vision loss

Question 1

causes of sudden vision loss

Answer 1

retinal detachment, vascular causes, WET ARMD, closed angle glucoma, optic neuritis, stroke

Question 2

vision loss can happen due to occlusion of which 2 things?

Answer 2

retinal circulation

optic nerve circulation

Question 3

vision loss can occur from haemorrhage from

Answer 3

abnormal formed vessels - diabetes, wet ARMD

retinal tear

Question 4

symptoms of central retinal artery occlusion

Answer 4

sudden vision loss
Profound (Counting Fingers or less- remember CRA is ‘end artery’)
Painless

Question 5

signs of central retinal artery occlusion

Answer 5

RAPD (relative afferent pupil defect)
Pale oedematous retina, thread-like retinal vessels
red dot on fovea

Question 6

what are the causes of central retinal artery occlusion ?

Answer 6

Carotid artery disease

Emboli from the heart (unusual)

Question 7

management of central retinal artery occlusion

Answer 7

in first 24 hours - ocular massage - increasing pressure of eye to try dislodge emboli to branch and increase retinal perfusion
Vascular management
Establish source of embolus – carotid doppler
Assess and manage risk factors

Question 8

2 other types of retinal artery occlusion apart from CRAO

Answer 8

retinal artery branch occlusion

TRANSIENT CRAO–amaurosis fugax

Question 9

signs and symptoms of amaurosis fugax

Answer 9

transient painless visual loss
curtain like blindness
vision restored fully around 5 minutes
nothing noramlly seen on examination

Question 10

treatment of amaurosis fugax

Answer 10

Immediate referral TIA clinic

Aspirin

Question 11

other cause of transient visual loss

Answer 11

migrane

Question 12

causes of central retinal vein occlusion

Answer 12

Systemic causes
Atherosclerosis }
Hypertension } Virchow’s triad
Hyperviscosity }

Ocular causes	
raised IOP (venous stasis)

Question 13

symptoms and signs of central retinal vein occlusion

Answer 13

Symptoms:
Sudden visual loss
Moderate to severe visual loss (6/9 – P of L)

Signs:
Retinal haemorrhages
Dilated tortuous veins
Disc swelling and macular swelling

Question 14

treatment of central retinal vein occlusion

Answer 14

Based on treatment of systemic or ocular causes (eg hypertension, diabetes, glaucoma)

Monitor : may develop complications due to development of new vessels

• laser treatment may be required to avoid complications from these vessels eg vitreous haemorrhage)
• anti- VEGFs used (VEGF = vascular endothelial growth factor)

Question 15

what colours do a central retinal vein and artery occlusion look like on fundoscopy?

Answer 15

artery occlusion - pale

vein occlusion - dark

Question 16

what 2 types of ischemic optic neuropathy are there?

Answer 16

arteritic - GCA

non-arteritic - artherosclerosis

Question 17

what do both types of ischemic optic neuropathy cause?

Answer 17

sudden, profund loss of vision with a swollen disc

Question 18

how does giant cell arteritis cause ischemic optic neuropathy?

Answer 18

Lumen of artery becomes occluded (posterior ciliary arteries)

Visual loss from ischaemia of optic nerve head

Question 19

symptoms of arteritic ischemic optic neuropathy

Answer 19

Visual symptoms
Sudden visual loss
Profound (CF – NPoL)
Irreversible blindness
swollen disc

Question 20

why is arteritic ischemic optic neuropathy important to diagnose?

Answer 20

immediate treatment may prevent bilateral visual loss

Question 21

what are the symptoms of giant cell arteritis?

Answer 21

Headache (usually temporal)
Jaw claudication
Scalp tenderness (painful to comb hair)
Tender/enlarged scalp arteries
Amaurosis fugax
Malaise
Very High ESR , PV and CRP
Temporal artery biopsy may help diagnosis

Question 22

what treatment must be started quickly to prevent visual loss in other eye for giant cell arteritis?

Answer 22

corticosteroids, starting at 40-60mg prednisolone and gradually reducing. Steroid sparing agents such as methotrexate and azathioprine may be added.

Question 23

what can cause vitrous hamorrhage?

Answer 23

retinal tear

bleeding from abnormal vessels

Question 24

signs and symptoms of vitrous haemorrhages

Answer 24

Symptoms
     Sudden Loss of vision
      ‘Floaters’ 
Signs 
       Loss of red reflex
       May see haemorrhage on fundoscopy

Question 25

treatment for vitrous haemorrhages

Answer 25

Management Identify cause Vitrectomy for non-resolving cases

Question 26

cause for retinal detachment

Answer 26

Vitrous gel – when you get older the gel becomes more liquid based and then the vitrous can collapse and pull the retina with it – this causes the flashing The floaters are due to epithelial cells getting pulled off by the retina and then you see these

Question 27

symptoms and signs of retinal detachment

Answer 27

Symptoms Painless loss of vision Sudden onset of flashes/floaters (mechanical separation of sensory retina from retinal pigment epithelium) Signs May have RAPD - relative afferent pupillary defect May see tear on ophthalmoscopy

Question 28

management of retainal detachment

Answer 28

surgical

Question 29

symptoms and signs of wet age related macular degeneration

Answer 29

Symptoms Rapid central visual loss Distortion (metamorphopsia) Signs haemorrhage/exudate

