Gradual Loss of Vision

Question 1

Questions

Answer 1

Same as sudden

Question 2

What are common causes of loss of vision gradual

Answer 2

Macular degeneration
Diabetic retinopathy
Hypertensive retinopathy
Cataract
Open angle galucoa
Optic atrophy

Question 3

What are less common causes

Answer 3

Coloboma
Retinal dystrophy
Drug induced
Retinitis pigments

Question 4

What causes hypertensive retinopathy

Answer 4

Chronic hypertension

Malignant hypertension.

Question 5

What does it lead too

Answer 5

Ischaemia

No risk of new vessel formation

Question 6

What are 4 stages

Answer 6

1 = arteriolar narrow
2 = AV nipping
3 = cotton wool exudate + blot haemorrhage 
4 = papilloedema

Question 7

What is most common cause of blindness in 30-60

Answer 7

Diabetic retinopathy

Question 8

How does DM lead to retinopathy

Answer 8

High BG causes endothelial dysfunction 
Increased vascular permeability 
- Exudates released
- Blot haemorrhage 
Cotton wool spots due to ischaemia
Micro-aneurysm of capillary
Intra-retinal microvascular abnormality = dilated and torturous vessel
Neovascularisation due to release of VEGF in response to ischaemia

Question 9

What is mild non-proliferative

Answer 9

1+ microaneurysm

Question 10

What is moderate

Answer 10

Microaneurysm 
Blot haemorrhage 
Hard exudate 
Cotton wool spot 
venous bleed
IRMA less severe

Question 11

What is severe

Answer 11

Blot haemorrhage
Aneurysm all 4 quadrant
Venous bleed 2+
IRMA 1+

Question 12

What is proliferative

Answer 12

Retinal neovascularisation

Question 13

What can it lead to

Answer 13

Vitreous haemorrhage + retinal detachment

Question 14

What is maculopathy

Answer 14

Hard exudate causing changes to macula affecting visual acuity

Question 15

When is it more common

Answer 15

Type II

Question 16

How do you visualise changes

Answer 16

Fundoscopy

Question 17

How do you Rx

Answer 17

DM Control
Regular screening
Lower BP

Question 18

How do you treat proliferative

Answer 18

Laser photocoagulation

Anti-VEGF (Raibizumab)

Question 19

What is most common cause of blindness worldwide

Answer 19

Macular degeneration

- Degeneration of photoreceptors in macula

Question 20

What causes

Answer 20

Dry due to atrophy (Early age related)

Wet due to blood / fluid (Late age related)

Question 21

What causes dry

Answer 21

Non-exudative
Alterations to retinal pigment epithelium
Atrophy of macula as photoreceptors die
Linked to oxidative stress / inflammation

Question 22

What causes wet

Answer 22

Secondary to dry
Neovascularisation causes leakage of serous fluid into eye or bleeding
If bleed = catastrophic and leads to scarring
Often stimulated by VEGF
Cause scarring of macula = central visual loss
Sub-retinal haemorrhage
Can cause sensory detachment

Question 23

What are symptoms

Answer 23

Progressive loss central vision
Particular near objects 
Difficulty in dark adaption 
Photopsia - flashing 
Crooked or wavy appearance to straight lines

Question 24

What may be present

Answer 24

Area of central field visual loss with normal surrounding Patient aware = +Ve scrotoma

Question 25

What does distortion of vision / crooked lines suggest

Answer 25

Problem with macula Known as metamorphosia If patient complains of this = refer urgently

Question 26

What is it till proven otherwise

Answer 26

Wet related macular degeneration

Question 27

What are other causes

Answer 27

Macular hole if older | Myoptic degeneration / central serous retinopathy if younger

