ACUTE VISUAL LOSS

Done By:
Hisham Nasser Almutawa
Acute Visual Loss
Sources: The slides, the lecture recording, and Lecture Notes - Ophthalmology 11th Edition

Classification of acute visual loss:

i. Media opacities
ii. Retinal disease
iii. Optic nerve disease
iv. Visual pathway disorders
v. Functional disorders
vi. Acute discovery of chronic visual loss

Most common causes of acute visual loss:

1. Acute glaucoma
2. Central retinal artery occlusion
3. Central retinal vein occlusion
4. Retinal detachment
5. Optic neuritis

Important questions in the history:

 Is it transient or persistent? (Transient such as migraine or TIA)
 Is it monocular or binocular? (Optic neuritis is usually monocular)
 Did it occur suddenly or developed over hours, days or weeks? (Vascular
causes develop within minutes to hours)
 What is the patient’s age and general medical condition? (Angle-closure
glaucoma affect patients older than 40)
 Did the patient have normal vision in the past and when his was vision last
tested?

Examinations:
 Visual acuity
 Visual fields (Confrontation test)
 Pupillary reactions (Any lesion affect optic nerve from the retina until the
lateral geniculate body should have afferent pupillary defect)
 Ophthalmoscopy (Normal cup:disc ratio is 0.3)
 External examination of the eye with a pen light
 Tonometry to measure the intraocular pressure.(normal: 10-21 mm Hg, ocular
HTN: 22-29, glaucoma: ≥ 30)
I: Media Opacities
If there is an opacity whether in the cornea (corneal scar), pupil, lens (cataract),
vitreous body (vitreous hemorrhage) or retina, there will be visual loss. Thus, absent
red reflex indicates media opacity.

Corneal Edema:
The most common cause is increased intraocular pressure, which occurs in angle-
closure glaucoma.
Doctor Essam has opened other slides for Glaucoma, chronic glaucoma is better
covered in another lecture, and acute glaucoma is covered in this lecture

Glaucoma:
Any type of glaucoma will, eventually, cause optic neuropathy due raised intraocular
pressure. It usually affects the visual field, and only affects the visual acuity when the
central visual field is involved.

Chronic Glaucoma:
Chronic glaucoma is painless (because of gradual increase in IOP) and present late
when the macula (central vision) is affected.

Risk factors:
- Family history - Myopia
- Age - Diabetes mellitus
- Black race - Hypertension

Presentation:
- Visual field defect - Raised IOP - Optic disc cupping

Diagnosis:
- Intraocular pressure.
- Optic disc. The most important, because there is normal tension
glaucoma, and the patient might not notice any visual loss until it affects
the central vision.
- Visual field.

Treatment: Normal optic disc

- Medical treatment - Laser treatment - Surgical treatment

Glaucomatous optic disc

Acute Angle-Closure Glaucoma:
Acute glaucoma is painful loss of vision.

Risk factors:
- Age > 40 - Female gender
- Hyperopia - Short stature

In hyperopia the anterior chamber depth is shallow, and the lens after the age of 40
loses its elasticity and increases in size and this will narrow the angle and make it
prone to angle-closure glaucoma.

Stages of primary angle-closure glaucoma: This is an old classification, and the

Doctor said you do not need to know this
- Prodromal stage: pupils dilate in the dark, which will narrow/close the angle,
increasing the resistance of the aqueous flow from posterior to anterior chamber,
therefore increasing the IOP causing ocular pain. If the patient turns on the light at
this stage pain will be relieved.
- Intermittent stage: the same concept of prodromal stage, but here the patient has
borne the pain for some time, causing some parts of the adhesion not to open after
turning on the light.
- Acute angel-closure glaucoma: if the pain was ignored.
- Chronic angle-closure glaucoma: multiple attacks.
- Plateau iris syndrome: closure of the angle secondary to a large or anteriorly
positioned ciliary body.

Presentation:
Symptoms:
- Severe ocular pain - Photophobia
- Sudden loss of vision - Watering
Signs:
- Conjunctival redness - Shallow anterior chamber
- Corneal edema - Hyperemic disc
- Dilated pupils

Diagnosis:
Gonioscopy is the gold standard for diagnosing angle closure.

Treatment:
Laser peripheral iridotomy
Intraocular pressure can be reduced with topical and systemic medications,
laser treatment and surgery.
Hyphema:
Blood in the anterior chamber.
Caused by trauma to the eye, bleeding disorders, or
any disease causing neovascularization (tumors,
DM, intraocular surgery and chronic inflammation)

Vitreous Hemorrhage:
Blood in the vitreous body.
Caused by trauma, diabetic retinopathy, vein occlusion, hypertension, or
subarachnoid hemorrhage.
Diagnosis: Absent red reflex, and confirmed by slit lamp. The vitreous
hemorrhage can also be seen in B scan.

II: Retinal Diseases

Retinal Detachment:
Separation of the retina from the choroid.
could be partial or complete detachment, and could involve or spare the
macula.

Types:
1. Rhegmatogenous (rupture) retinal detachment
2. Tractional retinal detachment: fibrous tissue caused by inflammation or
neovascularization (diabetic retinopathy) pulls the sensory retina from the
retinal pigment epithelium (RPE).
3. Exudative retinal detachment: fluid accumulating underneath the retina
without the presence of a break.
Rhegmatogenous (rupture) retinal detachment

Risk factors:
- High myopia - Retinal detachment of the other eye
- Iatrogenic vitreous loss following - Severe eye trauma
cataract surgery

Presentation:
- Painless loss of vision - Floaters and flashing lights
 Macula sparing retinal detachment causes visual field defect.
 Macula involving retinal detachment casus marked drop in visual acuity.