Question 30

wet ARMD treatment

Answer 30

Previously: Laser Photodynamic therapy Now: Anti-VEGF treatment – injected into vitreous cavity. Stops new blood vessels growing by binding to VEGF (vascular endothelial growth factor)

Question 31

cause of wet ARMD

Answer 31

new vessels begin to grow in choroid body and these vessels leak which cause scarring and retina to be displaced from choroid

Question 32

causes of gradual visual loss

Answer 32

``` CARDIGAN Cataract Age related macular degeneration (dry type) Refractive error Diabetic retinopathy Inherited diseases e.g. retinitis pigmentosa Glaucoma Access (to eye clinic) Non-urgent ```

Question 33

what is cataracts?

Answer 33

cloudiness of lens

Question 34

causes of cataracts

Answer 34

``` Many different causes Age related Congenital – intrauterine infection (importance of checking red reflex in neonates) Traumatic Metabolic – diabetes Drug-induced (steroids) ```

Question 35

cataracts management

Answer 35

Management is surgical removal with intra-ocular lens implant if patient is symptomatic

Question 36

symptoms and signs of dry ARMD

Answer 36

Symptoms Gradual decline in vision Central vision ‘missing’ (scotoma) Signs Drusen – build up of waste products below RPE - retinal pigment epithelium Atrophic patches of retina

Question 37

treatment of dry ARMD

Answer 37

No cure – treatment is supportive with low vision aids eg magnifiers

Question 38

what is a refractive error?

Answer 38

the eye cannot focus clearly

Question 39

what is myopia?

Answer 39

short sighted | cannot see far away as lens is too powerful and brings things to focus before the retina

Question 40

what is hypermetropia?

Answer 40

long sighted | lens isnt powerful enough to focus close objects on the retina

Question 41

What causes unilateral, sudden vision loss?

Answer 41

``` retinal artery embolisim retinal vein thrombosis vitreous haemorrhage (wet ARMD, retinal tear) temporal arteritis retinal detachment optic neuritis migraine acute glaucoma ```

Question 42

what causes bilateral, sudden vision loss?

Answer 42

bilateral occipital lobe ischaemia or infarction bilateral occipital lobe trauma severe bilateral papilloedema rapidly progressive chiasmal compression bilater optic nerve damage 3.g methyl alcohol poisoning hysteria

Question 43

what causes unilateral, gradual vision loss?

Answer 43

asymmetic cateract development choiroiditis inferior retinal detachment malignant melanoma of the choroid

Question 44

what causes bilateral, gragual visual loss?

Answer 44

``` diabetic maculopathy hypertensive retinopathy cateracts chronic glaucoma Chiasmal or bilateral optic nerve compression bilateral optic nerve damage ```

Question 45

What causes diabetic retinopathy?

Answer 45

1. retinal capillary microaneurysms and excessive vascular permeability 2. vascular occlusion and proliferation of new blood vessels and accompanying fibrous tissue 3. contraction of fibrovascular proliferations and vitreous

Question 46

What are cotton wool spots?

Answer 46

cotton wool spots occur secondary to microvascular occlusion and represent retinal microinfarcts of the nerve fibre layer

Question 47

Some pathology that occurs in diabetic retinopathy

Answer 47

retinal thickening, oedema and hard exudates occur as a result of leakage from capillaries; hard exudates are composed of lipoprotein and lipid filled macrophages Flame-shaped haemorrhages occur when the rupture of microaneurysms occurs at nerve level blot haemorrhages occur if rupture of microaneurysms occur deep in the retina

Question 48

how could proliferative diabetic retinopathy cause sudden visual loss?

Answer 48

In PDR, the fibrovascular proliferation extends beyond the internal limiting membrane. The new vessels are leaky, fragile, and often misdirected. They may grow off the retina and into the vitreous. As the vitreous shrinks with age, it pulls on these fragile vessels and can cause them to tear, resulting in a vitreous haemorrhage and sudden vision loss. These vessels may also scar down, forming strong anchors between the retina and vitreous causing traction on the retina. If enough force is created, a tractional retinal detachment may occur. This is another mechanism by which PDR can cause sudden vision loss. If the retina is not re-attached soon, especially if the macula is involved, vision may be permanently compromised.

Question 49

what is the most common cause of sudden vision loss in diabetic retinopathy?

Answer 49

macular oedema. Macular oedema can occur in NPDR, but it is more common in more severe cases of DR due to the leakiness of the new blood vessels

Question 50

What is astigmatism?

Answer 50

usually irregular corneal curvature

Question 51

What is presbyopia?

Answer 51

weakening of the eye with age

Question 52

What is glucoma?

Answer 52

progressive optic neuropathy Fluid builds up behind the iris and pushes the iris forward – sometimes so much that it shuts off the angle – this is acute glaucoma

Question 53

symptoms of acute glucoma

Answer 53

VERY painful, red eye/visual loss/headache/nausea/vomiting

Question 54

treatment of acute glucoma

Answer 54

need to lower IOP with drops/oral medications to stop blindness

Question 55

Symptoms and signs of open angle glucoma

Answer 55

``` symptoms Often NONE Optician may discover it Signs Cupped disc Visual field defect May/may not have high IOP ```

Question 56

Treatment of open angle glucoma

Answer 56

eye drops, lasers, surgery to reduce IOP