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Sudden Loss of Vision Flashcards

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1
Q

What are the most common causes of sudden painless loss of vision and what is it in elderly

A 
Ischaemic optic neuropathy
Vascular
Vitreous haemorrhage
Retinal detachment
Retinal vein or artery occlusion
GCA - usually pain

If elderly = vascular till proven otherwise

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2
Q

What do you do if someone presents with acute visual loss

A

Stay calm and reassure
Get a clear Hx
Treat Sx e.g. pain / nausea
Early referral to ophthalmology and urgent senior review

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3
Q

What does loss of vision tend to indicate

A

Problem in posterior part of eye

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4
Q

What are the 4 categories

A

Vascular / ischaemic problem
Vitreous problem
Retinal detachment
Macular problem

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5
Q

What are vitreous issues

A

Posterior vitreous detachment

Proliferative retinopathy

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6
Q

What are macular problems

A

Age related = gradual
Macular hole
Central serous retinopathy

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7
Q

What causes vascular / ischaemic issues

A 
Atherosclerosis
Embolism
Dissection
Vasculitis
Hypo-perfusion
Venous disease
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8
Q

What would cause unilateral loss

A

Problem in eye or optic nerve
Retinal vein or artery occlusion
Can be central or branch
Ischaemic optic neuropathy

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9
Q

What causes bilateral

A

After decussation of fibres at chasm
CVA / TIA
- Amourosis fujax
Retinal migraine

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10
Q

Is someone presents with visual loss what do you want to ask

A 
General PMH / drug review 
Uni or bilateral
When did you lose vision
- Sudden 
- Gradual 
What is vision loss like 
- General blur
- Particular part lost (suggest branch) 
- Whole field (central vein) 
- Any tunnel 
- Lke a curtain 
Is there anything else in vision?
- Flashes?
- Floaters? 
- Any distortion
Any pain associated 
- Pain on eye movement
- Photophobia
- Headache 
Is the eye red 
Any trauma 
Is BP / DM well controlled
Any thrombotic / haematological conditions./ use of OCP
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11
Q

What does curtain coming down suggest

A

Amourosis fujax
DM
Vitreous haemorrhage

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12
Q

What causes amaurosis fujax

A

Embolism in retinal artery

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13
Q

How do you Rx

A

Aspirin 300mg

Refer urgent to TIA clinic

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14
Q

What does CVA cause

A

Hemianopia

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15
Q

How does migraine present

A

Zig zag or blobs

Prior to headache forming

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16
Q

What causes ischaemic optic neuropathy

A

Occlusion of ciliary artery damaging optic nerve

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17
Q

What does it present with

A

Monocular visual loss
Afferent pupil defect
Pale disc on fundoscopy if long term

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18
Q

What causes central retinal vein occlusion

A 
Age
Hypertension 
Hyperviscosity e.g. polycythaemia 
Glaucoma - raised IOP 
Vasculitis - GCA
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19
Q

How does it present

A

Sudden painless loss of vision
Tends to be more over days to weeks
where as arterial = seconds - minutes
Pupil defect

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20
Q

How do you differentiate ischaemic from non-ischaemic causes of occlusion

A

Ischaemic

  • Extensive
  • Deep haemorrhage
  • Relative afferent pupil defect
  • Severe visual loss
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21
Q

What is seen in the retina on fundoscopy ???

A 
Blood leaks everywhere + fluid build up as vein to take away = blocked
Margarita pizza 
Swollen optic disc
Blot haemorrhage 4+ 
Dilated vessel
Cotton wool
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22
Q

What investigations do you do

A 
Ophthalmology blood screen + referral 
- FBC, U+E, CRP, ESR, clotting + vasculitis screen 
Inflammatory markers to rule out GCA 
BP check 
FBC for hyperviscosity 
Blood sugar 
Lipids and cholesterol
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23
Q

How do you Rx

A

Refer opthamology within 2 weeks or urgent if young
Monitor for complications
Treat vascular RF

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24
Q

What are complications

A

90% chance of long term visual loss
Neovascularisation due to release of VEGF to create collateral
- May cause vitreous haemorrhage
Macular oedema