Question 28

How does macular hole present

Answer 28

Central loss of vision | Distortion

Question 29

What are RF for macular degeneration

Answer 29

Age Smoking CVS RF FH - some form of genetics

Question 30

What are ocular RF

Answer 30

Hypermetropia | Light iris

Question 31

What is seen on slit lamp / fundoscopy

Answer 31

``` Drusen - yellow deposition in macula - 1st signs Can scar later Loss of retinal pigment epithelium Areas of hypo and hyperpigmentation ```

Question 32

If wet what also may be seen

Answer 32

Red patches suggesting haemorrhage

Question 33

What is 1st line investigation

Answer 33

Slit lamp

Question 34

What other tests are used to confirm Dx

Answer 34

OCT = 1st line to Dx wet - Also used to monitor - Will see oedema separating but should reduce with Rx Fluroscein angio used in wet to guide whether VEGF useful - Sees if there is leaky vessels

Question 35

How do you Rx dry type

Answer 35

Vitamins slow progression Stop smoking Control BP

Question 36

How do you Rx wet

Answer 36

Anti-VEGF 4 weekly injection into vitreous chamber Laser photocoagulation Regular follow up with OCT and visual assessment

Question 37

What does anti-VEGF do

Answer 37

Limits progression and staibilies loss

Question 38

What are retinal dystrophies

Answer 38

Inherited disorders affecting photoreceptors | Causes loss of vision

Question 39

How do you Dx

Answer 39

EOG

Question 40

What is a coloboma

Answer 40

Hole in structure of the ey e

Question 41

If in iris

Answer 41

Key shaped hole in pupil | Can't control how much eye enters eye

Question 42

If in retina

Answer 42

Strange white space where degeneration occured | Poor central vision

Question 43

If in optic disc

Answer 43

Wont develop and will be blind

Question 44

What is CHARGE

Answer 44

``` Coloboma Heart defect Atresia choanae Retarded growth Genital hypoplasia Ear abnormalities ```

Question 45

What is the leading cause of curable blindness

Answer 45

Cataract

Question 46

What are types of cataract

Answer 46

Immature Mature Secondary

Question 47

What are immature cataracts

Answer 47

Fine in the day as pupil constricted so light doesn't touch opaque lens In dark pupil dilates and vision = hazy

Question 48

What is mature

Answer 48

Hazy all the time | Need surgery

Question 49

What is secondary

Answer 49

Due to nuclear sclerosis | Sutual and zonular common in childhood

Question 50

What causes cataract

Answer 50

Normal part of ageing process Lens gradually opacifies as avascular and can't shed Harder for light to reach retina

Question 51

How does patient present

Answer 51

Reduced vision Faded colour vision Glare / halo Loss of red reflex

Question 52

What are RF

Answer 52

``` Age Smoking Alcohol DM Long term steroid Radiation Myotonic dystrophy Metabolic ```

Question 53

What shows cataract

Answer 53

Slit lamp

Question 54

What must be done prior to surgery

Answer 54

Ocular biometry | Opthamolscopy after pupil dilation shows normal funds and optic nerve

Question 55

How do you treat non-surgical

Answer 55

Stronger glasses | Brighter lightening

Question 56

What is surgery

Answer 56

Only effective Rx | Replace with artificial lens

Question 57

What do you need post surgery

Answer 57

Steroid + Ax eye drop 4 weeks Eyewear Post op optician at 6 weeks Stop smoking

Question 58

if cataract present at birth

Answer 58

REFER urgent to exclude retinoblastoma + surgical correction

Question 59

What are complication of surgery

Answer 59

``` Posterior capsule opacification / rupture Retinal detachment Endophthalmitis Wound leak Astigmastic may become noticeable after ```

Question 60

What is retinitis pigmentosa

Answer 60

Inherited condition causing inflammation of retina and rod and cone cells

Question 61

What does it cause

Answer 61

Tunnel vision - Tends to affect predominantly rods which is more peripheral vision - Cones preserved till late which is for central and colour Night blindness = first sign Can cause earlier cataract formation

Question 62

How do you Dx

Answer 62

Fundoscopy

Question 63

What are other causes of tunnel vision

Answer 63

``` Papilloedema Glaucoma Choroidretintiis Optic atrophy Hysteria ```