Diagnosis:
- Swinging flashlight test will show afferent pupillary defect.
- Ophthalmoscope will show dilated pupil and elevated folded retina.
Treatment:
Vitreoretinal surgery

Retinal Vascular Occlusions:

Central/branch retinal artery occlusion:

Risk factors:
- IHD - Hyperlipidemia - Platelet disorders
Usually embolic in origin:
- Fibrin-platelet embolus - Cholesterol embolus - Calcific embolus.

Presentation:
- Sudden, painless, complete/partial loss of vision (only light
perception)

Diagnosis:
- In acute stage, retina is edematous (swollen and white), and fovea is Central retinal artery occlusion

red (Cherry red spot).

- In chronic stage, retina is atrophic (pale)
The visual loss is irreversible after 1 hour

Treatment:
- Vasodilators
- Digital ocular massage
Inferior branch retinal artery
- Paracentesis, to releasing of aqueous and lowering IOP
- Breathing into a paper bag to increase CO2 levels
*Differentials for cherry red spot:
- Niemann-Pick disease. - Tay-Sachs disease

Central/branch retinal vein occlusion:

Risk factors: HTN

Presentation:
- Sudden painless loss of vision (less acute than arterial occlusions) Ceteral retinal vein occlusion

Diagnosis:
- Ophthalmoscope will show:
 swollen optic disc
 Cotton wool spots
 Diffuse retinal hemorrhages
 Dilated and tortuous retinal veins
 Arteriovenous nipping Superior branch retinal vein
Treatment:
- Retinal laser treatment - Intravitreal steroid injections

III: Optic Nerve Diseases

Optic Neuritis:
Inflammation/demyelination of the optic nerve

Risk factors:
- Female gender - Multiple sclerosis

Presentation:
- Acute loss of vision, usually monocular
- Pain on eye movement (in retrobulbar neuritis)
- +/- Associated symptoms of MS

Diagnosis:
- Markedly reduced visual acuity (usually recovers after the MS attack)
- Reduced color vision
- Hyperemic swollen optic disc (might be normal if retrobulbar neuritis)
- Swinging flashlight test will show afferent pupillary defect. If APD is not
present, then it is not optic neuritis

IV: Visual Pathway Disorders

Discussed in another lecture

V: Functional Disorders
Hysterical or malingering visual loss, diagnosis of exclusion

VI: Acute discovery of chronic visual loss

Some people discover the chronic monocular visual loss when they cover the good
eye.

VI: Cortical Blindness

Normal fundal examination, APD must be absent (normal pupillary reaction)
Summary

Causes of acute visual loss:

1. Acute glaucoma (Painful)
2. Retinal detachment (Painless)
3. Vascular (arterial / venous) occlusion (Painless)
4. Optic neuritis (Painful on moving the eyes)

Glaucoma

Acute glaucoma Chronic glaucoma

Affect female Affect black people
Hyperopic Myopic
Acute increase in IOP Gradual increase in IOP

Painful Painless

Hyperemic disc Cupping disc

 Definition Risk factors Presentation Diagnosis Treatment

Acute glaucoma Primary acute -Age > 40 -Severe pain Gonioscopy Laser peripheral
angle-closure -Hyperopia -Loss of vision iridotomy
glaucoma -Female gender -Watering
-Conjunctival
redness
-Corneal edema
-Dilated pupils
-Hyperemic disc

Retinal Separation of the -High myopia -Painless loss of -APD Vitreoretinal

detachment retina from the -Post cataract op vision -Dilated pupil surgery
choroid vitreous loss -Floaters and and elevated
-Retinal flashing lights folded retina
detachment of
the other eye
-Severe trauma

Retinal artery Embolic in origin -IHD Sudden painless -Swollen and -Breathing into a
occlusion -Hyperlipidemia loss of vision white optic disc paper bag
-Platelet -Fovea is red -Paracentesis
disorders (Cherry red spot) -Vasodilators

Retinal vein HTN Sudden painless -Swollen disc -Retinal laser

occlusion loss of vision -Cotton wool treatment
spots -Intravitreal
-Retinal steroid injections
hemorrhages
-AV nipping

Optic neuritis Inflammation Female gender -Acute loss of -Reduced visual

of the optic nerve Multiple vision acuity & color
sclerosis -Pain on eye vision
movement -Hyperemic
swollen disc
-APD
MCQs:

Q1: A 23 - year - old female presents with loss of vision in the right eye over 3 days,
she also complains that the right eye is painful when she moves it. She is
otherwise fit and well, with no past ocular or medical history. Examination
reveals an acuity of counting fingers in the right eye, 6/6 in the left. The eye
is white, the pupils equal and reactive to light, but a right relative afferent
pupillary defect is present. Examination of the fundus is normal. What is the most
likely diagnosis?

A- Central retinal vein occlusion

B- Acute glaucoma
C- Optic neuritis
D- Posterior cerebral artery occlusion

Q2: A 72 - year - old man with a previous diagnosis of glaucoma presents with a
sudden loss of vision in the right eye. There is no pain. He is hypertensive.
There is a family history of macular degeneration. Examination reveals a
visual acuity of counting fingers in the right eye, 6/6 in the left. The eye is
white, intraocular pressure is not raised. The pupils are equal and no relative
afferent pupillary defect is present. Dilated fundoscopy reveals a
swollen optic disc and multiple hemorrhages scattered over the retina.
The retinal veins appear dilated and tortuous. What is the most likely diagnosis?

A- Central retinal artery occlusion

B- Central retinal vein occlusion
C- Retinal detachment
D- Giant cell arteritis

Correct answers:
Q1: C
Q2: B