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25
How do you Rx complications
Anti-VEGF Laser photocoagulation to burn off vessels Dexamethasone for oedema
26
What causes central retinal artery occlusion
``` Atherosclerosis Hypertension Emboli Inflammation - GCA Glaucoma ```
27
What is CRAO
A form of stroke Ophthalmic emergency Time critical as can cause permanent damage to retinal ganglion cell
28
What must you do
Look for cause - DM - Smoking - Cholesterol
29
How does it present
``` Sudden painless loss of vision Seconds - minutes Afferent pupil defect Usually monocular Branch = certain part Retinal vein = whole field ```
30
What is seen on retina
Cherry red spot Pale optic disc Pale as no blood May still have red arteries due t collateral If chronic = complete pale as retinal cells dead
31
What do you do if suspect
Refer ophthalmology Ophthalmic screen - FBC, U+E, CRP, ESR, clotting + vasculitis Want to know if on anti-coagulant as may affect management
32
How do you Rx
GCA = potential reversible Ocular massage to lower pressure (10 seconds pressing if 5s interval) - Aim to dislodge thrombus into a branch of artery) Nitrates to dilate Inhaled carbogen (CO2 + O2) removes AH and reduce pressure Anterior chamber paracentesis Infusion of tPA in artery - Careful if on anti-coagulant Intra-arterial fibrinolysis = new technique where put needle into eye
33
What is posterior vitreous detachment and what is role of vitreous
Separation of vitreous membrane from retina VH - Keep structure of eye - Allow focusing of light onto retina / macula
34
What causes / what are the types
Rhegmatogenous - Natural part of aging as fluid less viscous and does not hold shape / idiopathic ``` Non-Rhegmatogenous - Trauma e.g. surgery - Vasculitis - Hypertension - DM Scar tissue / new tissue grows on retina and pulls it away from layers underneath or fluid collect under ```
35
How does it present
Sudden floaters in eye Flashes of light Blurred vision If have these Sx go to E.D as could be start of retinal detachment or could cause tear
36
What does it suggest if dark curtain descend or peripheral visual field just comes in and closes
Retinal detachment
37
What do you do if patient complains of symptoms suggestive
Opthmaologist within 24 hours to rule out retinal tear or detachment as will cause permanent loss of vision
38
How do you Dx and Rx
``` Symptoms improve over 6 months Ophthalmic blood screen Intra-ocular USS / CT / MRI - RULE out tear/ detachment Slit lamp - Look at back of eye to see impact on optic nerve ``` Rx - Urgent cryotherapy photo-coagulation - Vitre-retinal surgery if associated tear or go onto detach 85% chance of recovery if treated
39
What does posterior vitreous detachment rarely cause
Retinal tear and detachment | Vitreous haemorrhage
40
What causes retinal detachment
Fluid entering space between 9th and 10th layer - Blunt trauma causing tear and VH to enter - Liquified VH (part of ageing process - vitreous detachment causing tear)
41
How does retinal detachment present
``` Features of vitreous detachment - Flashes / floaters Dense shadow that peripherally progresses to centre Veil or curtain PERIPHERAL field defect Sight threatening ```
42
What are RF
``` Age FH Myopia Trauma Cataract surgery Posterior vitreous detachment DM retinopathy ```
43
When do you have major concern
Myopia - short sighted Recent trauma / surgery More likely to detach Loss of vision like a curtain
44
How do you Rx
Surgical repair within a few days Emergency yas outer retina replies on choroid Posture patient so fluid moves away from macula
45
When do you do emergency surgery
If macula attached to detachment
46
Can can delay in Dx lead too / complications
Macula and central vision loss Vitreous haemorrhage DOES not cause retinal haemorrhage
47
What causes retinal haemorrhage
Retinal vein occlusion | Diabetic retinopathy
48
What is vitreous haemorrhage
Bleeding into VH
49
What causes vitreous haemorrhage
Bleed from any disruption to retinal vessel - DM proliferative retinopathy - Retinal tear or detachment which has torn into vessel - Posterior vitreous detachment - Ocular detachment - shaken baby syndrome
50
If DM
Proliferative retinopathy til proven otherwise
51
If non-DM
Rental tear or detachment tip proven otherwise
52
What does vitreous haemorrhage cause
Painless loss of vision Haze Red hue Floaters
53
What puts you at higher risk
``` DM Vitreous detachment Bleeding diosrder Anti-coagulant Severe myopia ```
54
How do you Dx
``` Dilated fundoscopy shows visible blood Slit lamp Orbital USS Floruscein angiography Orbital CT ```
55
What is issue with fundoscopy
May show haemorrhage | Can't visualise retina due to haemorrhage
56
What does slit lamp show
RBC in vitreous
57
Why is orbital USS used
Used to rule out retinal tear or detachment
58
Why do you do flurscein angiography
Look for neovascularisation
59
How do you Rx
Conservative If fresh should resolve in days to week Sleep with raised posture to decrease BP Surgical vitrectomy if significant bleed - Remove all VHand replace Laser photocoagulation once stable if less severe Variable prognosis
60
What do floaters in vision suggest
Vitreous pathology Vitreous detachment = most common Vitreous haemorrhage = most common in DM Uveitis
61
What must you exclude if floaters in vision
Retinal tear or detachment with ocular USS
62
What causes diffuse loss if >50
Central retinal vein or artery occlusion Retinal detachment Optic neuropathy CVA
63
What causes diffuse loss <50
Optic neuropathy | Retinal detachment usually due to trauma

Ophthalmology (10 decks)

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