentrically fixating), pupils NAD, visual fields by confrontation normal, fundus photography and OCT performed What are the findings on fundus photography and OCT? Mx? Risk?
Macular hole Mx: vitrectomy, removal of macular traction (through peeling of internal limiting membrane +/- epiretinal membrane), insection of gas ~10% risk of macular hole developing in other eye
42
Contrast between dry and wet age-related macular degeneration in terms of typical Hx, pathophysiology and Mx
43
Which is more common: dry or wet macular degeneration?
Dry (~90%)
44
Contrast the expected fundus examination findings in dry vs wet macular degeneration
45
What is the biggest RF for development of diabetic retinopathy? List 6 other RFs
Duration of DM is greatest RF Poor glycaemic control Poorly controlled HTN Hypercholesterolaemia Nephropathy Pregnancy Obesity
46
What is the most common cause of visual impairment in diabetic retinopathy?
Diabetic macular oedema (also the greatest cause for visual disability in working age people in developed nations)
47
What signs may be seen in diabetic retinopathy on fundoscopy?
Circinate ring Lipid (hard) exudates Intra-retinal haemorrhages or vascular abnormalities Neovascularisation of the disc (NVD) or everywhere (NVE) Microaneurysms Venous beading Vitreous haemorrhage
48
Hx: I'm concerned about my vision, I have nearly been in a few car accidents and my night vision is so poor that I have had to stop driving in the dark altogether - blindness tends to run in my family O/E: R VA 6/6, L VA 6/6, PEARL, no RAPD, IOP normal, visual field testing and fundoscopy performed Describe the findings on visual field testing and fundoscopy Dx?
Retinitis pigmentosa
49
What is retinitis pigmentosa?
Most common retinal dystrophy, may be sporadic or inherited and typically affects rods first ("rod-cone dystrophy") Usually presents in young adulthood
50
Hx: rapid decrease in visual acuity, presentation age \<20 O/E: lipid deposits beneath the macular in RPE Dx?
Stargardt's disease
51
Hx: decreased central vision O/E: vitelliform appearance of macular (i.e. egg yolk appearance) Dx?
Juvenile vitelliform dystrophy (Best's disease)
52
53
Hx: several days of decreased L visual acuity O/E: L VA 6/12, fundoscopy performed Dx?
Posterior uveitis (in this case CMV retinitis)
54
What is posterior uveitis?
Includes retinal vasculitis, retinitis, choroiditis
55
7 causes of posterior uveitis
Systemic inflammatory disorders (e.g. Bechet's, sarcoidosis) Viruses (e.g. CMV, HSV, HZV, HIV) Fungal (e.g. candida, aspergillus, cryptococcus) Protozoa (e.g. toxoplasmosis gondii) Bacterial (many varieties, e.g. TB, syphilis) Lymphoma Many causes associated with anterior uveitis
56
Mx of posterior uveitis
Thorough Ix of cause: antimicrobials for infective cause, topical steroids for anterior uveitis, systemic therapies Assess risk of bilateral vision loss Variable prognosis
57
Hx: eye trauma Findings on fundoscopy?
58
Overweight female in her 20s presents to ED Hx: I get terrible headaches and now my vision has got blurry O/E: bilateral swollen optic discs (papilloedema) What is this a sign of? What are some possible causes and what Ix should be performed? What do you think is the most likely Dx in this patient?
Sign of raised ICP Causes include causes of mass effect (haemorrhage, haematoma, tumours), increased CSF production (choroid plexus tumour) and reduced CSF reabsorption (venous sinus thrombosis, aqueduct/foramen stenosis, idiopathic intracranial HTN) Ix: urgent neuroimaging to exclude space-occupying lesion, then LP if cause not clear Most likely: idiopathic (benign) intracranial HTN
59
Mx of idiopathic intracranial HTN
Weight loss is the most effective treatment Medical Rx: acetazolamide, other diuretics, corticosteroids Surgical Rx: optic nerve sheath fenestration, lumbar-peritoneal (LP) shunt
60
Hx: I woke this morning and have very poor vision in one eye No PHx O/E: R VA 6/6, L VA 6/60, left RAPD, IOP normal, reduced L colour saturation, fundoscopy performed Describe the findings on fundoscopy Dx? What are the possible implications of this Dx with regard to the long term prognosis?
Optic neuritis Incidence in general population is low (5/100,000) while prevalence in MS patients is 70%
61
Mx of optic neuritis
MRI brain and urgent referral to neurologist to Ix for MS High dose prednisolone regime (IV methylprednisolone 1g/day for 3/7, then oral 1mg/kg daily for 11/7, then wean over 4/7) may speed up visual recovery but does not appear to impact on long term visual prognosis
62
Compare the 5 year risk of developing MS in patients with optic neuritis but no lesions on MRI vs those with 2+ lesions on MRI
No lesions: 16% chance 2+ lesions: 51% chance
63
DDx for bilateral disc swelling
Generally papilloedema; nerve fibre layer swelling due to raised ICP due to delay of axoplasmic flow Malignant HTN Pseudopapilloedema (partially myelinated nerve fibre layer
64
Causes of raised ICP
Mass effect: haemorrhage, haematoma, tumours Increased CSF production: choroid plexus tumour Reduced CSF production: venous sinus thrombosis, aqueduct/foramen stenosis, idiopathic intracranial HTN
65
DDx for unilateral disc swelling
Arteritic anterior ischaemic optic neuropathy (AION) Non-arteritic anterior ischaemic optic neuropathy (NAION) Inflammatory disorders (i.e. optic neuritis) Orbital compressive lesion (i.e. tumours) Infections Causes of unilateral swelling related to raised ICP: Foster-Kennedy syndrome, raised ICP where one optic disc is already atrophic NB These conditions can occur bilaterally
66
Causes of pseudopapilloedema
Optic disc drusen Hypermetropia (i.e. shorter eye axial length can give the disc a swollen appearance) Tilted discs
67
Papilloedema and psuedopapilloedema: which is which?
68
What is GCA?
Medium to large vessel vasculitis involving arteries with a greater quantity of elastic tissue in media and adventitia
69
Clinical features of GCA
Headache Scalp tenderness Jaw claudication Associated PMR Acute unilateral loss of vision (usually due to ischaemic optic retinopathy but can be due to CRAO)
70
Key Ix for GCA
ESR (classically \>100) CRP Temporal artery biopsy
71
What is the risk of the second eye losing vision if one eye is affected with a presentation of GCA?
20-50% This is a sight threatening emergency!
72
Mx of GCA
High dose prednisolone (40-60mg/day), usually good response to steroids
73
Classical signs of POAG
Increased optic cup-to-disc ratio Progressive visual field loss (often not noticed by the patient until glaucoma is very advanced; commonly detected incidentally)
74
POAG
A chronic degenerative condition affecting the optic nerve
75
RFs for POAG
Positive FHx High myopia DM Elevated IOP
76
Mx of POAG
Lowering IOP (even from normal levels) is associated with delayed progression of disease
77
What causes of visual loss require referral to an opthalmologist?
Any that can be explained by refractive error alone (i.e. cannot be corrected with pinhole)

MD2 Opthalmology (3 decks)

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