70yo woman presents with sudden onset loss of vision in her right eye half hour ago no improvement...

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Acute Visual Loss Dr Shueh Wen Lim

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Page 1: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Acute Visual Loss

Dr Shueh Wen Lim

Page 2: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Case 1 – Mrs Smith

70yo woman presents with sudden onset loss of vision in her right eye half hour ago

No improvement sinceNo previous ophthalmic historyWhat are your DDx?

Page 3: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

DDx

Retinal vessels Central/ branch retinal artery occlusion Central/ branch retinal vein occlusion

Vitreous Vitreous haemorrhage (diabetic complications) Retinal detachment

Macula ARMD – ‘wet’ ARMD

Optic nerve Anterior ischemic optic neuropathy: arteritic, non-artertic Optic neuritis

Cerebral cortex Stroke: homonymous hemianopia

Transient vision loss – amaurosis fugax

Page 4: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

What else would you like to know about the patient?

Page 5: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Case 1 – Mrs Smith

Hx Sudden onset while she was gardening Painless, no associated redness Hx of transient blurring of vision 2 weeks

ago but recovered Medhx – IHD, diabetes (on meds)

Ex Visual acuity <6/60 right eye, 6/9 left eye RAPD Fundus exam

Page 6: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

RAPD

Page 7: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

What is the most likely dx?

Page 8: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

CRAO

Pale oedematous retinaThin attenuated vesselsCherry red spotEmbolus may be seenOptic disc not pale or swollenAfter 6 weeks: Cherry red spot recedesOptic disc pallor becomes evident

Page 9: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

CRAO

Ix CDV RFs – lipids, fasting BSL ESR, CRP (r/o GCA) Carotid US Echocardiogram ± Thrombophilia screen

Mx Urgent referral to ophthal Ocular massage Lower IOP (diamox 500mg stat ± ant chamber

paracentesis) Long term aspirin?

Page 10: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Case 2 – Mr Lee

Similar hx 65 yo p/w sudden and painless loss of

vision in left eye Hx of DM and HTN

Similar ex 6/60 left eye, 6/9 right eye RAPD Fundus exam

Page 11: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

What is the most likely dx?

Page 12: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

CRVO

Intraretinal flame-shaped haemorrhages (visible in all four quadrants)

Optic disc swellingDilated, tortuous veinsCotton wool spots

Page 13: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

CRVO

Mx Check BP Screen for diabetes, hyperlipidemia Thrombophilic screen in younger pts

2 major complications Macular edema Neovascularisation of iris and retina

Page 14: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Case 3 – Mrs Abdullah

Hx 70yo lady p/w sudden onset loss of vision in her right eye Generalised muscle pain and weakness (but untreated for

past 8 months) Been feeling poor for the past 4 weeks with a flu and fever

that she hasn’t been able to shake Moderate severe headaches during the time Unable to chew food properly because ‘it hurts’, lost 5kgs Pmedhx: T2DM, smoker

Visual acuity Hand movements in right eye, 6/6 left eye RAPD in right eye

Page 15: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

What is the most likely dx?

Page 16: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Anterior Ischemic Optic Neuropathy

Fundoscopy Pale, swollen optic disc Some haemorrhages, cotton wool spots

Mx ESR (urgent!), CRP, plt count Temporal artery biopsy High dose systemic steroids (but always

check for RFs that may C/I or complicate Rx with steroids)

Page 17: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Case 4 – Mr Holmes

Hx 69yo man who p/w painless loss of vision Recent hx of increased number of visual

floaters and flashes “Dark shadow” in the visual field of left

eye High myopia since 15yo, T2DM

Ex Loss of red reflex RAPD

Page 18: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

What is the most likely dx?

Page 19: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Retinal detachment

Separation of sensory retina from the retinal pigment epithelium

Risk factors High myopes Ocular trauma DM Previous eye surgery eg cataract removal

Visual acuity will be affected only if central macula is affected

Examination Abnormal red reflex RAPD ‘Tobacco dust’ Detached retina (grey area)

Urgent opinion from ophthalmologist- surgery?

Page 20: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Wet (neovascular) AMD

Page 21: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Vitreous haemorrhage

Page 22: 70yo woman presents with sudden onset loss of vision in her right eye half hour ago No improvement since No previous ophthalmic history What are

Questions?

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