ACUTE VISUAL LOSSUBC Ophthalmology Interest Group Seminar Series1.18.2012
ANATOMY REVIEW
24 mm
Photo courtesy: Heather O’Donnell, PGY2, UBC
PRIMARY CARE APPROACH History
Onset ie. minutes vs days, following trauma?
Transient vs permanent Mono vs binocular Associated symptoms eg. pain, swelling,
floaters Other medical conditions and eye history Medications
Eye Exam Visual acuity
Equivalent to vitals for the eye
VISUAL ACUITY TESTING
Eye Exam Visual acuity
Equivalent to vitals for the eye Pupils, RAPD
Another ‘vitals’, from eye/neuro/trauma point of view Confrontational visual field Extraocular movement Tonometry External examination Slit lamp: lids, conjunctiva, AC Dilated examination, fundoscopy
CASE 1 Previously well 75F presents to ED for
sudden R eye pain and blurry vision while watching TV at night
c/o “halo” around lights Symptoms not resolved Hx: cataract in both eye, mild HTN No medications
CASE 1 OD CF, OS 20/25 R pupil fixed 4mm Rock hard globe Corneal edema Conj injections Opposite eye looks
normal Nausea, vomit x 1
Photo courtesy: A. Doan, MD, University of Iowa
IMPRESSION AND PLAN? A. Urgent head CT r/o mass lesion in
brain causing high ICP B. Acute bacterial conjunctivitis, pt
needs abx eye drops C. Chemical keratitis, rinse eye in
sterile water for 10 min immediately D. Acute angle closure glaucoma,
consult ophthalmology STAT
ACUTE ANGLE CLOSURE GLAUCOMA Results from aqueous outflow obstruction
by iris, rise in IOP, ischemia and permanent glaucomatous damage: emergency!
IOP = 42 mmHg (normal 12-20mmHg) Acetazolamide and timolol were given
initially, followed by pilocarpine 1 hour later.
IOP decreased to 19 mmHg Laser peripheral iridotomy arranged the
next day is the definitive treatment
LASER PERIPHERAL IRIDOTOMY
Photo courtesy: A. Doan, MD, University of Iowa
CASE 2 50M highly myopic
pt sees GP for c/o new onset of “flashing lights and floaters”
Blurry vision but no pain
Otherwise healthyRev Ophthalmol, 2006, 6:15
CASE 2 OD 20/80, OS
20/20 Pupils, anterior
segment normal Vitreous: tobacco
dust IOP: OD 10
mmHg, OS 13 mmHgRev Ophthalmol, 2006, 6:15
RETINAL DETACHMENT Rhegmatogenous most common, start as a
tear, fluid build up beneath neuroretina separates it from retinal pigment epithelium
High myopia is a risk factor In office: avoid pressure on globe, protect the
eye Immediate ophthalmological consult required Surgery is definitive treatment, often urgent
CASE 3 75F with sudden
painless loss of vision OD yesterday comes to GP office
A “grey spot” in her vision, grown over 10 min
Hx incl. CAD, HTN, TIA
Denies eye problemsPhoto courtesy: AAO 2011
CASE 3 OD CF, OS 20/30 R pupil sluggish
3mm RAPD EOM full Cornea, AC
grossly normal IOP 10mmHg B/L Cranial nerves
intactPhoto courtesy: AAO 2011
MANAGEMENT A. Assure pt that her vision is
unsalvageable, she needs to start Plavix to prevent a stroke
B. Send pt to emergency department STAT C. Compress and release the eye right now D. You don’t know what this is, so you
make a regular referral to ophthalmologist in 2-3 weeks
CRAO Central retinal artery occlusion often
secondary to embolus in a vasculopathic patient
Ophthalmological emergency Immediate restoration of retinal blood
flow is necessary to save sight Even with compress, sight is often not
salvageable. Need to evaluate etiology
CASE 4 85F comes to GP for sudden vision loss
today 2 months of transient double vision She has been feeling fatigued with
muscle and joint aches for the last 6 months
New headache in her R temple particularly when she combs her hair
Her jaw is painful when she’s eating
BMJ 2011, 343d4783
CASE 4 OD LP, OS 20/40 R pupil 3mm RAPD EOM full VF: wide spread loss Anterior segment
normal ESR from last week:
80 mm/h
Dx: A. Temporal arteritisB. Amaurosis fugaxC. Multiple sclerosisD. Compressive
optic neuropathy
NEXT STEP? A. Urgent neurology referral as stroke is
imminent B. Start patient on high dose steroids
empirically because benefits outweigh risks C. Ophthalmology referral for a temporal
artery biopsy to confirm diagnosis D. Urgent MRI of brain as it’s most sensitive
and specific for confirming a central lesion
TEMPORAL ARTERITIS Aka giant cell arteritis. Another classic
ophthalmological emergency Suspect in older women with new
headache, vision loss, and systemic sx Elevated ESR/CRP helps to rule in dx Must initiate high dose steroids
immediately followed by temporal artery biopsy
SUMMARY Approach: Hx, Va, Pupils, out to in, front to
back Acute vision loss is often a sign of serious
ocular disease process: Acute angle closure glaucoma Retinal detachment Central retinal artery occlusion Temporal arteritis
Urgent ophthalmological referral is needed (timeframe usually minutes to hours)
Immediate action is also required; time is sight
QUESTIONS ? Acknowledgement
Case editor: Steven Schendel, PGY-4 UBC
Contact R Tom Liu, UBC Med 2013 [email protected]
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