L14 Vision Loss

Question 1

Acute vision loss

Answer 1

Acute angle closure glaucoma
Retinal detachment
Central retinal artery/vein occlusion
Optic neuritis

Question 2

Chronic vision loss

Answer 2

Cataracts 
Open angle glaucoma
Macular degeneration
Diabetic retinopathy
Hypertensive retinopathy

Question 3

Vision loss Hx

Answer 3

Duration
    Acute/chronic
Quality
     Unilateral/bilateral
     Floaters, focal, metamorphopsia
Assoc Sxs
Systemic conditions

Question 4

Vision loss exam

Answer 4

Visual field 
Pupils
Tonometry
Pen light/slit lamp
Dilated fundus exam

Question 5

Vision loss management

Answer 5

refer to ophthalmology…always

Question 6

Problem focused eye exam: vision loss

Answer 6

Visual acuity
Visual fields
Pupils PERRLA
Tonometry
Slit lamp/pen light
Dilated fundus exam

Question 7

Visual field testing

Answer 7

One eye at a time
Count fingers
Amsler grid

Question 8

Glaucoma

Acute angle closure

Answer 8

Acute rise of IOP due to outflow obstruction (aqueous outflow)
Rare in real life, common on boards

Question 9

Open angle glaucoma’s

Answer 9

Chronic narrowing of angle
Optic neuropathy
IOP not always elevated significantly
Optic nerve damage
Much more common

Question 10

Sxs of Acute angle glaucoma

Answer 10

Acute decreased vision
Halos around lights
Headaches
Nausea and vomiting
Severe eye pain
Feeling of pressure aka elevated IOP

Question 11

Clinical presentation of Acute angle closure glaucoma

Answer 11

Decreased vision
Circumlimbal injection/ciliary flush
Steamy cornea
Mid-dilated pupil
Narrow anterior chamber
Firm globe

Question 12

Management of Acute angle closure glaucoma

Answer 12

Ophthalmologic emergency
Topical ocular hypertension meds
    B-blockers
    Alpha-2 agonists
Oral/IV osmotic agents (mannitol)
Laser peripheral iridotomy
Surgical trabeculectomy
NO mydriatics

Question 13

Open Angle glaucoma clinical presentation

Answer 13

Early-asymptomatic
Late-chronic painless visual field loss
     Peripheral first
     Central later
Exam findings
  Increased intraocular pressure 
   Increased cup/disc ratio
  No AV nicking 
  No exudates

Question 14

Open angle glaucoma management

Answer 14

Ophthalmologic referral
Topical ocular hypertension medications
    B-blockers
    Alpha-2 agonists
Laser trabeculoplasty
Surgical trabeculectomy

Question 15

Cataract clinical presentation

Answer 15

Lens opacity-age related, congenital, traumatic
Gradual, CHRONIC, PAINLESS loss of vision, “foggy”
Glare, esp at night
Decreased visual acuity
Clouding/opalescent changes to the lens

Question 16

Management of cataract

Answer 16

Ophthalmology referral if lifestyle is affected
Glasses Rx
Surgery
   Extracapsular cataract extraction
   Intraocular lens implant
Excellent prognosis

Question 17

Macular degeneration causes

Answer 17

Age-related macular degeneration (ARMD) or toxic effect of drugs

Question 18

Macular degeneration symptoms

Answer 18

#1 cause of central legal blindness in western world
Gradual or acute blurred vision
Metamorphopsia (wavy/distorted vision)
Central scotoma (blind spot)
Might have decreased vision
Amsler grid distortion

Question 19

Dry A-R Macular degeneration clinical presentation

Answer 19

Drusen bodies (lipid deposits), pigment mottling
Geographic atrophy
Vision loss slow/gradual
One or both eyes

Question 20

Wet ARMD clinical presentation

Answer 20

Subretinal neovascular degeneration
    Subretinal fluid or blood
Fibrosis/scarring
Rapid vision distortion, loss of central vision
More common in one eye

Question 21

Management of macular degeneration

Answer 21

Ophthalmology referral
Vitamins (antioxidants/zinc)
Omega 3 fatty acids
Stop smoking!
Amsler grid checks daily
Photocoagulation, photodynamic therapy, intravitreal steroid/monoclonal antibodies
Low vision aids
Stop offending drugs

Question 22

Retinal Detachment (RD) definition and types

Answer 22

Separation of the retina from the underlying epithelial layer
Rhegmatogenous RD
Nonrhegmatogenous RD

Question 23

Rhegmatogenous RD

Answer 23

Posterior vitreous detachment

Traumatic RD

Question 24

Nonrhegmatogenous RD

Answer 24

Traction RD
Assoc with diabetes
Exudative (rare)

Question 25

Clinical presentation of RD

Answer 25

``` Painless, can progress rapidly Floaters Photopsias (flashes) Loss of vision (complete or partial) Progressive scotoma (central vision loss) Curtain-like vision loss (top —> bottom) Might be peripheral only Raised whitish retina Bilateral 20% of the time ```

Question 26

Management of RD

Answer 26

``` Ophthalmology referral Medical Laser/cryo surgery Surgery Scleral buckle Vitrectomy ```

Question 27

Hypertensive Retinopathy presentation

Answer 27

``` Retinal vascular changes due to systemic hypertension Asymptomatic Characteristic ophthalmic changes Copper wiring Silver wiring AV nicking Cotton wool spots Retinal hemorrhages Retinal edema/exudates Disc edema ```

Question 28

Management of Hypertensive Retinopathy

Answer 28

Systemic blood pressure control Ophthalmology referral If severe Associated visual loss

Question 29

Diabetic retinopathy classifications

Answer 29

Proliferative/nonproliferative

Question 30

Non proliferative diabetic retinopathy clinical presentation

Answer 30

``` Blurred vision Retinal hemorrhage Retinal edema Macular edema Cotton-wool spots Venous dilation Hard exudates (micro-aneurysms) ```

Question 31

Proliferative Diabetic retinopathy

Answer 31

Neovascularization Preretinal and vitreous hemorrhage (can cause sudden blindness) Subsequent fibrosis Traction retinal detachment Macular edema Retinal thickening and edema involving the macula

Question 32

Management of diabetic retinopathy

Answer 32

Blood sugar control Ophthalmology referral Laser photocoagulation Vitrectomy

Question 33

Retinal vascular occlusion

Answer 33

Central retinal artery occlusion CRAO Embolic Central retinal vein occlusion CRVO Thrombotic

Question 34

CRAO

Answer 34

``` Embolic refer to ophthalmologist no effective tx evaluate etiology to prevent future strokes carotid plaques carotid thrombi ```

Question 35

CRVO

Answer 35

``` thrombotic refer to ophthalmologist aspirin observation tx for retinal edema or ischemia evaluate etiology if young severe hypertension hyper coagulable state ```

Question 36

optic neuritis clinical presentation

Answer 36

acute inflammatory demyelination of the optic nerve monocular vision loss over hours to days central scotoma painful might have abnormal color vision might have flashes of light 1/3 visible papillitis w/ disc swelling on fundoscopic exam

Question 37

management of optic neuritis

Answer 37

MRI of brain and orbits IV methylprednisone for severe vision loss or 2 or more white matter lesions on MRI rapid recovery does not impact long-term vision function no treatment improvement in 2-3 wks typically 20/40 vision by one year 30% will develop MS at 5 years

Question 38

Who to refer to ophthalmologist

Answer 38

``` all pts with vision loss acute: ASAP chronic: arrange consult pts with known hx of glaucoma pts with DM chronic eye conditions uncertain dx worried pt worried pa ```