Acute Visual Loss

ACUTE VISUAL LOSSBy:

Dina Hazwani binti Azlang4th year medical student,

Faculty of Medicine,

UiTM, Malaysia.

Causes of acute visual loss

Transient-optic neuritis

Permanent-retinal detachment-CRA obstruction-acute congested glaucoma-trauma

DEFINITION

Separation of neurosensory retina ( NSR ) from the retinal pigment epithelium (RPE) by sub-retinal fluid (SRF) accumulation

CLASSIFICATION Rhegmatogenous RD ( Rhegma = break )

Retinal break(hole/tear)- subretinal fluids seeps & separate neurosensory retina from the underlying pigmented epithelium.

Non-rhegmatogenous RD Tractional ( sensory retina is pulled away from the RPE by

contracting vitreoretinal membranes, eg proliferative diabetic retinopathy)

Exudative ( SRF derived from the choriocapillaries gain access to the subretinal space through damage RPE. Eg choroidal tumours, exophytic retinoblastoma, posterior scleritis )

TYPE OF RETINAL TEARS

RHEGMATOGENOUS RD

Retinal breaks responsible for RD are caused by interplay between Dynamic vitreoretinal traction Predisposing degeneration in peripheral retina

Increased in patients who: Myopic eyes Have undergone cataract surgery Severe eye trauma Age: 40-60 Sex: M:F-3:2 Retinal degenerations

SIGN AND SYMPTOMS Photopsia (sparks or flashes)- Caused by traction on the retina at

sites of vitreoretinal adhesions Vitreous floater Visual field defect ~ dark curtain, cloudy Fall in acuity ~ detached macula Vision loss maybe filmy, cloudy, irregular or curtain-like. One large floater in the middle of the field of vision or a

wavy distortion of objects.

4 ‘F’s

Marcus Gunn pupil (relative afferent pupillary defect)

Opthalmoscopy ; Grey opalescent retina, balloning forward. Extensive detachment of the retina will pull of the

macular.

The billowy, gray spinnaker-like folds represent the detached retina—the part that has become elevated from its attachment to the underlying retinal pigment epithelium.

FRESH RETINAL DETACHMENT

TREATMENT Immediately. Retinal Reattachment surgery

Basic principlesSealing of retinal breaks

By cryocoagulation, photocoagulation or diathermy(to create an adhesion between the pigment epithelium and

the sensory retina)SRF drainage

Allow immediate apposition between sensory retina and RPE By using fine needle

Maintain chorioretinal apposition Scleral buckling Pneumatic retinopaxy

Definition An inflammatory & demyelinating disorder

affecting the optic nerve. It can be classified opthalmoscopically and

aetiologically

CLASSIFICATION

Aetiological Demylinating – common

cause Parainfectious – follow a viral

infection Infectious – may be sinus-

related or a/w cat scratch fever, Lyme ds, cryptococcol meningitis in pt wt AIDS& herpes zoster

Autoimmune

Opthalmoscopic/Anatomical

Retrobulbar neuritis – Papillitis: inflam & demyelinating

optic disc- Hyperamia & oedema

Neuroretinitis – optic disc & surrounding retina in macular area.

What is the most common cause for the optic neuritis?Multiple sclerosis. Long term studies indicated that up to 75% of female patient initially developed optic neuritis ultimately developed MS.

SYMPTOMS Visual loss – Sudden, progressive,profound

(progressively blurrier over a period of hours or days)

Blurred vision in bright light – typical Pain behind the eyes

esp in retrobulbar neuritis aggravated by ocular movement

(esp:downward&upward) Loss/reduce of color vision Preceding history of viral illness

SIGNS Reduced visual acuity Impaired color vision Visual field changes - Central scotoma Swinging flash test – affected pupil will dilate

when flash light is moved from normal to abnormal eye (Marcus gunn pupil)

OpthalmoscopicPapillitis- hyperaemia of disc & blurring marginDisc- edematous& obliterating cup, splinter

hrrge, fine exudateRetinal veins tortous and congested

Swollen of optic disc.

MANAGEMENT Treat the underlying cause- cardiovascular or

neurodegenerative disease. Treatment: steroid to reduce the inflammation

and swelling

35 year-old woman presented with unilateral worsening of vision of left eye, accompany by discomfort of eye movement for two weeks durationVisual acuity of left eye is 6/60.Impaired color vision.There is left afferent pupillary defect and a central scotomaFunduscopy reveals the above image.What is the likely diagnosisA. Optic Nerve GliomaB. Cavernosus Sinus thrombosisC. Grave’s diseaseD. Pituitary AdenomaE. Optic Neuritis

CASE Optic neuritis

Reference

1.Kanski, Clinical Ophthalmology 5th edition.

Thank You…